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PDAT3 > 5 - Potassium Disorders > Flashcards

5 - Potassium Disorders Flashcards

1
Q

Normal Potassium level

A

3.5 - 5 mEq/L

(0.4% plasma)

Total body K+ = 50 mEq/kg

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2
Q

What affect on Plasma K+ ?

Insulin EXCESS

B2-Adrenergic AGONIST
albuterol, etc

  • *A1 antagonist**
  • ZOSINS

Aldosterone

A

DECREASE PLASMA K+

Mechanism:
Stimulate Na-K ATPase Pump

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3
Q

What affect on Plasma K+ ?

Insulin Deficit

B2-adrenergic Antagonist

A1 AGONIST

DIGOXIN TOXICITY

A

INCREASE K+

Mechanism:
INHIBITS Na-K ATPase Pump

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4
Q

What affect on Plasma K+ ?

Injury / Trauma

Exercise

Catabolism

HYPERosmolality

A

INCREASE K+

Mech:
Release of K+ from Cells

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5
Q

What affect on Plasma K+ ?

Anabolism

Metabolic Alkalosis
High pH // Basic

A

DECREASE K+

Mech:
IntraCellular Shift of K+

Acid-Base Status

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6
Q

What affect on Plasma K+ ?

  • *Metabolic ACIDOSIS**
  • low pH* // acidic
A

INCREASE K+

Acid Base status

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7
Q

What affect on Plasma K+ ?

ALDOSTERONE

A

DECREASE in K+

Aldosterone Stimulates the NaK ATPase Pump

K+ pumped out and excreted

also:
Insulin EXCESS
B2-Adrenergic Agonist
A1 antagonist

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8
Q

What affect on Plasma K+ ?

Insulin DEFICIT

A

INCREASE in Plasma K+

Low Insulin –> Inhibits NaK ATPase Pump

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9
Q

Increase of pH 0.1
effect on Potassium ?

A

↑ pH 0.1 –> ↑ K+ 0.6 mEq/L

  • *Metabolic Acidosis**:
  • *<7.35**

IC shift of H+ & EC shift of K+
H+ in // K+ OUT

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10
Q

Corrected Potassium Level
Due to:
Acid-Base Effect

A

Each 0.1 pH is a 0.6 K+ Change

Ex.

  • *Measured pH = 7.0** // Measured K+ = 4.4
  • *4x 0.1 pH** units –> 4x 0.6 K+ units

Corrected K+ = 4.4 - 4(0.6) = 2.0 K+

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11
Q

HypoKalemia

Serum K+ Levels

A

< 3.5 mEq / L

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12
Q

HypoKalemia

Susceptible Population
&
Outcomes

A

Left Ventricular Hypertrophy

Cardiac Aschemia // CHF

Nephrotic Syndrome

Outcomes:
Eseential HYPERtension
Ischemic / Hemorrhagic STROKE
Arrhythmias
Death

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13
Q

Causes of HypoKalemia

A

Insufficient DIETARY intake
Minimum daily + intake = 1.6-2gm (40-50 mEq)

IntraCellular Shift of K+
Medications
Metabolic ALKALOSIS

Excessive K+ LOSS
Diarrhea / Skin burn or sweat
Renal:
HYPERaldosteronism // Medications // Acidosis

HypoMagnesemia

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14
Q

Medications that cause a
INTRAcellular Shift of K+

HypoKalemia

A

B2 Adrenergic Agonist

Phosphodiesterase Inhibitors
Theophylline // Caffeine

INSULIN

Barium / Verapamil Overdose

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15
Q

Medications that cause
Excessive K+ LOSS - RENALLY

HypoKalemia

A

Diuretics / Osmotic Diuresis

High Dose:
Penicillin-Aminoglycosides - Amphotericin B

HYPERaldosteronism

Renal Tubular Acidosis Type 1+2

High Sodium Diet

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16
Q

How THIAZIDE DIURETICS
Cause HypoKalemia

A

Thiazide Blocks Na+ reabsorption–> urination
VVVV
This causes K+ to be brought back into COLLECTING DUCT
VVVV
To be EXCRETED / urinated

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17
Q

Mild - Moderate Symptoms
of HypoKalemia

Mild = 3.1 - 3.4

Moderate = 2.7-3.0

A

In order of INCREASING severity:
N/V

Tiredness

Minimal Muscle Weakness
Proximal Muscle Weakness
(lower > upper limbs)

Constipation

ECG changes

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18
Q

SEVERE Symptoms of
HypoKalemia

<2.7 mEq/L

A

ECG Changes

RHABDOMYOLYSIS

Ascending Symmetric Paralysis
with intact sensorium

Cardiac ARRHYTHMIAS

HYPERtension

STROKE

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19
Q

ECG Signs / Symptoms
of
HypoKalemia

A

ALL UP:
HYPERpolerization
Prolonged Action Potential
Prolonged Refractory Periods
INCREASED Automaticity & Excitability

T-WAVE INVERSION
goes from UP–> DOWN

Prominent U WAVE
QTintervalprolongation
ST segment depression

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20
Q

Goal K+ Level for HIGH RISK PATIENTS
HypoKalemia

Who are the High risk patients?

