Treatment of severe hyperkalemia should meet three basic stages. The first is stabilizing the myocardium - which has decreased its susceptibility to cardiac arrhythmias - with intravenous administration of 10% calcium gluconate over 3-5 minutes and ECG monitoring. The effects can be observed when the infusion starts, and duration of action is 30 to 60 minutes. The second stage consists of diverting potassium to intracellular space with insulin (10 U in 25 g glucose); β2 agonists, such as nebulization of salbutamol (10-20 mg in 4 mL saline and sodium bicarbonate solution), are used if the patient is in metabolic acidosis. The administration of insulin/glucose decreases plasma potassium levels in 15 to 30 minutes after the start of infusion, and duration of action is 2 hours. Salbutamol is the most widely used β2 agonist for hyperkalemia treatment. It is administered by nebulization, has a rapid onset of action, and the effects can be noticed 30 minutes after starting administration. Salbutamol may also be administered intravenously at a dose of 0.5 to 2.5 mg. The effects of different routes of administration in serum potassium are not well defined; however, complications such as tachycardia, increased blood pressure, and palpitations are more common with intravenous administration. Salbutamol may be used concomitantly with insulin, whose effects are potentiated. The effect of sodium bicarbonate on hiperkalemia is less than that of insulin and β2 adrenergic receptors and seems to occur only in the presence of metabolic acidosis.