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NICU guideline identifier

Hyperkalaemia in the neonate

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If you consider treatment for hyperkalaemia, discuss with the specialist on call.

Definition and diagnosis

  • Hyperkalaemia is defined as a serum potassium concentration greater than 7 mmol/L1
  • Hyperkalaemia is common when capillary blood samples are haemolysed. The first step should be to confirm high serum K+ with a non-haemolysed venous or arterial sample.
  • ECG changes (peaked T waves, broad QRS complexes, and arrhythmias) indicate significant hyperkalaemia and require urgent treatment with calcium gluconate.2


  • Hyperkalaemia in the NICU is most commonly associated with non-oligurigic hyperkalaemia in the first 72 hours of life of the very preterm infant. Immature function of the erythrocyte Na/K - ATPase is believed to be the reason for non-oliguric hyperkalaemia.
  • Oliguric renal failure (e.g.: due to hypoxic event, drug error or renal tubular acidosis) or haemolysis are other causes for hyperkalaemia.3
  • Hyperkalaemia is believed to be exacerbated by:
     - metabolic acidosis, due to exchange of intracellular K+ with extracellular H+
     - renal impairment and hypovolaemia


ECG changes:

  • Peaked T-waves
  • Prolonged PR interval
  • Broadened QRS complexes
  • Disappearing of the P-wave
  • Arrhythmias
  • Ventricular tachycardia and impaired AV conduction.


1.  10% Calcium Gluconate

Dose: 0.5 mL/kg IV (0.1 mmoL/kg) over 10-30 min. The dose of calcium gluconate may be repeated.
Effect: Stabilizes myocardial membrane potential, should be given if the infant is at risk of, or has ECG changes and/or arrhythmias.
Side effects:  Cardiac arrhythmias and seizures with severe hypercalcaemia.

2.  Stop IV K+

Remove K+ from IV (i.e.: replace TPN with 10% glucose with Na+)

3.  IV Glucose and Insulin

Dose: Glucose: 8-16 mg/kg/min (e.g.: 2.5-5 ml/kg/hr 20% glucose (20 ml of 50% glucose and 30 ml of water in a 50 ml syringe)) in addition to maintenance fluid, aim for blood glucose concentration (BGC) > 12 mmol/l. When BGC >12 mmol/L, start insulin infusion (0.1-0.6 units/kg/hr).3,4
Effect: Shift of ionized K+ from the extracellular to the intracellular space. K+ is transported over the membrane in combination with glucose.
Side effects:  Hypoglycaemia, hyperglycaemia

4.  Salbutamol

Dose: Intravenous: 4 micrograms/kg over 10 min or nebulized via ETT: 400 micrograms/dose (made up to a total of 4 ml with normal saline) up to 2 hrly.3,5,6
N.B Be aware: salbutamol comes in two different preparations, for IV administration and as sterinebs: they are not interchangeable !
Effect: Salbutamol is a beta-adrenergic agonist and stimulates the membrane Na+/K+ - ATPase. Singh et al report a small randomized trial of nebulized salbutamol compared with saline for very preterm infants. Nebulized salbutamol reduced plasma K+ rapidly with no adverse effects noted.5
Side effects:  Tachycardia, hypertension, tremor, hypokalaemia, hyperglycaemia. Inhaled Salbutamol seems to be generally well tolerated.  5,6

5.  Sodium bicarbonate

Correction of an existing metabolic acidosis can be considered

Dose: Sodium bicarbonate dose (mL) = base deficit x 0.6 x weight (kg).
Effect: May facilitate shift of K+ from the extracellular to the intracellular space.
Side effects:  Increased vascular volume, serum osmolarity, serum sodium, hypercapnia and respiratory acidosis, hypocalcaemia, oedema, congestive heart failure, hyperirritability, intraventricular haemorrhage.

6.  Resonium

Should be avoided in preterm infants

Dose: 0.5 - 1 g/kg rectally
Effect: Binds intestinal K+ and prevents intestinal absorption.
Side effects:  Intestinal perforation and constipation in preterm infants.7 IV Salbutamol seems more effective than resonium.6

7.  Exchange transfusion or peritoneal dialysis


  1. Gruskay J, Costarino AT, Polin RA, Baumgart S. Nonoliguric hyperkalemia in the premature infant weighing less than 1000 grams. J Pediatr. 1988;113:381-6.
  2. Lista G, Bastrenta P, Castoldi F, Meneghin F, Zuccotti G. Severe bradycardia in an extremely low birth weight preterm infant with hyperkalaemia. Resuscitation [Internet]. European Resuscitation Council, American Heart Association, Inc., and International Liaison Committee on Resuscitation.; 2011;82:640-1.
  3. Vemgal P, Ohlsson A. Interventions for non-oliguric hyperkalaemia in preterm neonates. Cochrane database Syst Rev. 2012;5:CD005257.
  4. Hu PS, Su BH, Peng CT, Tsai CH. Glucose and insulin infusion versus kayexalate for the early treatment of non-oliguric hyperkalemia in very-low-birth-weight infants. Acta Paediatr Taiwan;40:314-8.
  5. Singh BS, Sadiq HF, Noguchi A, Keenan WJ. Efficacy of albuterol inhalation in treatment of hyperkalemia in premature neonates. J Pediatr. 2002 ;141:16-20.
  6. Yaseen H, Khalaf M, Dana A, Yaseen N, Darwich M. Salbutamol versus cation-exchange resin (kayexalate) for the treatment of nonoliguric hyperkalemia in preterm infants. Am J Perinatol. 2008;25:193-7.
  7. Setzer ES, Ahmed F, Goldberg RN, Hellman RL, Moscoso P, Ferrer PL, et al. Exchange transfusion using washed red blood cells reconstituted with fresh-frozen plasma for treatment of severe hyperkalemia in the neonate. J Pediatr. 1984;104:443-6.

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Document Control

  • Date last published: 01 August 2015
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years