A

> 4.0 mEq/L

for
HypoKalemic HYPERTENSIVE patients
due to:
STROKE RATE 2-3x HIGHER for them

  • *Increase in K+ intake** is
  • inversely related to Blood Pressure*
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21
Q

Treatment Algorithm
HypoKalemia

A

First:
Treat the Underlying Cause
Treat HypoMagnesemia
AVOID drugs that lower K+

Second:
Assess Severity of Hypokalemia
Mild Asymtomatic // Moderate Asymptomatic // SEVERE SYMPTOMATIC
Do NOT treat based on K+ Levels
TREAT BASED ON SYMPTOMS

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22
Q
  • *Estimation of Potassium Deficit**
  • *HypoKalemia**

if:
K+ > 3.0 mEq/L

A

Each ↓ 0.1 mEq/L K+
vvvv
10 mEq Deficit

Ex for Normal Patient:

  • *Measured K+** = 3.5 –> Goal = 3.0
    3. 5 - 3.0 = 0.5 = 5 x 10 –> 50 mEq
23
Q
  • *Estimation of Potassium Deficit**
  • *HypoKalemia**

K+ <3.0 mEq/ L

A

2- STEP PROCESS
Each ↓ 0.1 mEq/L K+
VVVV
20 mEq Deficit

Ex. CARDIAC PATIENT
Measured K+ = 2.2 –> Goal = 4.0 (cardiac pt)
3.0 - 2.2 = 0.8 = 8x20 = 160 mEq
4.0 - 3.0 = 1.0 = 10x10 = 100 mEq
Total 260 mEq

24
Q
  • *Hypokalemia Example**:
  • *Estimation of K+ Deficit**
**K+ = 2.0
pH = 7.5**

For a Cardiac Patient

A

GOAL for Cardiac Patient = 4.0
K+ = 2.0 //pH = 7.5

1st, Correct the K+:
pH = 7.5 - 7.4 (normal) = 0.1
0.1 x 0.6 = + 0.6 K
Corrected K+ = 2.6

2nd Estimate K+ deficit for <3.0
3.0 - 2.6 (corrected K+) = 0.4 –> 4x20 = 80 mEq

3rd Estimate K+ deficit for >3.0
4.0 - 3.0 = 1.0 –> 10x10 = 100mEq

Total K+ Deficit = 180 mEq

25
Q

Foods High in K+

Typically takes days to increase potassium

A

HIGHEST
Dried FIGS // MOLASSES

Very High = >12.5 mEq / 100gm
Dried Fruits = Dates + Prunes
Nuts / Avocados / Lima Beans
Bran / Cereals / Wheat Germ

High = 6.2 mEq /100gm

  • *Veggies** = Spinach / Tomato / brocolli / beet / carrot / potatoes
  • *Fruits** = banana / cantaloupe / kiwi / orange / mango
  • *Meats =** ground beef / steak / pork / veal / lamb
26
Q

ORAL Treatment Dose
for HypoKalemia

Most Commonly:
KCL TABLET

A

DIVIDE DOSE into no more than:
<40 mEq doses
at a time, every:
q3-4 hours

This is to reduce GI ADR
other ADR:
N/V/D
Ab pain/discomfort
GI ulceration / bleeding /Esophageal Irritation

27
Q

Oral PROPHYLACTIC Dose
for HypoKalemia

A

10-20 mEq / day
and titrate as needed

ADRs:
N/V/D
Ab pain/discomfort
GI ulceration / bleeding /Esophageal Irritation

28
Q

Parenteral Potassium Supplement DOSE
for:

Peripheral Access or Non-Cardiac Monitoring
&
MAX

A

10 mEq/hr

Route has to be at some type of RATE:
IVPB or Continuous Infusion

NEVER IM - IVP - SC

  • Too FAST or TOO MUCH –>
  • CARDIAC ARRYTHMIAS**

MAX Concentration, must be DILUTED
Max IVPB = 40 mEq/250mL
Max Continuously flowing IV fluids = 40-60 mEq/1000 mL

29
Q

Parenteral Potassium Supplement DOSE
for HypoKalemia

Central Access w/ Cardiac Monitoring

A

20 mEq/hr

Route has to be at some type of RATE:
IVPB or Continuous Infusion

NEVER IM - IVP - SC
Too FAST or TOO MUCH –>
CARDIAC ARRYTHMIAS​

Max Concentration, must be DILUTED
Cardiac Monitoring = 40 mEq/100 ml

30
Q

Parenteral Potassium
SALT FORMS

Chloride vs Acetate vs Phosphate

A

K+ Chloride
MOST COMMON

K+ Acetate
Use where chloride is contraindicated

K+ Phosphate
Use only in patients with concomitant
HypoKalemia & HypoPhosphotemia

