Should we Remove Calcium from our Resus Trolleys?

It was the paradigm par excellence, the first emergency measure for hyperkalaemia with ECG changes or arrhythmias: the administration of calcium gluconate.

However, this recently published, large systematic review changes everything. And it was already obvious before, but no one simply looked closely enough:

“There was no evidence to support a clinical beneficial effect of calcium for treatment of hyperkalaemia.”

This review examined 101 studies published up to 2024 to determine which pharmacological drugs are truly effective in acute hyperkalaemia. Two of these studies examined this in patients with cardiac arrest.

The result of this work was sobering and clear. Neither calcium gluconate nor bicarbonate resulted in a relevant reduction in potassium levels. It is repeatedly stated that calcium stabilises membranes, based on studies from the 1960s. However, even the presumed “membrane stabilisation” does not seem to be truly verifiable. 
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Calcium gluconate did not improve hyperkalaemia-related ECG changes and even had a worse outcome in the context of resuscitation!

Calcium-Gluconate

• There is NO clinical benefit of calcium in the treatment of hyperkalaemia
• ​There is NO evidence of an improvement in ECG changes
• Calcium gluconate during resuscitation was even associated with a worse outcome

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Bicarbonate

• There is NO evidence of any clinically relevant benefit of bicarbonate
• Bicarbonate has NO effect on potassium levels

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Insulin-Glucose-Infusion

• Insulin and glucose are effective in treating hyperkalaemia, with an average reduction in potassium of 0.7–1.2 mmol/L.

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​Beta-Agonists (Salbutamol/Albuterol)

• Inhaled administration lowers potassium levels by an average of 0.9 mmol/L
  
• Intravenous administration of salbutamol with insulin lowers potassium most efficiently (by an average of 1.2 mmol/L)

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NEW ILCOR-Guidelines 2025 on the Treatment of Hyperkalaemia

• Intravenous Insulin and Glucose, Beta-Agonists or the combination of both are clearly recommended.

• Routine use of Sodium-Bicarbonate is NOT recommended (very low evidence).
• No clear Recommendation for Calcium-Gluconate (very low evidence)
• ​For the usage of Calcium-Gluconate during cardiac arrest there is simply insufficient evidence and the possibility of harm

Read the article: Review Article - ILCOR 2025