1. Hypokalemia & Hyperkalemia
Laila Tavazo, REM

2. Distribution of potassium
The intracellular concentration of potassium ranges from 140 to 150 meq/L.
The extracellular concentration of potassium meq/L.

3. Electrolyte disorders of potassium
Hyperkalemia is the most dangerous acute electrolyte abnormality Serum K level > 5.0 meq/L
Hypokalemia is the most common electrolyte abnormality Serum K level < 3.5 meq/L

4. Five Most Common Causes of Hypokalemia
Renal losses
Diuretic use, drugs, steroid use, metabolic acidosis, hyperaldosteronism, renal tubular acidosis, diabetic ketoacidosis, alcohol consumption
Increased nonrenal losses
Sweating, diarrhea, vomiting, laxative use
Decreased intake
Ethanol, malnutrition
Intracellular shift
Hyperventilation, metabolic alkalosis, drugs
Endocrine
Cushing’s disease, Bartter’s syndrome,
insulin therapy

5. Hypokalemia causes

7. Clinical features Non specific complaint: Neuromuscular:
Palpitations, Skeletal muscle weakness or cramping, Depression, Easy fatigue ability
Neuromuscular:
Paralysis, paresthesia fasciculation, decreased tendon reflexes , confusion, respiratory failure
Cardiovascular:
Heart block, AF, VF, Asystole, Cardiac arrest, ↑sensitivity to digoxin toxicity
GI:
Constipation4, nausea or vomiting , anorexia, abdominal cramp, paralytic ileus
Renal:
polyuria, nocturia, or polydipsia,

8. Diagnostic strategy Clinical presentation Measurement of serum K level
ECG

9. ECG findings

10. Management of hypokalemia
Increasing the intake of foods high in potassium content
Oral potassium supplements
Giving potassium intravenously when rapid replacement is needed.

11. Oral replacement
Oral replacement is available in liquid, powder, and tablet form. Potassium chloride is the most commonly used supplementation, and 40 to 60 mEq orally every 2 to 4 hours is typically well tolerated.
it is easy to administer, safe, inexpensive, and readily absorbed from the GI tract

12. Management
Transient, asymptomatic, or mild hypokalemia may resolve spontaneously or may be treated with enteral potassium supplements.
Outpatient therapy and follow-up in hours may be acceptable for mild hypokalemia patients with no underlying heart disease.

13. IV Management cardiac monitoring is necessary in patients with
profound hypokalemia (< 2.5 meq/L), or
if cardiac arrhythmias are present, or
if IV potassium is going to be rapidly administered.
IV potassium should normally be diluted in saline solution so that the maximum concentration is 40 meq/L (peripheral lines) or 60 meq/L (central lines) and IV potassium.

14. IV infusion rate for severe or symptomatic hypokalemia
Standard IV replacement rate
meq/h
Serum potassium < 2.5 meq/L, or
Moderate-severe symptoms
meq/h
Serum potassium < 2.0 Meq/L, or
Life-threatening symptoms
> 40 meq/h .

15. Management of hypokalemia
Potassium replacement therapy is immediately indicated for:
Severe hypokalemia (< 2.5 meq/L), or
If the hypokalemia is causing muscle paralysis, or
Malignant cardiac arrhythmias .

16. Magnesium Replacement Therapy
Magnesium replacement therapy is often necessary in malnourished alcoholics with hypokalemia.
Hypomagnesemia should be suspected if the serum potassium does not increase within ~ 96 hours of the commencement of potassium supplementation therapy.

17. Five Most Common Causes of Hyperkalemia
Spurious elevation
Hemolysis due to drawing or storing of the laboratory sample or post–blood sampling leak from markedly elevated white blood cells, red blood cells, or platelets
Renal failure
Acute or chronic
Acidosis
Diabetic ketoacidosis, Addison’s disease, adrenal insufficiency, type 4 renal tubular acidosis
Cell death
Rhabdomyolysis, tumor lysis syndrome, massive hemolysis or transfusion, crush injury, burn
Drugs
Beta-blockers, acute digitalis overdose, succinylcholine, angiotensin-converting enzyme inhibitors, angiotension receptor blockers, nonsteroidal anti-inflammatory drugs, spironolactone, amiloride, potassium supplementation

18. Clinical features Cardiovascular Neuromuscular: GI: cardiac arrhythmia
heart blocks, Brady dysrhythmias, pseudo infarction ST segment elevation, and the classic “sine wave” pattern.
Neuromuscular:
Muscle cramps, generalized weakness, paresthesia, tetany, and focal or global paralysis
GI:
nausea, vomiting, and diarrhea

19. ECG findings

20. Hyperkalemia with QRS widening merging into T wave, absent P wave.

21. Hyperkalemia after potassium-lowering therapy has begun
Hyperkalemia after potassium-lowering therapy has begun. Tall peaked T waves, decreased P wave.

22. The same patient after dialysis. The electrocardiogram is now normal.

23. Treatment of Hyperkalemia
MEDICATION
FEATURES
Stabilize cardiac membrane
Calcium chloride (10 mL, maximum 20 mL) or calcium gluconate (10-30 mL), IV push
For wide QRS, restores the electrical gradient; does not decrease serum Potassium
Shift potassium into cells
Insulin, 10 units, IV push, combined with 100 mL of 50% dextrose, IV push High-dose nebulized albuterol by face mask (15-25 mg by continuous inhalation) Bicarbonate mL Normal saline mL
If severely acidotic In conjunction with nephrologist if dialysis dependent
Remove potassium from the body
Hemodialysis Normal saline and furosemide Ion exchange resin
Emergently in cardiac arrest, urgently in renal failure; may delay if renal function is normal In patients with rhabdomyolysis or tumor lysis syndrome with intact urine output Not effective acutely

24. Thanks for your kind attention