Hypokalemia-causesHypokalemia-causes

Decreased K intakeDecreased K intake– Low calorie diets – rareLow calorie diets – rare

Increased K entry into cellsIncreased K entry into cells– AlkalosisAlkalosis– Increased insulinIncreased insulin– Increased CatecholaminesIncreased Catecholamines– ChannelopathiesChannelopathies– Increased RBC productionIncreased RBC production– HypothermiaHypothermia– Chlorquine intoxChlorquine intox

HypokalemiaHypokalemia Increased GI lossesIncreased GI losses

– Vomiting, Diarrhea, NG tube, laxatives Vomiting, Diarrhea, NG tube, laxatives Increased Urinary lossesIncreased Urinary losses

– DiureticsDiuretics– Mineralocorticoid excessMineralocorticoid excess– Nonreabsorbable ionsNonreabsorbable ions– Metabolic acidosisMetabolic acidosis– HypoMgHypoMg– NephropathiesNephropathies– Ampho BAmpho B– PolyuriaPolyuria– LicoriceLicorice

HypokalemiaHypokalemia

Increased Sweat LossesIncreased Sweat Losses DialysisDialysis PlasmaphoresisPlasmaphoresis

PresentationPresentation

Neuro muscular K 2-2.5Neuro muscular K 2-2.5– Weakness prox > distal, loss of reflexesWeakness prox > distal, loss of reflexes

CardiacCardiac– ArrhythmiasArrhythmias– EKGEKG

U waves, prolonged QT, small T waveU waves, prolonged QT, small T wave

Hyper HypoK+

K+K+

K+

K+

K+

K+

K+

K+K+

T wave

Familial Periodic Familial Periodic ParalysisParalysis TypesTypes

– Hyper Kalemic – HyperPPHyper Kalemic – HyperPP– Hypo Kalemic – HypoPPHypo Kalemic – HypoPP– Thyrotoxic- TPPThyrotoxic- TPP

Genetic mutationGenetic mutation– Autosomal dominant and sporadic Autosomal dominant and sporadic

ChannelopathiesChannelopathies

Inability to find a decent TV program Inability to find a decent TV program despite having cable and 150 despite having cable and 150 channels to chose from.channels to chose from.

Functional disturbances of ion Functional disturbances of ion channels in the cell membranechannels in the cell membrane

– ““Flaccid muscle weakness Flaccid muscle weakness due to under excitability of due to under excitability of sarcolemma.”sarcolemma.”

HypoPPHypoPP Rare, potentially fatal episodes of Rare, potentially fatal episodes of

muscle weaknessmuscle weakness– Asian populationAsian population

Acute attacks due to KAcute attacks due to K+ + moving into cellsmoving into cells Precipitated by exercise, carbs, stressPrecipitated by exercise, carbs, stress K levelK level

– LowLow– NormalNormal* (low K + Rhabdo)* (low K + Rhabdo)

Often self limitingOften self limiting

Treating K problemsTreating K problems

ABCsABCs IV – O2 – MonitorIV – O2 – Monitor Stat labsStat labs Check Mg, CPK, TFTsCheck Mg, CPK, TFTs Oral K is good for non life threatening Oral K is good for non life threatening

hypoKhypoK– Watch N/VWatch N/V– Use PO KCl if hypo K is due to loss of ClUse PO KCl if hypo K is due to loss of Cl

HypoPP - RxHypoPP - Rx

Administer KAdminister K+ +

– 10-20meq/hr IV (Higher via central line if 10-20meq/hr IV (Higher via central line if severe)severe)

– 40-60meq PO x240-60meq PO x2 Check the KCheck the K+ + q 15-30minq 15-30min Rx thyrotoxicosis w/ propanololRx thyrotoxicosis w/ propanolol

HypoPP - DischargeHypoPP - Discharge

Daily oral K does not prevent attacksDaily oral K does not prevent attacks Carbonic anhydrase inhibitors- Carbonic anhydrase inhibitors-

Acetozolamide Acetozolamide Low carb diet Low carb diet Consult/referralConsult/referral

Caveats – K problemsCaveats – K problems

1meq decrease in K represents 1meq decrease in K represents 300meq deficit300meq deficit**– If hypo K is due to lossIf hypo K is due to loss– Remember, 98% of K is in the ICFRemember, 98% of K is in the ICF

0.1 drop in pH raises K by 0.60.1 drop in pH raises K by 0.6– Think of acid/base problemsThink of acid/base problems

Is this primary or secondary problem?Is this primary or secondary problem?

Dangers in Rx PPDangers in Rx PP

Check the type before starting KCheck the type before starting K– Must confirm if hypo, hyper or nl Must confirm if hypo, hyper or nl

Remember this is a cellular shiftRemember this is a cellular shift– Rebound hyper K can occur if you are too Rebound hyper K can occur if you are too

aggressive w/ K replacementaggressive w/ K replacement Watch for respiratory insufficiencyWatch for respiratory insufficiency

!

