1. DYSKALEMIAS PROF S.SHIVAKUMAR`S UNIT DR.J.BHARATH MD PG

2. HYPOKALEMIA MILD: 3.5-3.0 Meq/L MODERATE: 2.9-2.5 Meq/L SEVERE: BELOW 2.5 Meq/L

3. HYPOKALEMIA CAUSES REDISTRIBUTION OF K –INSULIN –SYMPATHETIC STIMULATION ALCOHOL WITHDRAWEL,MI,HEAD INJURY. –DRUGS THEOPHYLINE, RITODRINE, PSEUDOEPHEDRINE, CAFFEINE. –HYPOKALEMIC PERIODIC PARALYSIS MAGNESIUM DEFICIENCY

4. CAUSES CONT… NON-RENAL LOSS DIARRHEA,VOMITING. RENAL-LOSS DIURETICS STEROID –HYPERALDOSTERNISM,CUSHING SYNDROME. LIDDLE SYNDROME BARTER SYNDROME. GITELMAN SYNDROME. SPURIOUS HYPOKALEMIA.

5. MANIFESTATIONS ECG CHANGES AND ARRHYTHMIAS MUSCLE WEAKNESS –RESPIRATORY PARALYSIS RENAL TUBULAR DYSFUNCTIONS HEPATIC ENCEPHALOPATHY PARALYTIC ILEUS

6. MANAGEMENT PRINCIPLES CORRECTION OF DEFICIT AND MINIMIZING ON GOING LOSSES. TRANS-CELLULAR SHIFT SHOULD BE SUPLEMENTED ONLY WHEN MANIFESTATIONS+ SLOW CORRECTION-USUALY. RAPID CORRECTION-ONLY IN EMERGENCY. CORRECTION OF TOTAL DEFICIT TO BE DONE OVER A PERIOD. CONCOMITANT MAGNESIUM DEFICIENCY SHOULD BE ADDRESSED

7. MANAGEMENT CONT… WHEN TO CORRECT? BETWEEN 3.0 AND 3.5 ONLY IN SYMPTOMATIC. BELOW 3.0 EVEN IN ASYMPTOMATIC. IN HIGH + RISK PATIENTS [CCF,IHD,MI,ARRHYTHMIAS,ON DIGITALIS, SEVERE HEPATIC DISEASES, MILD TO MOD SHT] TARGET LEVEL IS MORE THAN 4 Meq/L

8. MANAGEMENT CONT… BY WHICH FORM OF K+ KCl IS THE PREPARATION OF CHOICE SINCE 1.CORRECT ASSOCIATED METABOLIC ALKALOSIS DUE TO CHLORIDE LOSS THERE BY PREVENTS KALIURESIS. 2.FASTER RATE OF CORRECTION OF K+ THAN ALL OTHER. 3.OTHER PREPARATIONS CAN PRECIPITATE / AGGRAVATE METABOLIC ALKALOSIS. POT PHOSPHATE IN HYPOKALEMIA AND HYPO PHOSPHATEMIA. POT BICARB IN HYPOKALEMIA WITH SEVERE METABOLIC ACIDOSIS..

9. MANAGEMENT CONT… STRENGTH OF PREPARATION KCL ELIXIR- 15 ML = 20 Meq IV KCL- 1 ML = 2 Meq

10. MANAGEMENT CONT… BY WHICH ROUTE? WHEN THERE ARE SIGNS AND /OR SYMPTOMS OF HYPOKALEMIA,OR CAN'T TAKE ORALLY IV. OTHERWISE ORAL CORRECTION. VEHICLE SOLUTION SHOULD BE DEXTROSE FREE. 0.9% NS IS THE PREFERED ONE. RL IN SELECTED CONDITIONS.

11. MANAGEMENT … CONT CALCULATING TOTAL DEFICIT. FOR EACH 0.27 Meq/L FALL IN SE K+ THERE WILL BE 100 Meq/L OF K+ LOST FROM THE BODY. –Eg; IF SE K+ IS 3.0 Meq/L TOTAL K+ LOSS IS AROUND 200Meq/ L. TOTAL CORRECTION SHOULD BE DONE OVER SEVERAL DAYS AND NOT IN A SINGLE DAY.

12. MANAGEMENT CONT… HOW MUCH CAN BE GIVEN IN A DAY? USUALLY 80-120 Meq/DAY. MAXIMUM: 150 Meq.

13. MANAGEMENT CONT… HOW MUCH TO ADD WITH EACH PINT? –USUALLY 10-20 Meq/PINT –IN EMERGENCY UPTO 200 Meq/PINT –<30 Meq/PINT CAN BE INFUSED THROUGH PERIPHERAL VEIN. –>30 Meq/PINT REQUIRE CENTRAL VEIN. –FEMORAL VEIN PREFERRED.

14. HYPOKALEMIA CONT… RATE OF FLOW 10-20 Meq/HOUR –USUALLY RECOMMENDED. MAX RATE OF INFUSION-40-100 Meq/HOUR. ONLY FOR SHORTER PERIOD. –IF MORETHAN 20 Meq/ HOUR GIVEN ECG MONITORING REQD.

15. MANAGEMENT CONT ORAL THERAPY KCL ELIXER 15 ML-8 TH HOURLY TO 15 ML 4 TH HOURLY.

16. MANAGEMENT CONT… OTHER MEASURES –TO AVOID RENAL LOSS. K+ SPARING DIURETICS,ACEI,ARB, LOW Na INTAKE. –TO AVOID UGI LOSS. PROTON PUMP INHIBITORS. –TO AVOID INTRA CELLULAR SHIFT DUE TO SYMPATHETIC OVER ACTIVITY. AS IN HEAD INJURY THYROTOXIC PREIODIC PALSY,HEAD INJURY,THEPHYLINE OVERDOSE- BETA BLOCKER CAN BE USED.

