Severe Hyperkalemia: Lytic Cocktail Regime

"Staff Nurse, saya nak order Lytic Cocktail satu!"

Regimen Lytic Cocktail for severe hyperkalemia (In Sequence!)

(with cardiac monitoring)
1) IV (slow bolus) Ca Gluconate 10%, 10mls over 5 mins STAT
2) IV (bolus) D50%, 50mls STAT
3) IV (bolus) Insulin Regular (Actrapid) 10iu STAT

IV Ca gluconate 10%
a. NOT for hyperkalemia secondary to digoxin toxicity
b. effect should be seen in few min (onset: 5 min) & lasts 30-60 min
c. may be repeated once or twice PRN
d. works as membrane stabilizer = restore normal gradient between threshold potential and resting membrane potential
c. Complication to observe - hypercalcemia

IV D50%
a. May not require if patient severe hyperglycemia, DKA or HHS
b. In conjunction with insulin to prevent hypoglycemia

IV Insulin regular
a, Facilitate glucose uptake into cell, resulting intracellular K+ shift
b. Complication to observe - hypoglycemia (that's why give D50)

Emergency treatment of hyperkalemia (other than Lytic Cocktail regime)

1. Neb salbutamol 20mg over 10min 
- redistribution of K+
- monitoring - ECG, HR

2. IV Frusemide 40mg 
- elimination of K+
- monitor - fluid balance, BUSE/Creat

3. IV NaHCO3 150 mmol/L
- for metabolic acidosis with hyperkalemia

4. Oral Ca Polystyrene Sulfonate (Kalimate)
- onset >2hr; duration 4-6 hr

5. RRT
- rapid reduction of K+
- PD for rate of K+ removal is slower than HD

Source: 
1. ETD HSAJB
2. Weisberg, L. S. (2008). Management of severe hyperkalemia. Critical Care Medicine, 36(2), 3246-3251.