Summary

The management of acute hyperkalemia is multifacet and ultimately requires elimination of potassium
CIGAR- LOOPS stands for
Calcium Salts
Insulin + Glucose
Albuterol
Resins ( Sodium polystyrene and Sodium Zirconium Cyclosilicate)
Loop Diuretics
Sodium Bicarbonate
Each agent has an unique purpose with evidence-based indications and dosing

Drug Summary Chart

Drug	Mechanism of Action	Dose	Onset of Action	Duration of Action	Adverse Effects	Pearls
Calcium Chloride	Antagonizes cardiac conduction abnormalities	Intravenous,5-10 mL	1-3 mins	30-50 mins	Hypercalcemia	Central line administration continuous ECG monitoring
Calcium Gluconate	Antagonizes cardiac conduction abnormalities	Intravenous, 10-20 mL	1-3 mins	30-50 mins	Hypercalcemia	Peripheral vein administration Initial dose: 1g IV to lower risk of tissue necrosis
Insulin-Dextrose	Shifts K+ intracellularly	Intravenous, regular insulin 5-10 units, plus glucose 50%, 25g	15-60 mins	4-6 hours	Hypoglycemia, hypokalemia, hypersensitivity	Dextrose is required unless patient is diabetics Lowers serum K+ levels by ~1.5 mEq/L
Albuterol	Shifts K+ intracellularly	Inhalation, nebulized albuterol, 10-20 mg in 4mL normal saline, inhaled over 10 minutes	15-30 mins	2-4 hours	Mild tachycardia	Lowers serum K+ levels by ~1.0 mEq/L
Sodium Bicarbonate	Shifts K+ intracellularly	Intravenous, NaHCO3, 50-100mEq	15-30 mins	1-2 hours	Hypocalcemia, injection site extravasation, intracellular acidosis, hypernatremia, hyperosmosis, shift O2 release by hemoglobin	Potentiates potassium-lowering effect of insulin Not beneficial for patients with acute hyperkalemia
Furosemide	Renal K+ excretion	Intravenous, 40-80 mg	2-4 hours	Varies	Hypovolemia, hypokalemia, hypomagnesemia	Efficacy diminishes in patients with severe kidney failure May be combined with thiazides or acetazolamide
Sodium polysterene sulfonate resin (SPS)	Binds K+ in colon	Intraoral, 15-60g in 20% sorbitol Intrarectal, 30-60g in 20% sorbitol	1-3 hours	Varies	Bowel obstruction, digestive perforation, hypocalcemia, hypomagnesemia, edema, high blood pressure	Preferred route: Intraoral for longer GI transit but for faster administration, opt for IR but with ↓ effects K+ removed from the body: 0.5-1 mEq/g resin
Patiromer	Ca2+-K+ cation exchange resin	Intraoral,4.2-16.8 g once or twice daily	7-48 hours	12-24 hours	Hypomagnesemia, constipation	Not been clinically tested in the emergency setting K+ removed from the body: Mean 0.75 mEq/g resin
Sodium Zirconium Cyclosilicate (ZS-9)	Preferentially binds K+ throughout GI tract	Intraoral,10g up to three times daily	1-6 hours	4-12 hours	Minor GI symptoms (UTI), edema, increased sodium levels	Not for acute managementdue to delayed onset of action K+ removed from the body: 0.7 mEq/L per 10g dose

Hyperkalemia Pharmacotherapy

Introduction

Participants 396

Summary

Drug Summary Chart