Treatment for hyperkalaemia
Patients with chronic digoxin accumulation and a serum potassium concentration of more than 6 mmol/L (severe hyperkalaemia) need potassium-lowering therapies. Often hyperkalaemia in this situation has multiple causes (eg kidney failure, potassium-sparing diuretics). In contrast to acute digoxin poisoning, digoxin immune Fab is not likely to lower the serum potassium concentration—it should only be used in consultation with a clinical toxicologist.
Insulin, glucose, sodium bicarbonate and salbutamol reduce the serum potassium concentration by shifting potassium into the cells. Calcium stabilises the myocardium, but does not reduce the serum potassium concentration. Calcium was previously avoided when managing hyperkalaemia in patients with digoxin toxicity, but the risk of harm was overstated.
For adults, to reduce serum potassium concentration by shifting potassium into cells, use:
short-acting insulin 10 units intravenously1. This reduces the serum potassium concentration by 0.5 to 1.5 mmol/L over 30 minutes. Repeat the dose once after 30 minutes if the serum potassium concentration is still raised chronic digoxin accumulation
PLUS EITHER
1 glucose 50% 50 mL intravenously, by slow injection, via a large peripheral vein. Repeat the dose once after 30 minutes if the serum potassium concentration is still raised chronic digoxin accumulation - hyperkalaemia
OR
1 glucose 10% 250 mL intravenously, by slow injection, via a large peripheral vein. Repeat the dose once after 30 minutes if the serum potassium concentration is still raised chronic digoxin accumulation - hyperkalaemia
PLUS
sodium bicarbonate 8.4% 50 mL (50 mmol) intravenously, over 5 to 10 minutes, with ECG monitoring. Repeat the dose once after 15 minutes if the serum potassium concentration is still raised chronic digoxin accumulation
PLUS
salbutamol 10 mg via intermittent nebulisation. This reduces the serum potassium concentration by 0.5 to 1.5 mmol/L in 30 to 90 minutes. chronic digoxin accumulation salbutamol
For children, to reduce serum potassium concentration by shifting potassium into cells, use:
short-acting insulin 0.1 units/kg up to 10 units intravenously1. This reduces the serum potassium concentration by 0.5 to 1.5 mmol/L over 30 minutes. Repeat the dose once after 30 minutes if the serum potassium concentration is still raised
PLUS
glucose 10% 2.5 mL/kg intravenously, by slow injection, via a large peripheral vein. Repeat the dose once after 30 minutes if the serum potassium concentration is still raised
PLUS
sodium bicarbonate 8.4% 1 mL/kg up to 50 mL (1 mmol/kg up to 50 mmol) intravenously, over 5 to 10 minutes, with ECG monitoring. Repeat the dose once after 15 minutes if the serum potassium concentration is still raised
PLUS
salbutamol 2.5 to 5 mg via intermittent nebulisation. This reduces the serum potassium concentration by 0.5 to 1.5 mmol/L in 30 to 90 minutes. salbutamol
If hyperkalaemia does not respond to treatment, seek advice from a clinical toxicologist.
If the patient has a life-threatening arrhythmia or severe ECG changes due to acute hyperkalaemia, in addition to the above measures, give calcium to stabilise the myocardium. Calcium gluconate is preferred to calcium chloride as it causes less local irritation.
For adults with life-threatening arrhythmia or severe ECG changes due to acute hyperkalaemia, use :
1 calcium gluconate 0.22 mmol/mL2 6.6 mmol (30 mL) intravenously, over 2 to 3 minutes, via a large peripheral vein, with ECG monitoring. Repeat the dose once after 10 minutes if required chronic digoxin accumulation
OR
1 calcium chloride 0.68 mmol/mL (10%) 6.8 mmol (10 mL) intravenously, over 2 to 3 minutes, via a large peripheral vein, with ECG monitoring. Repeat the dose once after 10 minutes if required. chronic digoxin accumulation
For children with life-threatening arrhythmia or severe ECG changes due to acute hyperkalaemia, use :
1 calcium gluconate 0.22 mmol/mL2 0.13 mmol/kg up to 6.6 mmol (0.6 mL/kg up to 30 mL) intravenously, over 2 to 3 minutes, via a large peripheral vein, with ECG monitoring. Repeat the dose once after 10 minutes if required chronic digoxin accumulation
OR
1 calcium chloride 0.68 mmol/mL (10%) 0.14 mmol/kg up to 6.8 mmol (0.2 mL/kg up to 10 mL) intravenously, over 2 to 3 minutes, via a large peripheral vein, with ECG monitoring. Repeat the dose once after 10 minutes if required. chronic digoxin accumulation