Management of acute hyperkalaemia: evidence, practice and pitfalls

Acute hyperkalaemia is a medical emergency requiring rapid clinical evaluation. Point-of-care blood gas analysis may overestimate serum potassium concentration and should be confirmed with a laboratory sample unless urgent treatment is required. When ECG (electrocardiogram) changes are present, immediate cardiac protection is a priority. Current guidelines recommend administering intravenous 10% calcium gluconate to restore cardiac conduction velocity. Intravenous insulin rapidly shifts potassium into cells. It is given with intravenous dextrose to reduce the risk of hypoglycaemia. A reduced insulin dose can be considered in patients with significant kidney dysfunction. Salbutamol shifts potassium into cells and has a synergistic effect with insulin. Nebulised salbutamol administration offers similar efficacy to intravenous delivery with fewer adverse effects. The routine use of intravenous sodium bicarbonate or oral potassium binders is not recommended for immediate lowering of serum potassium in acute hyperkalaemia. Sodium bicarbonate should be reserved as an adjunctive treatment for patients with concurrent metabolic acidosis. Post-acute care focuses on addressing reversible triggers and, once hyperkalaemia resolves, restarting important drugs that can increase potassium concentrations, if their benefit outweighs the risk (e.g. renin-angiotensin-aldosterone system inhibitors).