• Mean change in the serum potassium level from baseline to 180 minutes and 24 hours [ Time Frame: 180 minutes and 24 hours ]
• Proportion of patients who had a serum potassium level of 4 mmol/l to less than 4.9 mmol/l at 60, 180 minutes and 24 hours [ Time Frame: 60 minutes, 180 minutes and 24 hours ]
• Proportion of patients who require re-treatment or dialysis at 60, 180 minutes and 24 hours [ Time Frame: 60 minutes, 180 minutes and 24 hours ]
• Proportion of patients with adverse effects at 60 and 180 minutes [ Time Frame: 60 minutes and 180 minutes ]
  Proportion of patients with adverse effects at 60 and 180 minutes :

  1. Hypokalemia (serum potassium level <3.5 mmol/l and <4 mmol/l)
  2. Hypomagnesemia (serum magnesium level of less than 0.58 mmol per liter)
  3. Hypoglycemia (serum glucose level < 4.0 mmol/l)
  4. Hyperglycemia (serum glucose level > 10.0 mmol/l)
  5. Gastrointestinal disorders:

  i. Diarrhea ii. Nausea iii. Vomiting f. Tachycardia (> 130/min) g. Tremor
• Proportion of patients with heart rhythm disorders or high grade atrioventricular bloc that required urgent medication during the first 180 minutes [ Time Frame: 180 minutes ]
• Proportion of patients with electrocardiographic abnormalities, at 60, 180 minutes and 24 hours [ Time Frame: 60 minutes 180 minutes and 24 hours ]
  Proportion of patients with electrocardiographic abnormalities, at 60, 180 minutes and 24 hours , including:

  1. Auricular extrasystoles
  2. Ventricular extrasystoles
  3. Atrioventricular block
  4. QRS Interval Prolongation (> 120 ms)
  5. QT interval prolongation (> 500 ms)
• Proportion of major cardiovascular events at 60, 180 minutes and 24 hours [ Time Frame: 60minutes 180 minutes and 24 hours ]
  Proportion of major cardiovascular events at 60, 180 minutes and 24 hours :

  1. cardiac arrest
  2. stroke
  3. acute heart failure
  4. complete atrioventricular block with ventricular rate under 30 bpm
  5. ventricular fibrillation
  6. ventricular tachycardia

Hyperkalemia is a common electrolyte disorder, especially among patients with chronic kidney disease, diabetes mellitus, or heart failure. Globally, the reported incidence of hyperkalemia varies from 1.1 to 10 per 100 hospitalizations, depending on the patient cohort and comorbidities. Hyperkalemia is a potentially life-threatening electrolyte disturbance that can be fatal if left untreated. Several studies have established the association between hyperkalemia and all-cause mortality. Because of the deleterious cardiac effects of hyperkalemia, its management is an emergency intervention. However, robust evidence is lacking to guide the emergency management of patients with hyperkalemia. Emergency treatment approaches are largely based on small studies, anecdotal experience, and traditionally accepted practice patterns within institutions. Therefore, a rigorous evaluation of the first-line treatments of hyperkalemia in emergency departments is needed and a large scale randomized clinical trial is warranted before robust recommendations for clinical practice can be made. Our clinical trial will improve the safety of patients with acute hyperkalemia and will help clinicians in their day by day practice to choose the treatment that significantly reduces morbidity and mortality during acute hyperkalemia management. Our results will be delivered in a timely fashion, owing to the high prevalence of hyperkalemia in the emergency department setting and to the commitment of the INI-CRCT network of Excellence, along with ED specialists used to work jointly.

the primary objective of our trial is to compare insulin/dextrose intravenous infusion, nebulized salbutamol or combination of nebulized salbutamol and insulin/dextrose intravenous infusion to reduce serum potassium concentration at 60 minutes, as first-line treatment, in emergency departments.

• Drug: Salbutamol
  10 mg of salbutamol nebulized in 30 minutes (with oxygen 8 liters per minute or with air) 10 units of regular insulin (rapid-acting, insuline asparte, intravenous injection) as an intravenous bolus with 500 ml of 10% dextrose in water administered over a 30-minute period.
  Other Name: Salbutamol and Hyperkaliemia
• Drug: Insulin Aspart

  Patients in the experimental group will receive either:

  1. 10 mg of salbutamol nebulized in 30 minutes (with oxygen 8 liters per minute or with air); OR
  2. 10 units of regular insulin (rapid-acting, insuline asparte, intravenous injection) as an intravenous bolus with 500 ml of 10% dextrose in water administered over a 30-minute period plus 10 mg of salbutamol nebulized in 30 minutes (with oxygen 8 liters per minute or with air). The nurse will start by giving the 10 units of insulin and the dextrose, and then, immediately, she will start the nebulization of salbutamol.
  Other Name: Insulin and Hyperkaliemia

• Experimental: Salbutamol
  Patients in this experimental group will receive : 10 mg of salbutamol nebulized in 30 minutes (with oxygen 8 liters per minute or with air);
  Intervention: Drug: Salbutamol
• Active Comparator: Insuline + dextrose
  Patients in the experimental group will receive : 10 units of regular insulin (rapid-acting, insuline asparte, intravenous injection) as an intravenous bolus with 500 ml of 10% dextrose in water administered over a 30-minute period
  Intervention: Drug: Insulin Aspart
• Experimental: Insuline + Dextrose + Salbutamol

  Patients in the experimental group will receive either:

  1. 10 mg of salbutamol nebulized in 30 minutes (with oxygen 8 liters per minute or with air); OR
  2. 10 units of regular insulin (rapid-acting, insuline asparte, intravenous injection) as an intravenous bolus with 500 ml of 10% dextrose in water administered over a 30-minute period plus 10 mg of salbutamol nebulized in 30 minutes (with oxygen 8 liters per minute or with air). The nurse will start by giving the 10 units of insulin and the dextrose, and then, immediately, she will start the nebulization of salbutamol.
  Interventions:

  • Drug: Salbutamol
  • Drug: Insulin Aspart

Inclusion Criteria:

• Patient older than 18 years old
• Patient admitted to the emergency department,
• Patient with local laboratory serum potassium level superior or equal to 6 mmol/l,
• Patient who provide written informed consent prior to participation in the study

Exclusion Criteria:

• Hemolysis or thrombocytosis > 106/mm3 or hyperleukocytosis > 105/mm3 on the first blood sample suspecting a pseudohyperkalemia,
• Diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome,
• Pregnant or lactating woman, women with childbearing potential who didn't have effective contraception*,
• Patient expected to require emergency intubation and ventilation,
• Patient expected to require dialysis, diuretics or bicarbonate within the first 60 minutes,
• Patient with heart rhythm disorders or high grade atrioventricular bloc who require urgent medication as soon as admission or serum potassium level result,
• Hypersensitivity to the tested active substance or excipients,
• Acute coronary syndrome,
• Patient not affiliated to a health insurance plan,

• Patient under guardianship, curatorship or safeguard of justice.

  • The contraceptives considered as highly effective and acceptable by CTFG recommendations will be considered effective under this protocol. The list of contraceptives considered as highly effective and acceptable by CTFG recommendations is detailed in Appendix 7