Lesson 11 of11
In Progress


Jimmy October 26, 2021

The management of acute hyperkalemia is multifacet and ultimately requires elimination of potassium

CIGAR- LOOPS stands for

    Calcium Salts

    Insulin + Glucose


    Resins ( Sodium polystyrene and Sodium Zirconium Cyclosilicate)

    Loop Diuretics

    Sodium Bicarbonate

Each agent has an unique purpose with evidence-based indications and dosing

Drug Summary Chart

DrugMechanism of ActionDoseOnset of ActionDuration of ActionAdverse EffectsPearls
Calcium ChlorideAntagonizes cardiac conduction abnormalitiesIntravenous,5-10 mL1-3 mins30-50 minsHypercalcemiaCentral line administration
continuous ECG monitoring
Calcium GluconateAntagonizes cardiac conduction abnormalitiesIntravenous, 10-20 mL1-3 mins30-50 minsHypercalcemiaPeripheral vein administration
Initial dose: 1g IV to lower risk of tissue necrosis
Insulin-DextroseShifts K+ intracellularlyIntravenous, regular insulin 5-10 units, plus glucose 50%, 25g15-60 mins4-6 hoursHypoglycemia, hypokalemia, hypersensitivityDextrose is required unless patient is diabetics
Lowers serum K+ levels by ~1.5 mEq/L
AlbuterolShifts K+ intracellularlyInhalation, nebulized albuterol, 10-20 mg in 4mL normal saline, inhaled over 10 minutes15-30 mins2-4 hoursMild tachycardiaLowers serum K+ levels by ~1.0 mEq/L
Sodium BicarbonateShifts K+ intracellularlyIntravenous, NaHCO3, 50-100mEq15-30 mins1-2 hoursHypocalcemia, injection site extravasation, intracellular acidosis, hypernatremia, hyperosmosis, shift O2 release by hemoglobinPotentiates potassium-lowering effect of insulin
Not beneficial for patients with acute hyperkalemia
FurosemideRenal K+ excretionIntravenous, 40-80 mg2-4 hoursVariesHypovolemia, hypokalemia, hypomagnesemiaEfficacy diminishes in patients with severe kidney failure
May be combined with thiazides or acetazolamide
Sodium polysterene sulfonate resin (SPS)Binds K+ in colonIntraoral, 15-60g in 20% sorbitol
Intrarectal, 30-60g in 20% sorbitol
1-3 hoursVariesBowel obstruction, digestive perforation, hypocalcemia, hypomagnesemia, edema, high blood pressurePreferred route: Intraoral for longer GI transit but for faster administration, opt for IR but with ↓ effects
K+ removed from the body: 0.5-1 mEq/g resin
PatiromerCa2+-K+ cation exchange resinIntraoral,4.2-16.8 g once or twice daily7-48 hours12-24 hoursHypomagnesemia, constipationNot been clinically tested in the emergency setting
K+ removed from the body: Mean 0.75 mEq/g resin
Sodium Zirconium Cyclosilicate (ZS-9)Preferentially binds K+ throughout GI tractIntraoral,10g up to three times daily1-6 hours4-12 hoursMinor GI symptoms (UTI), edema, increased sodium levelsNot for acute managementdue to delayed onset of action
K+ removed from the body: 0.7 mEq/L per 10g dose