Potassium
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Transcript of Potassium
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Joel M. Topf, MDNephrology Attending
Potassium
Emergencies
• Decreased intake of potassium Alcoholics Anorexia
• Transcellular shift of potassium ß-agonists Dobutamine
• Renal potassium excretion Diuretics Decreased chloride delivery Hyperaldosteronism
Etiologies of hypokalemia
EKG findings with hypokalemia• hypokalemia produces
EKG changes which are not necessarily related to the K+ level Flattening of T waves Increased prominence of
U waves (look at V4, 5, 6) ST depression Increased prominence of
P waves Inversion of T waves
• 81-year-old woman develops chest pain during treatment of an asthma exacerbation.
• The patient was found to be: Disoriented Complaining of stabbing,
non-radiating chest pain Nausea, vomiting,
dyspnea Severe muscle weakness
• Potassium of 0.9 mEq/L. • History of taking herbal
remedies, including natural licorice. Licorice contains
glycyrrhizic acid
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Hypokalemia and Arrhythmias• Norwegians with AMI• N= 1035
23 K ≤ 3.0 94 K = 3.1-3.5 357 K = 3.6-4.0 393 K = 4.1-4.5 141 K = 4.6=5.1 24 K ≥ 5.2
• Results are the incidence of arrhythmias by K level
0
10
20
30
40
50
≤3.0 3.1-3.5 3.6-4.0 4.1-4.5 4.6-5.1 ≥5.2
VF, VFl, VT, AF VT, VF VF
Nordrehaug, JE, Acta Med Scand, Sup. 1981 647, 101-107
Treatment of hypokalemia
• Give potassium Oral is preferred route
20-40 mEq qd-q6h
KCl is superior to Kphos or K-acetate
IV for patients who are NPO or have dangerously low potassium
• Liberal use of K sparing diuretics
• Check and correct Mg deficiency
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How much K to give
• Altered cellular distribution No total body K deficit so
any K given will need to be excreted after the maldistrib-ution is rectified
• A compilation of 7 separate metabolic balance studies reveals the following graph
2
3
4
5
0 100 200 300 400 500 600 700 800
K Deficit (mmol/70 kg body Wt)
Serum K (mmol/L)
Serum K Replacement
3.0 100
2.0 200
1.0 400
Check the Creatinine first
Problems with IV potassium
Concentrated IV potassium solutions cause phlebitis
Dilute IV potassium in saline causes volume overload
IV potassium in dextrose cause a release of insulin
lowering plasma potassium
Hyperkalemia
0
0.05
0.1
0.15
0.2
0.25
Control Infusion
QRS duration T-Wave Amplitude
Treatment of hypokalemia: IV KCl• N = 40 ICU patients
with arterial lines and hypokalemia. Patients given 20
mmol of KCl in 100 mL
Pre-infusion K = 2.9 26 central vein 14 peripheral Continuous EKG
monitoring in 31 and pre and post 12 lead EKG in all 40.
0.0
0.1
0.2
0.3
0.4
0.5
0 15 30 45 60 75 90 105 120
Time (min)
∆ K (mmol/L)
0
2
4
6
8
10
12
14
16
18
20
Control Infusion
PAC PVC
Kruse, JA, Et al J Clin Pharm. 1994 34, 1077-1082
Hyperkalemia• Plasma potassium
over 5.5 mEq/L• Primary problems
are weakness and arrhythmias Bradycardia Ventricular fibrillation
• Increased intake of potassium Enteral Parenteral
Etiologies of hyperkalemia
• Transcellular shift of potassium Lack of insulin Beta-blockers Cardiac glycosides Tissue destruction
• Renal potassium excretion Renal failure Decreased distal delivery of Na Hypoaldosteronism
Hyperkalemia: Clinical Sequelae• Arrhythmia• Paralysis
Due to abnormal nerve conduction
Ascending paralysis mimicking GBS documented with K of 7
In review of all reported cases of hyperkalemic paralysis:
Ave. K = 9Half were on a K
sparing diuretic
Evers, S. Et al. Secondary hyperkalaemic paralysis. J Neurol Neurosurg Psychiatry 64, 249-252 (1998).
EKG findings with hyperkalemia
• Short QT interval
• Peaked T waves
• Widened QRS complex
• The EKG changes into a sinusoidal pattern
EKG Changes with hyperkalemia
Treatment of hyperkalemia: Calcium• If EKG signs are present
give calcium• Calcium Chloride is
more effective than calcium gluconate
• Onset of action is instant and duration approx. 1 hour
• May repeat until EKG normalizes
• Avoid if patient has digoxin toxicity
In animal studies, verapamil ablates the cardioprotective effect of calcium.
