mohamedcairopedneph.com/document/hypokalemia protocol.pdf · mohamed alaa thabet professor of...
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Mohamed Alaa Thabet
Professor of Pediatrics
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The reference rangefor serum potassium level
3.5 - 5 mEq/L.
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Potassium
q< 2 mo 3 - 7 mmol/L
q2 -12 mo 3.5 - 6 mmol/L
q>12 mo 3.5 - 5 mmol/L
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Hypokalemia
Defined as a potassium level < 3.5 mEq/L.
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ECG
• Prolongation of QT interval• ST-segment depression• T-wave flattening• Appearance of U waves• Ventricular arrhythmias• Atrial arrhythmias
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Hypokalemia
• Moderate 2.5 - 3 mEq/L.
• Severe < 2.5 mEq/L.
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Signs and symptoms
Ø Asymptomatic,
Ø Nonspecific ,
Ø Underlying cause rather than thehypokalemia itself.
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Complaints
ü Polyuria
ü Palpitations
ü Weakness and fatigue
ü Muscle cramps and pain
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Physical Findings
• Decreased muscle strength
• Decreased tendon reflexes
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Physical Findings
• Hypoventilation,
• Respiratory distress
• Respiratory failure
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Physical Findings
• HTN
• Hypotension
• Arrhythmias
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Physical Findings
• Signs of ileus
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Physical Findings
• Growth failure
• Cushingoid appearance
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Hypokalemic periodic paralysis
v AD
v Episodic
v Flaccid, generalized weakness
v Hypokalemia during the attacks.
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Thyrotoxic periodic paralysis
v Hyperthyroidism.
v Asian males.
v Increased Na-K-ATPase activity.
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Hypokalemia can only occur for
4 reasons:
1. Losses2. Shift into cells3. Decreased intake4. Medication effects
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Causes:Diminished intake
• Malnutrition • Anorexia nervosa• Parenteral nutrition• Chronic clay ingestion.
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Drugs
• Diuretics,
• Steroids
• Bicarbonate
• Beta-agonist, Theophylline,
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Drugs
• Amphotericin B,
• Ampicillin, high-dose penicillins
• Aminoglycosides (Gentamicin),
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HistoryThe patient's medications
should be reviewed to ascertain whether any of
them could cause hypokalemia.
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A shift of potassium to the intracellular space
q Alkalosis (metabolic or respiratory)
q Insulin or glucose administration
q Intensive beta-adrenergic stimulation»Stress»Beta agonists- e.g.: albuterol.
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Causes
The most common cause of hypokalemia is extra-renal loss in acute and chronic
GIT diseases.
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Causes
• GI losses–Vomiting ???–Diarrhea–Nasogastric suctioning –Enemas or laxative use
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Causes
• Renal losses–Renal tubular acidosis–Bartter and Gitelman syndromes–Liddle syndrome –Hyperaldosteronism–Magnesium depletion
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Genetic disorders
q Bartter syndrome
q Gitelman syndrome
q Liddle syndrome
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Bartter syndrome
Characterized by urinary wasting of:» K» Na» Cl» Ca
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Gitelman syndrome
Hypocalciuric, Hypomagnesemicvariant of Bartter
syndrome
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Renal losses of potassium1. Primary or 2ry aldosteronism
2. Exogenous mineralocortcoid.
3. Renin-angiotensin-aldosterone cascade activation (Diuretics).
4. Renal tubular defects (RTA)– Proximal, especially with therapy– Some distal types
5. Presentation of a non-resorbable anion distally, obligating acation, leading to increased K excretion in the presence ofaldosterone.– Bicarbonate– Penicillin derivatives
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First-line Approach
q History q Historyq History
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First-line Approach
q Drug History
q Family History
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Low Renin
Family History
CAHAME
Liddle’sGordon’s
GRAAR AD
HTN
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First-line Approach
q Physical examination.1. HTN2. Getalia
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Hypokalemia & HTN
• CAH• Cushing syndrome• Liddle syndrome, Licorice, • Renovascular disease• Renin secreating tumors• Adrenal adenoma or hyperplasia
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First-line Approach
q History q Physical examination. q Urine K ( Spot UK )
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Spot UK
A random UK > 20 in presence of hypokalemia indicates renal K wasting
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Spot urine potassium & History
Low urine potassiumq GIL loss: (Diarrhea , laxatives ?)
q Poor intake (Diet ,TPN ?)
q Intracellular shift (Drugs, episodic weakness ?)
