Written by Jacob Altholz
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This article argues for albuterol and insulin/glucose and against calcium use for hyperkalemia.
Potassium pains – calcium not up to snuff?
This article sought to review the major pharmacological methods for managing hyperkalemia regardless of cause. Interventions included IV insulin/glucose, inhaled albuterol, IV albuterol in glucose, a combination of IV albuterol/insulin, IV bicarbonate, and IV calcium. Most studies included in the review focused only on those patients with hyperkalemia but who had not had a cardiac arrest.
In order of the strength of the effect, 8-12 units of insulin/glucose, 10-20mg of inhaled of albuterol, 0.5mg of IV albuterol in glucose, and a combination of 0.5 mg albuterol/10 units insulin/glucose IV effectively decreased measured potassium concentrations. Potassium concentrations decreased in insulin/glucose alone by 0.7 mmol/L and in the combination of IV albuterol/insulin in glucose by 1.2 mmol/L. Bicarbonate was not effective, with a measured average decrease of 0.1 mmol/L. Secondary evaluations of ECG changes showed consistent resolution of the hyperkalemic manifestations as the laboratory abnormality resolved.
Calcium was only evaluated in two studies in those with cardiac arrest, and results largely indicated worse outcomes, both in those with and without hyperkalemia. Though many of the studies have a severe risk of bias, the evidence currently argues against administration of calcium, both in cardiac arrest regardless of potassium concentration and those with hyperkalemia alone.
How does this change my practice?
This makes me think differently when evaluating a patient with hyperkalemia. The use of IV albuterol is not common anywhere I have practiced, though it appears to be effective. The arguments against calcium are fairly compelling, and I feel less likely to reach for calcium in a shotgun approach to cardiac arrest.
Another Spoonful
We’ve previously covered concerns about empiric calcium for arrest, such as the COCA RCT and this study on peds IHCA.
Source
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