Bisogno, J. L., Langley, A. & Von, D. M. M. Critical Care Medicine. 22, 697-704 (1994).
Nugent, M., Tinker, J. H. & Moyer, T. P. Anesthesiology 60, 435-439 (1984).
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Ca Content (mmol/mL)
Ca Gluconate Ca Cl
• Stop intake of potassium Enteral Parenteral
• Induce a transcellular shift of potassium Insulin Albuterol
• Enhance potassium excretion Renal Colonic
Treatment of hyperkalemia:
Treatment of hyperkalemia: Speed
• N=10, no diabetics• Hemodialysis
patients, K = 5.5.• 5 protocols:
1. Bicarbonate 8.4%.2. Bicarbonate 1.4%.3. Epinephrine
0.05µg/kg/min4. Insulin 5mU/kg/min +
Glucose 5mg/kg/min5. Hemodialysis w/ 1 K bath
-1.5
-1.3
-1.1
-0.9
-0.7
-0.5
-0.3
-0.1
0.1
0.3
0 10 20 30 40 50 60
Time (min)
Change in K
NaHCO3 8.4% NaHCO3 1.4%
Epinephrine Insulin Glucose
Dialysis
Blumberg Et al. Amer J Med; 1988: 85, 507-512.
Bicarbonate for hyperkalemia: duration
• N=12• Hemodialysis patients,
K ≥ 5.8.• Given sodium
bicarbonate 4 mmol/min for 1 hour 0.5 mmol/min for 5 hours
• Total 390 mmol 8 amps of bicarbonate and
a liter of fluid for a decrease in K of 0.5 mmol/L
-1.5
-1.3
-1.1
-0.9
-0.7
-0.5
-0.3
-0.1
0.1
0.3
0 60 120 180 240 300 360
Time (min)
Change in K
p>0.05 P<0.05
Blumberg Et al. Kidney International; 1992: 41, 369-374.
At 1 hour the small drop in K was fully accounted for by dilution.
At 6 hours 50±7% of the fall in K was due to ECF expansion
Albuterol for hyperkalemia• N=10• Hemodialysis patients
with pre-dialysis K > 5• Given Nebulized:
Saline. K=5.74 10mg albuterol. K=5.93 20 mg albuterol. K=5.81 on separate days.
• Patients served as their own controls.
-1.0
-0.8
-0.6
-0.4
-0.2
0.0
0.2
0.4
0 30 60 90 120
Time (min)
Change in K
Saline 10 mg 20 mg
Allon Et al. Annals of Int Med; 1989: 110, 426-429.
Albuterol for hyperkalemia: Synergy?• N=12• Hemodialysis patients
with pre-dialysis K > 5• No diabetics or ß-
blockers• Given:
10 u IV insulin + D50 20 mg nebulized
albuterol. Combination of both Patients served as their
own controls.
-1.5
-1.2
-0.9
-0.6
-0.3
0.00 15 30 45 60
Time (min)
Change in K
Insulin Albuterol Combination
Allon Et al. Kidney International; 1990: 38, 869-872.
Treatment of hyperkalemia:
• Move potassium into the cells Insulin and Glucose
Glucose 0.5-1 Amp
Insulin 10 unit IV
Albuterol10-20 mg
nebulized
Do not use sodium bicarbonate Cooper, DJ et al, Annals Int Med 1990;112:492-8.
Treatment of hyperkalemia:
• Move potassium into the cells Insulin and Glucose
Glucose 0.5-1 Amp
Insulin 10 unit IV
Albuterol10-20 mg
nebulized
Do not use sodium bicarbonate
0.5
0.6
0.7
0.8
0.9
1
1.1
1.2
Before After
Ionized Calcium (mmol/L)
Bicarbonate Saline
Cooper, DJ et al, Annals Int Med 1990;112:492-8.
Treatment of hyperkalemia:• Increase the
excretion of potassium Furosemide (Lasix)
Only in patients with working kidneys
20 x sCr IV push Sodium polystyrene
resins (Kayexalate) in patients whose kidneys don’t work
30 g Dialysis
• Make sure the glucose is normal
• Rule out urinary obstruction
Life after death
• 70-year-old man who developed cardiac arrest secondary to hyperkalemia (K=8.5) from chronic renal failure from obstructive uropathy.
• The patient experienced electromechanical dissociation and approximately 26 minutes of asystole after which the resuscitation was suspended
• 8 to 10 minutes after declaration of death, as the emergency department personnel were preparing to transport him to the morgue, the patient was noted to have spontaneous respiration.
• The patient survived and was discharged without apparent neurologic sequelae.
Quick, G Et al. Annals of Emergency Med; 1994: 24, 305-311.