High urine potassium q Renal loss ( Diuretics ?).
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Second-line Approach
q PRA, PAC & cortisol
q ABG
q Spot Ucl
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Low ReninLow Aldosterone
Cortisol
Ectopic ACTHCushing syndrome
Liddle’sLicorice
11 b hydorxylase D17 a hydorxylase D
High Normal Low
Lin SH, et al. Am J Med Sci 2003; 325: 153-156.
HTN
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Liddle syndrome
Amiloride & Triamterene are
effective treatments but
Spironolactone is not.
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Low ReninLow Aldosterone
Spironolactone
AME Liddle’sNO BP
reduction
HTN
BPreduction
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Third-line Steps Based on
High clinical index of suspicion
for the disorder
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Third-line Steps Based on
High clinical index of suspicion for the disorder
• Adrenal imaging (adenoma)
• Evaluation for renal artery stenosis
• Enzyme assays for 17-beta hydroxylase deficiency
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Third-line Steps Based on
High clinical index of suspicion for the disorder
• Drug screen (diuretics, sympathomimetics)
• Thyroid function in Asians with tachycardia.
• Serum anion gap (toluene toxicity)
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Third-line Steps Based on
High clinical index of suspicion for the disorder
• Pituitary imaging (Cushing syndrome)
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Treatment
1. Treat the cause 2. Reduction of losses3. Replenishment of stores4. Evaluation for potential toxicities5. Prevent future episodes, if possible
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The magnesium level
K level cannot be corrected until hypomagnesemia
has been corrected.
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Decreasing Potassium Losses
üTreat diarrhea or vomitingüDiscontinue diuretics/laxativesüK-sparing diureticsüControl hyperglycemiaüH2 blockers to patients on NG suction
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Replenishment of Potassium2.5-3.5 mEq/L
• Need only oral K replacement therapy.
• If cardiac arrhythmias or significant symptoms are present, treat as severe hypokalemia.
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Replenishment of Potassium<2.5 mEq/L
ØHospital admission; ØContinuous ECG monitoring, Ø IV potassium should be given. ØGradual replacement over a few hours.ØReplace Mg if low.ØCheck serial K levels.
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Pitfalls
qTake ongoing K losses into consideration. qAvoid glucose-containing parenteral fluids. qIf the patient is acidotic, correct the K first.qEvaluation for potential toxicities.
üDigitalis üOvercorrection hyperkalemia
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Severe Hypokalemia
Ø 0.5 mEq/kg/dose;Ø 0.5 mEq/kg/hr; Ø Max 10 mEq/hr; Ø Max 40 mEq/dose; Ø Max 200 mEq/day;
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Severe Hypokalemia
Øevaluate 1-2 hr after end of infusion;
Ø repeat as necessary based on lab values;
Øongoing losses may require >200% of normal daily maintenance
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MCQ• A 12 YEARS OLD BOY COMPLAINS OF
FATIGABILITY AND WEAKNESS
• PHYSICAL EXAM: BP 122/68, HR 72/MIN, NO ORTHOSTATIC CHANGES, NO EDEMA
• LABS (mEg/L): Na :135, K: 2.1, Cl: 85, Hco3:45, UNa=80, UK=70
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MCQ1:• WHY IS HIS POTASSIUM LOW?
A. VOMITINGB. DIURETIC USEC. BARTTER/GITELMAN D. None of the aboveE. All of the above
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MCQ2:WHAT TEST(S) WILL HELP YOU MAKE THE DIAGNOSIS?
A. Spot Urine KB. Spot Urine ClC. Spot Urine K/CrD. None of the aboveE. Any of the above
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MCQ3:WHICH SALT YOU ARE GOING TO USE TO TREAT THIS PATIENT?
A. k acetate B. K citrate C. K chloride D. None of the aboveE. Any of the above