1. Protect the heart: 

• Give calcium gluconate 10% 30mls IV over 5 mins. This should be done with continuous cardiac monitoring.

• This intervention will not lower the potassium level but should improve adverse ECG appearances if present. The patient will need to be reassessed with another 12 lead ECG after treatment, further doses may be required.

2. Shift potassium back into cells:  

1. 10u insulin in 100mls 20% glucose over 30mins via volumetric pump.

2. Consider salbutamol nebulisers.

3. Consider sodium bicarbonate if acidosis present, after a discussion with renal or critical care teams.

3. Remove potassium from the body

• The renal route is the best way to remove excess potassium from the body. However, there are times when renal function is compromised and haemodialysis or haemofiltration is required to remove the potassium. Opinion should be sought from the renal and critical care teams.

4. Monitor potassium and glucose :

• Monitor potassium at baseline, 1 hr, 2 hrs, 6 hrs and 24 hrs to assess for any rebound in serum potassium as the effects of insulin-glucose wears off.

• Monitor for hypoglycaemia. Monitor blood glucose for a minimum of 12 hours after insulin-glucose administration. This should be done at 1, 15mins, 30mins, 1 hr, 1.5hrs, 2 hrs, 3 hrs, 4 hrs, 6 hrs, 8 hrs and 12 hrs.

• Patients with pre-treatment blood glucose less than 7 mmol/l, should have 10% glucose at 50ml/hr for a further 5 hours. This is a further measure to avoid hypoglycaemia associated with insulin-glucose infusion. Target Blood glucose of 4-7 mmol/l, this may require titration of the glucose infusion.

5. Prevent reoccurance

• To prevent recurrence and stop further potassium accumulation, consider the following:

  • Low K+ diet, avoid drugs known to raise K+, treat hypotension, ensure the patient is adequately hydrated, consider loop diuretics, K+ removal from gut via administration of the drug calcium resonium.