• See also

    Resuscitation: Care of the seriously unwell child

    Resuscitation: Hospital management of cardiopulmonary arrest

    Intravenous fluids

    Electrolyte abnormalities


    • Hyperkalaemia: serum K+ >5.5 mEq/L, (N range = 3.5-5.0 mEq/L), or  >6.0 mEq/L in neonates
    • Hyperkalaemia is potentially life threatening, and can result in cardiac arrhythmias and sudden death


    • Hyperkalaemia as an artefact of collection process or technique
    • Decreased excretion (frequent cause)
      • Renal diseases: Acute/chronic renal failure, renal anomaly
      • Adrenal mineralocorticoid deficiency
    • Transcellular shift
      • Acidosis  eg Diabetic ketoacidosis, lactic acidosis
    • Increased production (Most often if in association with renal dysfunction)
      • Extensive trauma, rhabdomyolysis (crush injury, convulsion, infection), haemolysis, tumour lysis syndrome, burns
    • Exogenous source
      • Iatrogenic potassium administration (oral, IV)
      • Increased ingestion
      • Massive transfusion
    • Medication
      • eg NSAID, trimethoprim, heparin, chemotherapy, K-sparing diuretic, ACE inhibitor, beta blockers, succinylcholine, digoxin, mannitol


    History and examination:

    • Look for possible causes (see above)
    • Hyperkalaemia can be initially asymptomatic or can presents with severe symptoms/signs:
      • Respiratory depression
      • Palpitations, arrhythmia, cardiac arrest
      • Paraesthesia, flaccid paralysis
      • Ileus
    • Confirm that potassium in IV fluids and oral potassium supplements are stopped
    • Assess the patient's medication list - stop drugs that increase potassium or reduce its excretion

    Investigation and monitoring:

    Note: Patients with moderate or severe hyperkalaemia need continuous cardiac monitoring and IV access

    • Level of potassium should be confirmed with a second sample
      • If patient has renal dysfunction (renal failure or other renal disease), assume potassium level correct until proven otherwise
      • Acute increase of potassium is associated with higher risk of arrhythmia
    • Do an ECG to identify conduction disturbance:
      • Peaked T wave (early)
      • Prolonged PR, flattening of P wave, widening of QRS (increased risk of arrhythmia)
      • Absence of P wave, sine wave (fusion of QRS and T wave)
      • Ventricular arrhythmia, asystole

    Note: A normal ECG does not exclude risk for arrhythmia, as life threatening arrhythmia can occur without warning

    • Complete investigations and consider causes of hyperkalaemia:
      • Urea, creatinine and electrolytes
      • Glucose
      • Venous blood gas
      • +/- Urine analysis and urinary electrolytes
    • Consider other investigations depending on cause:
      • CK
      • Cortisol, aldosterone and hormonal precursor levels (particularly if hyponatraemic)
      • Level of digoxin (if relevant)


    Hyperkalaemia - Treatment: (flowchart)

    If pulseless arrhythmia, see Resuscitation

    ***Stop any source of potassium intake - IV fluid, parenteral alimentation, dietary supplement (including NGT feeding) and any potassium-sparing medication

    Severe hyperkalaemia

    - K+ >7.0 mEq/L or at risk of increasing and/or
    - Patient symptomatic and/or
    - ECG disturbance:

    • Calcium IV
    • Salbutamol neb
    • Insulin/glucose IV
    • Bicarbonate IV if metabolic acidosis
    • Dialysis:
      • Urgent if unstable
      • Rapid if stable but symptomatic or abnormal ECG
      • Consider if asymptomatic but severe hyperkalaemia
    • Resonium (Polystyrene sulfonate) PR (if dialysis unavailable)

    Consider hydrocortisone 1-2 mg/kg IV if suspicion of adrenal insufficiency

    Moderate hyperkalaemia

    - K+ 6-7 
    - Patient asymptomatic
    - Normal ECG

    • Salbutamol neb
    • Insulin/glucose IV
    • Resonium (Polystyrene sulfonate) PR or oral
    • Bicarbonate IV if metabolic acidosis

    Mild hyperkalaemia

    - K+ >5.5 
    - Patient asymptomatic
    - Normal ECG

    • Consider no treatment
    • Stop K supplements
    • Recheck result
    • Salbutamol neb
    • Polystyrene sulfonate PR or oral (resonium)
    • Bicarbonate IV if metabolic acidosis



    2 solutions :

    • Calcium gluconate 10%: 0.5 mL/kg slow IV injection
      • 2-5 minutes  if unstable, over 15-20 min if stable (Max: 20 mL)
      • Preferable if only peripheral line available
    • Calcium Chloride 10% : 0.1-0.2 mL/kg slow IV injection (as above) (Max: 10 mL)
      Note: Give under cardiac monitoring, discontinue if HR dropping significantly
      Avoid extravasations
      NOT to be given simultaneously with bicarbonate
      NOT to be given if digoxin toxicity
      Onset of Action: <3 minutes, should see normalisation of ECG. If not: repeat dose (twice)
      Duration: ~30 minutes


    • Salbutamol: nebulisation
      • Less than 25 kg : 2.5 mg neb 1-2 hourly
      • More than 25 kg : 5 mg  neb (Adu max 10-20 mg) 1-2 hourly
    • Salbutamol : IV *Only if severe hyperkalaemia after discussion with senior doctor from tertiary centre with monitoring for tachycardia

    Onset of Action: 30 minutes
    Duration: 2-3 hours


    to be given at the same time

    If severe hyperkalaemia:

    • Dextrose 10% :  5 mL/kg IV bolus (if no hyponatraemia)
    • Insulin short action: 0.1 U/kg IV bolus  (max 10 units)

    Then followed by infusion insulin/glucose (see below)
    If moderate hyperkalaemia:

    • Dextrose 10% IV at maintenance with 0.9% sodium chloride (normal saline)
    • Insulin short action infusion : 0.1 U/kg/h IV

    Note: Close monitoring of glucose every 30-60 minutes

    Onset of Action: 15 minutes
    Duration:  peak 60 minutes, 2-3 hours

    In metabolic acidosis only

    Severe hyperkalamia and metabolic acidosis

    • Sodium Bicarbonate 8.4% 1 mmol/mL : 1-3ml/kg IV over 5 minutes

    Mild to moderate hyperkalaemia and metabolic acidosis:

    • Sodium Bicarbonate 8.4% 1 mmol/mL : 1 mL/kg slow IV infusion over 30 minutes

    Note: Do NOT give simultaneously with Calcium
    Onset of Action: 30-60 minutes
    Duration: 2-3 hours


    To be organised with local paediatric renal or intensive care team. Transfer to tertiary centre


    Mild effect, multiple doses necessary, may be used as long term agent

    • Polystyrene sulfonate (resonium) 0.3-1 g/kg 6 hourly (max 15-30 g) PR or oral (with lactulose)

    Note:  NOT to be used if ileus, recent abdominal surgery, perforation, hypernatraemia
    Onset of Action:  1 hour PR, 4-6 hours oral
    Duration: variable

    Consider consultation with local paediatric team

    • Any child with moderate or severe hyperkalaemia
    • Underlying medical cause - eg renal abnormalities

    When to consider transfer to tertiary centre

    • Any child with severe hyperkalaemia
    • Any child requiring dialysis  
    • Child requiring care beyond the comfort level of the hospital

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Information Specific for RCH

    Consider early ICU review if severe hyperkalaemia 
    Notify child's home team (especially Renal) 

    Last updated March 2016