17. HYPERKALEMIA CAUSES: 1REDUCED RENAL EXCRETION RENALFAILIURE, RTA,HYPOALDOSTERONISM. 2.EXESSIVE INTAKE 3.BLOOD TRANSFUSION INDUCED. 4.TISSUE NECROSIS. 5.REDISTRIBUTION. 6.DRUGS NSAIDS,ACEI,ARB,CYCLOSPORIN,TACROLIMUS, DIGOXIN,SUCCINYL CHOLINE, EAC.

18. MANAGEMENT HYPERKALEMIA > 6 Meq/L WITH ECG CHANGES – MEDICAL EMERGENCY. SHOULD BE TREATED URGENTLY. ACUTE MANAGEMENT. ANTAGONISM OF CARDIAC EFFECT- IV CALCIUM. REDISTRIBUTION INTO CELLS- 1. INSULIN AND GLUCOSE 2. B-2 AGONISTS. 3. SODIUM BICARBONATE. DIALYSIS. WITH SLOW ONSET OF ACTION. DIURETICS. MINERELO CORTICOIDS. CATION-EXCHANGE RESINS.

19. MANAGEMENT CONT… CALCIUM- FIRST LINE DRUG IN EMERGENCY MANAGEMENT. RISES ACTION POTENTIAL THRESHOLD AND REDUCES EXCITABLITY WITHOUT CHANGING RESTING MEMBRANE POTENTIAL. PREPARATIONS AVAILABLE. –CALCIUM GLUCONATE,CALCIUM CHLORIDE. AVAILABLE STRENGTH. –10 ML AMPULES OF 10% SOLUTION.

20. MANAGEMENT CONT… DOSE 10 ML OF 10% CALCIUM GLUCONATE /3-4 ML OF CaCl2 OVER 2-3 MIN-UNDER ECG MONITORING. EFFECT STARTS IN 1-3 MIN. LASTS FOR 30-60 MIN. CAN BE REPEATED IF –NO CHANGE IN ECG FINDING, OR RECUR AFTER INITIAL IMPROVEMENT. CAUTION IF Pt IS ON DIGOXIN, ABOVE DOSE CAN BE ADDED TO 100ML 5%D-INFUSED OVER 20-30 MIN. FOR CaCl2 INFUSION –CENTRAL VEIN IS A MUST.

21. MANAGEMENT CONT… INSULIN-GLUCOSE. –DOSE 10 U OF REGULAR INSULIN IN 500 ML OF 10% D. INFUSED OVER 60 MIN. OR 10 U REGULAR INSULIN IV BOLUS FOLLOWED BY 100 ML OF 25% D. IF BLOOD SUGAR >200Mg% INSULIN ALONE ADMINISTERED WITHOUT ADDING DEXTROSE. EFFECT STARTS 10-20 MIN. LASTS FOR 4-6 HOURS.

22. MANAGEMENT CONT… CAN BE REPEATED IF NEEDED. EXPECTED FALL 0.5-1.2 Meq/L CAUTION HYPOGLYCEMIA ESPECIALLY WITH BOLUS INSULIN.

23. MANAGEMENT CONT.. BETA 2 AGONISTS ACTS BY ACTIVATING Na/K-ATPase. 10-20 Mg OF NEBULIZED SALBUTAMOL IN 4ML NS. OR 0.5 Mg OF SALBUTAMOL IN 100 ML 5% D IV OVER 10-15 MIN. ACTION STARTS AFTER NEBULIZATION-30 MIN. AFTER IV-WITHIN FEW MIN. ACTION LASTS FOR2-6 HOURS. EXPECTED FALL OF K+ 0.5-1.0 Meq/L FOR IV OR INHALATION. INSULIN + SALBUTAMOL=> 1.2-1.5 Meq/L.

24. MANAGEMENT CONT… SODIUM BICARBONATE. AS A SINGLE AGENT -NO ROLE. MAY HAVE SOME EFFECT IN ACIDEMIA WITH HYPERKALEMIA.

25. MANAGEMENT CONT… DIALYSIS DEFINITIVE AND MOST EFFECTIVE METHOD. HD IS MORE EFFECTIVE THAN PD IN ACUTE SETTING.

26. MANAGEMENT CONT… DIURETICS MORE EFFECTIVE IN LOW RENAL EXCRETORY STATES. ORAL TORSEMIDE, IV FUROSEMIDE ALONE OR ALONG WITH THIAZIDE ARE THE PREPARATIONS OF CHOICE.

27. MANAGEMENT CONT.. MINERALO CORTICOIDS MORE USEFUL IN CHRONIC HYPERKALEMIA. DOSE 0.1-0.3 Mg/DAY OF FLUDROCORTISONE. REDUCTION IN SE K+ - 0.7 Meq/L.

28. MANAGEMENT CONT… CATION EXCHANGE RESINS. USED IN CHRONIC HYPERKALEMIA. KAYEXALATE-SODIUM POLYSTYRENE SULFONATE. EXCHANGE Na+ FOR K+ IN COLON. ORAL OR ENEMA. ORAL DOSE 15-30 G IN WATER OR IN 70% SORBITOL. DOSE OF ENEMA 30-50 G IN 100 ML AQUEOUS SOLUTION. ACTION STARTS AFTER 4 HOURS. REDUCE K+ LEVEL BY 0.8 - 1.0 Meq/L. –CAUTION MAY CAUSE ISCHEMIC COLITIS OR COLONIC NECROSIS.