MM U D P I L E S U D P I L E S

Methanol/Ethylene glycolMethanol/Ethylene glycol– Certainly possibleCertainly possible– Pt deniedPt denied– No visual sxNo visual sx– No Ca oxalate xtalsNo Ca oxalate xtals– Woods lampWoods lamp– Osm gapOsm gap

M M U D PU D P II L E S L E S

UremiaUremia– BUN/Creat OKBUN/Creat OK

DKADKA– Not a diabetic, Glucose OKNot a diabetic, Glucose OK

ParaldahydeParaldahyde– No pungent odorNo pungent odor

IsoniazidIsoniazid– No hx TB RxNo hx TB Rx

M M U D PU D P II LL E S E S

Lactic AcidosisLactic Acidosis– Abd pain -> dead gutAbd pain -> dead gut– Decreased perfusionDecreased perfusion– Liver failureLiver failure– AlcoholsAlcohols– MedsMeds– Inborn errorsInborn errors– Lactate -> 27Lactate -> 27

M M U D PU D P II LL EE S S

Ethanol - Alcohol KetoacidosisEthanol - Alcohol Ketoacidosis– Binge drinker, Not eatingBinge drinker, Not eating

SalicylatesSalicylates– No Hx of ASA useNo Hx of ASA use

Hospital CourseHospital Course

Developed DTsDeveloped DTs + C. Dif culture+ C. Dif culture Feeding tube placedFeeding tube placed acute alcoholic hepatitis and severe acute alcoholic hepatitis and severe

dehydration and metabolic disarray dehydration and metabolic disarray with severe hypokalemia, with severe hypokalemia, hypophosphatemia, hypomagnesemia, hypophosphatemia, hypomagnesemia, acute renal failure, lactic acidosis, acute renal failure, lactic acidosis,

Alcohol ketoacidosisAlcohol ketoacidosis

Uncommon, often missedUncommon, often missed Binge drinkersBinge drinkers

AKA - 3 factorsAKA - 3 factors

1.1. Alcohol intakeAlcohol intake

2.2. Decreased caloric intakeDecreased caloric intake

3.3. Volume depletionVolume depletion

Results in starvation physiology

AKAAKA

Decreased caloric intakeDecreased caloric intake– Counter regulatory hormone releaseCounter regulatory hormone release– Epinephrine, cortisol, growth hormoneEpinephrine, cortisol, growth hormone– Elevated glucagon, decreased insulinElevated glucagon, decreased insulin– Promotes lipolysis and fatty acid Promotes lipolysis and fatty acid

mobilizationmobilization Volume depletionVolume depletion

– Elevated glucagon, decreased insulinElevated glucagon, decreased insulin

AKAAKA

Alcohol intakeAlcohol intake– Oxidation of ETOH-> ->acetateOxidation of ETOH-> ->acetate– NAD->NADH which raises glucagon, NAD->NADH which raises glucagon,

decreases insulindecreases insulin– Promotes betahydoxybutyrate vs Promotes betahydoxybutyrate vs

acetoacetateacetoacetate– Decreased gluconeogenisisDecreased gluconeogenisis

AKAAKA

SymptomsSymptoms– N, V, abd painN, V, abd pain– Dyspnea, tremulousnessDyspnea, tremulousness– Muscle pain, fever, diarrhea, syncope, SzMuscle pain, fever, diarrhea, syncope, Sz

PhysicalPhysical– Tacycardia, tachypnea, abdominal pain,Tacycardia, tachypnea, abdominal pain,– Hepatomegaly, hypotensionHepatomegaly, hypotension

AKAAKA

Differential DxDifferential Dx– CholecystitisCholecystitis– Peptic ulcer, gastritisPeptic ulcer, gastritis– Mesenteric ischemiaMesenteric ischemia– PacreatitisPacreatitis– Withdrawal syndromesWithdrawal syndromes– Metabolic acidosisMetabolic acidosis– DKADKA– Methanol, Ethylene glycolMethanol, Ethylene glycol

AKA - labsAKA - labs

pH –low, high or nlpH –low, high or nl– Metabolic acidosis -> ketonesMetabolic acidosis -> ketones– Metabolic alkalosis -> vomitingMetabolic alkalosis -> vomiting– Respiratory alkalosis -> hyperventilationRespiratory alkalosis -> hyperventilation

Serum ketones low, high or nlSerum ketones low, high or nl– BetahydoxybutyrateBetahydoxybutyrate

Lytes –abnormalLytes –abnormal Lactate – mildly elevatedLactate – mildly elevated

AKA-treatmentAKA-treatment

Volume replaceVolume replace Carbohydrate replacementCarbohydrate replacement

– D5NSD5NS Fix electrolyte abnormalitiesFix electrolyte abnormalities

– K, Mg, acidosisK, Mg, acidosis Address associated problemsAddress associated problems

– Withdrawal, Wernikes, GI bleed, hepatitis, Withdrawal, Wernikes, GI bleed, hepatitis, pancreatitis, pneumonia, rhabdo, etc.pancreatitis, pneumonia, rhabdo, etc.

I have never been lost, I have never been lost, but I will admit to being but I will admit to being confused for several confused for several weeks. weeks.