<prompt> A girl presented with severe hyperkalemia and peaked T waves on ECG. Fastest way of shifting potassium intracellularly is -Calcium gluconate IVOral resinsInsulin glucoseSodium bicarbonate  <response>: Ans. is c i.e., Insulin glucose Tall T waves on ECG indicate cardiac manifestation of hyperkalemia.Intravenous calcium gluconate is the first drug to be administered in a patient with hyperkalemia having E.C.G. abnormalities. - It stabilizes the myocardium immediately. - It acts within minutes and is characterized by improvement in E. C. G. appearance.But an important point to noteIt does not affect transcellular movement of potassium. Thus it wont help in reducing the hyperkalemia.Among the agents which cause transcellular intracellular movement of potassium.Intravenous insulin is the fastest way to lower serum potassium levelsThe goals of the therapy for the tt of acute hyperkalemia in chronological order are as follows:-Antagonize the affect of K on excitable cell membranesRedistribution of extracellular potassium into cellsEnhance elimination of potassium from the bodyAntagonize the effect of potassium on excitable cell membraneCalcium directly antagonizes the myocardial effect of hyperkalemia.It does so by reducing the threshold potential of cardiac myocytes.Calcium for injection is available as chloride or gluconate salt.The preferred agent is the gluconate salt since it is less likely than calcium chloride to cause tissue necrosis.The onset of action is 3 minutes.The duration of action is 30-60 minutes during which time further measures may be undertaken to lower pK.Redistribution of potassium into cells InsulinInsulin shifts potassium into cells.Potassium shift inside the cells is mediated by Na K ATPase.I. V. insulin is the fastest way to lower serum potassium level Q.The onset of action is 15 minutes and the effect is maximal bw 30-60 minutes.Dextrose is given along with insulin to prevent hypoglycemia.It was believed that administration of dextrose alone, can cause shift of potassium inside the cells by promoting insulin release.The administration of hypertonic dextrose alone for hyperkalemia is not recommended for two reasonsEndogenous insulin levels are unlikely to rise to the level necessary for a therapeutic effect.There is a risk of exacerbating hyperkalemia by inducing hypertonicity. b adrenoceptor agonistsThese drugs can also cause movement of potassium inside the cell.High dose albuterol shows their effect in 30 minutes and persists for at least 2 hours,The effect of insulin is additive with that of albuterol.Patients taking nonselective b adrenoceptor blockers will be unlikely to manifest the hypokalemic effects of albuterolEven among patients not taking b blockers as many as 40 seem to be resistant to the hypokalemic effect of albuterol.The mechanism for this resistance is unknown and currently, there is no basis for predicting which patients will respond.For this reason albuterol should never be used as a single agent for the treatment of urgent hyperkalemia. BicarbonateBicarbonate as a bolus injection was used in the emergency tt of hyperkalemia. Ironically this dogma was based on studies using a prolonged 4-6 hrs infusion of bicarbonate.It has now been demonstrated that short term bicarbonate infusion does not reduce pK in patients with dialysis dependent kidney failure, implying that it does not cause Kshift into cells.Sodium bicarbonate seems to have no effect to shift K into cells even after several hours.It is likely to be effective especially in combination with a diuretic drug in enhancing urinary K elimination in patients with some kidney function, although it use for this purpose has not been evaluated.Elimination of potassium from the bodyHyperkalemia occurs most often in patients with renal insufficiency.However renal potassium excretion may be enhanced even in patients with significant renal impairment by increasing the delivery of solute to the distal nephron.Sodium bicarbonateA sodium bicarbonate infusion administered during 4-6 hrs at a rate designed to alkalinize the urine may enhance urinary K excretion and would be desirable especially in patients with metabolic acidosis.The risk of volume expansion with the bicarbonate infusion can be mitigated by use of loop acting diuretics which would, be likely to enhance the kaliuresis.Exchange resinSodium polystyrene sulfonate is a cation exchange resin.In the lumen of intestine it exchanges sodium for secreted potassium.Most of this exchange takes place in the colon, the site of most potassium secretion in the gut.There are two concerns with the use of resin in the tt of urgent hyperkalemiaThe first is its slow effectWhen given orally, the onset of action is at least 2 hrs and the maximum effect may not be seen for more than 6 hrs.The second is its adverse effectIt can cause intestinal necrosis DialysisHemodialysis is the method of choice for removing potassium from the body.The rate of potassium removed with peritoneal dialysis is much slower than with hemodialysis. 