Hyperkalaemia - Guidelines for Acute Management in the Neonate

Publication: 01/05/2003  
Next review: 29/07/2025  
Clinical Guideline
ID: 204 
Approved By: Neonatology and Renal Medicine 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Hyperkalaemia - Guidelines for Acute Management in the Neonate

Definition of Hyperkalaemia

In newborns a serum K+ > 7.0mmol/L is abnormal.
However a raised K+ level on capillary sampling is commonly due to haemolysis and the true serum K+ levels must be confirmed as soon as possible with a venous or arterial sample.

Stop all potassium retaining drugs, avoid the use of suxamethonium and consider stopping all exogenous sources of potassium early if true hyperkalaemia is suspected.

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Cardiac Arrythmia

Arrythmias are unlikely unless K+ > 7.5mmol/L with ECG changes best confirmed on formal ECG.
Early changes include

  • peaked T waves,
  • prolonged PR interval and
  • widened QRS and are due to decreased conduction velocity.

Continued rises in K+ levels may lead to ventricular tachycardia or sinus bradycardia and in severe cases ventricular fibrillation and asystole.

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Emergency Treatment if Risk of Arrhythmia

Calcium gluconate 10% (IV) 0.5 mL/kg (0.11mmol/kg) as a membrane stabiliser to control cardiac excitability.1,2 See calcium gluconate monograph for administration information.
Onset is within 5 minutes.

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Cause of Hyperkalaemia

The cause must be considered and in general, appropriate management will reduce the potassium level. Extremely premature infants may develop hyperkalaemia without significant renal impairment.
True neonatal hyperkalaemia is relatively rare and is seen in the following conditions:

  1. Oliguric acute renal failure due to potassium retention.
  2. Shock with tissue damage causing potassium leakage from the intracellular space - some potassium will be redistributed to the intracellular space if acidosis is corrected (see below).
  3. Unexplained in the acute phase of respiratory distress syndrome - incidence may be reduced if mother receives antenatal steroids.3
  4. Hypoaldosteronism and hypoadrenalism (with hyponatraemia) - rare.
  5. Drug induced due to potassium retention (spironolactone, potassium supplements) or release from cells (suxamethonium).
  6. Accidental overdose in intravenous fluids. If this is considered retain IV fluids once stopped for analysis in pharmacy.

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When commencing treatment for Hyperkalaemia the following may aid identification of the cause and set a baseline for treatment:

  • Urea and electrolytes - monitor 4 hourly on gases and/or 6-8 hourly in lab until serum potassium has stabilised
  • Calcium, magnesium, chloride, bicarbonate, glucose and urine analysis.

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Other Aspects of Management

  • Recheck serum potassium levels after each intervention or at least every 4-6 hours until normal levels are stabilised.
  • Watch for fluid overload in the presence of renal failure and adjust fluid intake accordingly.
  • Monitor blood glucose hourly if treating with glucose and insulin.

Treatment of Hyperkalaemia

  • Treat any cardiac arrhythmia as above
  • Stop IV potassium
  • Remove any potassium from IV fluids
  • Intravenous salbutamol and if no response
  • Glucose and insulin and if remains persistent
  • Salbutamol infusion
  • Consider correcting any acidosis with sodium bicarbonate

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See LTHT drug formulary for details of preparation of solutions



Mechanism of Action

pH < 7.2 and BE >10

Sodium bicarbonate (IV) to correct acidosis - see formulary sodium bicarbonate monograph

Reduction of plasma K+ by redistribution to intracellular space

1st Line

Salbutamol bolus (by intravenous injection: 4microgram/kg as a single
dose over 5 minutes; can be repeated if necessary

Reduction of plasma K+ by redistribution to intracellular space

2nd Line

Glucose 20% 2.5 - 5 mL/kg/hour (equivalent to glucose 0.5 - 1 g/kg/hr) ideally via central line


Insulin 0.05 - 0.2 units/kg/hour increasing to keep blood sugar 4-7 mmol/L

Reduction of plasma K+ by redistribution to intracellular space

There is evidence to suggest that a combination of salbutamol and dextrose/insulin may be more effective than either alone and this should be considered in hyperkalaemia resistant to monotherapy.5

3rd Line
Persistent hyperkalaemia

Salbutamol infusion 0.3 - 1 microgram/kg/min (watch for fluid overload in renal failure)


Dialysis or exchange transfusion - discuss with Consultant Neonatologist and Paediatric nephrologists

Reduction in total K+

Guideline agreed with consensus from Neonatologists, Nephrologists and Pharmacists.

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Stepwise Approach to Management of Hyperkalaemia

(see full guidelines for details of each step)

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Record: 204

To provide a guide to the stepwise management of a neonate with hyperkalaemia. Treatment should be carried out alongside investigations into the underlying cause.

Clinical condition:

Hyperkalaemia in a neonate

Target patient group: Neonates
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. Neonatal Formulary 7th Edition 2015. BMJ Books. www.neonatalformulary.com 
  2. Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press, and RCPCH Publications <https://www.medicinescomplete.com> [Accessed on 19 July 2019]
  3. Uga N. Pediatr Int. Dec 2003;45(6):656-60. Antenatal steroid treatment prevents severe hyperkalaemia in very low birth weight infants.
  4. Grammatikopoulosa T. Acta Pediatr 2003;92(1):118-20. Benefits and risks of calcium resonium therapy in hyperkalaemic preterm infants.
  5. Mahony BA. Cochrane database of systematic reviews 2005 Apr. Emergency interventions for Hyperkalaemia.

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Approved By

Neonatology and Renal Medicine

Document history

LHP version 2.0

Related information

Not supplied

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