Acute treatment of hyperkalemia: remember insulin/glucose and albuterol

Myron Yaster MD, Ethan Sanford MD, Shawn Jackson MD PhD, Justin L. Lockman MD MSEd

Acute elevations in potassium can lead to life-threatening dysrhythmias. As pediatric anesthesiologists, we see this commonly in patients with kidney injury/failure, during liver transplantation, during transfusions of “old” packed red blood cells, in patients with crush injuries and burns, and occasionally with more rare causes such as congenital adrenal hyperplasia or other causes of adrenal insufficiency. Massive hyperkalemia also occurs in susceptible patients following succinylcholine administration or in children who develop malignant hyperthermia.

Hyperkalemia is defined as serum potassium levels greater than 6 mmol/L and is associated with (in order of increasing potassium): peaked, tall T waves, prolonged PR intervals, a widened QRS complex, heart block, a sine wave pattern, and ventricular fibrillation or asystole.

When faced with this life-threatening situation, rapid, well-rehearsed treatment is mandatory. Of course, the first thing to do is to open your SPA Pedi Crisis 2.0 (and if you haven’t done it already download it now…links available on the SPA website at https://pedsanesthesia.org/pedi-crisis-app/).

In today’s PAAD, Jessen et al.¹ conducted a systematic review and meta-analysis with some surprising new recommendations. Myron Yaster MD

Original article

Jessen MK, Andersen LW, Djakow J, Chong NK, Stankovic N, Staehr C, Vammen L, Petersen AH, Johannsen CM, Eggertsen MA, Mortensen SØ, Høybye M, Nørholt C, Holmberg MJ, Granfeldt A; International Liaison Committee on Resuscitation (ILCOR) Advanced Paediatric Life Support Task Forces. Pharmacological interventions for the acute treatment of hyperkalaemia: A systematic review and meta-analysis. Resuscitation. 2025 Mar;208:110489. doi: 10.1016/j.resuscitation.2025.110489. Epub 2025 Jan 4. PMID: 39761907.

“Elevations in potassium can lead to life-threatening arrhythmias and ultimately sudden cardiac death.² The general management of patients with hyperkalaemia is based on three proposed mechanisms: protection against arrhythmias (calcium), the transcellular shift of potassium (insulin and beta2-agonists), and the excretion of potassium (diuretics, potassium binders, dialysis).³ For patients in cardiac arrest, guidelines currently recommend administration of calcium, bicarbonate, and insulin with glucose.^4,5 The objective of this review was to assess the effects of acute pharmacological interventions for the treatment of hyperkalaemia in patients with and without cardiac arrest.”¹

What did the systematic review find? “A total of 101 studies were included, with two studies including patients with cardiac arrest. In meta-analyses including adult patients without cardiac arrest, treated with insulin in combination with glucose, inhaled albuterol (salbutamol), intravenous albuterol dissolved in glucose, or a combination, the average reduction in potassium was between 0.7 and 1.2 mmol/l (very low to low certainty of evidence). The use of bicarbonate had no effect on potassium levels (very low certainty of evidence). In neonatal and pediatric populations, inhaled albuterol and intravenous albuterol reduced the average potassium between 0.9 and 1.0 mmol/l (very low to low certainty of evidence). There was no evidence to support a clinical beneficial effect of calcium for treatment of hyperkalemia.”¹

The authors conclude: “Evidence supports treatment with insulin in combination with glucose, inhaled or intravenous salbutamol, or the combination. No evidence supporting a clinical effect of calcium or bicarbonate for hyperkalaemia was identified.”¹ While the authors should be commended for their scoping systematic review, we don’t necessarily think their results tell the whole story.

This is a good time to remind all of our readers that absence of evidence is not the same as evidence of absence. These studies don’t discriminate whether patients were hypocalcemic or acidemic at the time of hyperkalemia – correcting these abnormalities is clearly critical during hyperkalemia. In addition, it’s likely that the benefits of calcium and sodium bicarbonate are most apparent among critical patients who are peri-arrest, and may not be detected in this systematic review. We have all witnessed ECG improvements with administration of calcium, which has long been touted as a cardiac membrane stabilizer in this situation – and the lack of accompanying drop in serum potassium is not a reason to avoid using it. Thus, while insulin/glucose and albuterol should also be included in algorithms, we think it is still reasonable to use calcium and sodium bicarbonate in children with hyperkalemia when hypocalcemia and/or acidemia are present (or unknown), particularly as there appears to be no evidence of harm.

If hyperkalemia occurs in the OR, we recommend following (adapted from the Pedi Crisis 2.0 app’s treatment algorithm):

· Declare an emergency, call for help and open the Pedi Crisis app.

· If hemodynamically unstable, start CPR/PALS while continuing to treat.

· Hyperventilate with 100% oxygen.

· Stop all potassium containing IV solutions and use new or washed packed red blood cells.

· Give calcium gluconate 60-100 mg/kg IV or calcium chloride 20 mg/kg IV.

· Give dextrose 0.5 – 1 gram/kg (max 50 grams) and insulin 0.1 Units/kg IV (max 10 units).

· Give albuterol puffs or nebulized once cardiac rhythm is stabilized.

· Give sodium bicarbonate 1-2 mEq/kg IV.

· Give furosemide 0.5-1 mg/kg.

· Dialysis if refractory to treatment.

· If there is a cardiac arrest and it has lasted longer than 5-6 minutes, activate ECMO (if available).

Finally, we note that the lack of wide-spread availability of intravenous albuterol (at least in the U.S.) also presents a challenge to its use as an emergency agent.

What do you think? Send your thoughts and comments to Myron at MYasterster@gmail.com who will post in a Friday Reader Response.

References

1. Jessen MK, Andersen LW, Djakow J, et al. Pharmacological interventions for the acute treatment of hyperkalaemia: A systematic review and meta-analysis. Resuscitation 2025;208:110489. (In eng). DOI: 10.1016/j.resuscitation.2025.110489.

2. Littmann L, Gibbs MA. Electrocardiographic manifestations of severe hyperkalemia. Journal of Electrocardiology 2018;51(5):814-817. DOI: https://doi.org/10.1016/j.jelectrocard.2018.06.018.

3. Long B, Warix JR, Koyfman A. Controversies in Management of Hyperkalemia. The Journal of Emergency Medicine 2018;55(2):192-205. DOI: https://doi.org/10.1016/j.jemermed.2018.04.004.

4. Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021;161:152-219. DOI: https://doi.org/10.1016/j.resuscitation.2021.02.011.

5. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020;142(16_suppl_2):S366-s468. (In eng). DOI: 10.1161/cir.0000000000000916.