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Table 2 Treatments of hyperkalemia

From: Management of hyperkalemia in the acutely ill patient

Type of treatment Effect on potassium plasma level Administration Potential side effects Population at risk Preferred population
Myocardial protection
Calcium salt None 10–20 mL of calcium gluconate 10% i.v within 5 min Hypercalcemia Digitalis intoxication or hypercalcemia Hyperkalemia with ECG modifications
Hypertonic sodium (e.g., sodium bicarbonate) − 0.47 ± 0.31 mmol/L at 30 min 10–20 mL of sodium chloride 20% i.v within 5 min or 100 mL of 8.4% i.v sodium bicarbonate Venous toxicity, increasing PaCO2 (due to bicarbonate) Hypervolemia, patients with heart failure, hypernatremia, patient with respiratory insufficiency (due to bicarbonate) Hyperkalemia with ECG modifications, patient with metabolic acidosis or AKI
Intracellular potassium transfer
Insulin dextrose − 0.79 ± 0.25 mmol/L at 60 min 5 UI of rapid insulin + 25 grams of dextrose over 30 min or 10 of rapid insulin +  g of dextrose or 0.5 U/kg of body weight Hyperglycemia and hypoglycemia All patients Severe hyperkalemia with hourly monitoring of plasma glucose possible
Critically ill patients at increased of hyperglycemia-related side effects
Patients with acute neurological disease
β2 mimetics − 0.5 ± 0.1 mmol/L at 60 min 10 mg nebulized salbutamol Tachycardia, arrhythmias, myocardial ischemia Patients with ischemic cardiopathy Patient without heart failure, angina or coronary disease
Increase plasma lactate level Patient under β blockers therapy Spontaneously breathing patient
Elimination
Renal replacement therapy − 1 mmol/L within minutes High blood flow and dialysate flow in hemodialysis, high ultrafiltration rate in hemofiltration Complications related to catheter (i.e., infection, thrombosis, hemorrhage) Low availability of the technique Severe renal failure, multiple organ failure
Delay to initiate the treatment
Loop diuretics Unpredictable Variable Hypovolemia, hypokalemia, hypomagnesemia Hypovolemic patients Hypervolemic patients with normal or moderately altered renal function
Absorption
Sodium polystyrene sulfonate Unpredictable (no randomized controlled trial in acute hyperkalemia) 15 g one to four times per day Digestive perforation, hypocalcemia, hypomagnesemia Patients with abnormal transit, critically ill patients Treatment of chronic hyperkalemia
Patiromer 0.21 ± 0.07 mmol/L within 7 h (no randomized controlled trial in acute hyperkalemia) 8.4–25.2 g per day Potential interaction with co-administered drugs, hypomagnesemia, potential long-term calcium disorder Patients with abnormal transit Treatment of chronic hyperkalemia
ZS-9 0.6 ± 0.2 mmol/L within 2 h 10 g one to three times per day Edema Patients with abnormal transit Treatment of chronic and potentially acute hyperkalemia
  1. i.v intravenous, ECG electrocardiographic, β2 beta 2, ZS-9 sodium zirconium cyclosilicate