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Abstract
The foremost step in the initial clinical management of hyperkalemia is to decide
whether a hyperkalemic patient requires immediate treatment to avoid a life-threatening
situation (serum potassium concentration >6.0 mEq/l and EKG changes). When the decision
for urgent treatment of hyperkalemia is based on EKG changes, an important caveat
for clinicians is that absent or atypical EKG changes do not exclude the necessity
for immediate intervention. Once an urgent situation has being handled with intravenous
push of a 10% calcium salt, the initiation of short-term measures can be launched
by either a single or combined regimen of the three agents that cause a transcellular
shift of potassium – insulin with glucose, β<sub>2</sub>-agonist (albuterol), and
NaHCO<sub>3</sub>. As the first choice among these available options, we favor an
intravenous bolus of 10 units of insulin with 50 ml of 50% glucose alone or in combination
with 10–20 mg of albuterol by nebulizer. These can be repeated as required until the
institution of hemodialysis. The combination of insulin with glucose and NaHCO<sub>3</sub>
as an another option needs further clarification for its additive effects. However,
NaHCO<sub>3</sub> has lost its favor because of its poor efficacy as a potassium-lowering
agent when used alone. The next step is to remove potassium from the body – diuretics
(furosemide), cation exchange resin (kayexelate) with sorbitol, and dialysis (preferably
hemodialysis). The final important step for the managements of hyperkalemia is a long-term
plan to prevent its recurrence or worsening. In addition to every effort to elucidate
underlying causes and pathophysiologic mechanisms for hyperkalemia, an extensive search
must be made to uncover overt or sometimes covert medications that may have led to
the development of hyperkalemia. Furthermore, one must obtain detailed dietary and
medical history of hyperkalemic patients.