31
Q

MAX CONCENTRATION
for
Central Access Parenteral K+ Supplement

A

must be DILUTED

  • *Central Access w Cardiac Monitoring:**
  • *40 mEq / 100 mL**
32
Q

MAX Concentration
for
PERIPHERAL Access K+ Parenteral Supplementation

A

must be DILUTED

  • *Continuously FLowing IV Fluids**
  • *40-60 mEq / 1000mL**
  • *IVPB**
  • *40 mEq / 250ml**
33
Q

HYPERkalemia

Level

A

> 5 mEq/L

Susceptible Population:
Acute + Chronic RENAL DISEASE

34
Q

HYPERKalemia:
Etiology

A

Pseudo-HyperKalemia
Hemolysis / K+ EDTA in collecting tubes
Thrombocytosis / leukocytosis / Erythrocytosis

Increase Potassium load
Dietary Source / Protein supplements
Medications = PENICILLIN

Transcellular Shift
Hyperosmolality - GLUCOSE
Smatstatin

Impaired K+ Excretion
MEDICATIONS / HRHA / Adrena insufficiency

35
Q

Increase Potasium Load

HYPERkalemia Etiology

A

Dietary Source
Various Veggies / Fruits / Salt substitutes

PENICILLIN

Protein-Calorie Supplements

Stored Blood
Increase K+ 1 mEq/L/day

Anaerobic Excercise

Rhabdomyolysis

36
Q

Transcellular Shift

HYPERkalemia Etiology

A
  • *HYPERosmolality** (solute drag)
  • *Glucose / Mannitol**
  • *Somatostatin**
  • decrease INSULIN secretion*

SuccinylCholine

EXERCISE

B-Adrenergic blockers

HYPERkalemic Periodic paralysis

37
Q

Impaired K+ Excretion

MOST COMMON CAUSE

HYPERkalemia Etiology

A

Medications
Spironolactone // Amiloride // eplerenone / triamterene
Trimethoprim / Tacrolimus / Cyclosporine
NSAIDs
ACE-I / ARB

  • *HypoReninemic HypoAldosteronism = HRHA**
  • *DM** / sle / obstructive uropathy / sickle nephropathy

Adrenal Insufficiency
Autoimmune adrenal destruction, hemorrhage, metasteses

38
Q

HYPERkalemia
CARDIAC S/Sx

A

Decreased / slow ALL:
Depolarizes Cell membrane
Slow Ventricular Conduction
Decreased Duration of APs
ARRHYTHMIAS

TALL PEAKED T-WAVE
Prolonged PR Interval
BI-phasic trace

39
Q

HYPERkalemia
Neuromuscular S/Sx

A

Neuromuscular
Muscle TWITCHING

Cramping

Paraesthesias

Generalized WEAKNESS

Flaccid Paralysis

Decreased or absent Deep Tendon Reflexes

40
Q

HYPERkalemia
TREATMENT ALGORITHM

A

First:
Treat UNDERLYING CAUSE
Assess for PSEUDO-HYPERkalemia
PSUEDO - caused by burst cells, NOT TRUE HYPERK

Second - Assess for SEVERITY:
Mild = 5.5-6.4
Moderate = 6.5-8.0
SEVERE + SYMPTOMS
>8.0
have Min-Hours to SAVE LIFE

41
Q

Mild HYPERkalemia

K Level + Treatment

A

5.5 - 6.4 mEq/L

treat MODERATELY

Kayexalate
= Sodium Polystyrene, Elimination Drug

+/- Redistribution Drugs
Insulin + Glucose
beta 2 agonist // NaHCO3

42
Q

Moderate HYPERkalemia

K+ Level // Treatment

A

6.5 - 8.0 mEq/L

treat Moderately

Kayexalate
= Sodium Polystyrene Sulfonate

  • *Redistribution Drugs**
  • *Insulin + glucose** // beta agonist / NaHCO3

Furosemide
also an Elimination drug

43
Q

3 Things to Treat for

SEVERE / LIFE THREATENING
HYPERkalemia

>8.0
Cardiac Symptoms –> EKG Changes TALL PEAKED T-WAVE
Neuromuscular –> Cramping / Paralysis / Twitching

A
  • *Membrane Stabilization**
  • Reduce the* threshold potential of cardiac myocytes
  • -> restore the normal gradient w/ resting membrane potential

Intracellular Shifting
Stimulate Na-K ATPase
–> INCREASES serum pH

Elimination
Cation-Exchange resin
INCREASE delivery of Na + urine flow rate

44
Q

Membrane Stabilizing

HYPERkalemia TREATMENT

A

CALCIUM

  • *1gm** IVP over 2-3 min
  • can repeat in 5-10 min*

Monitor EKG

All this does is:
WORK ON ACTION POTENTIAL + _REVERSE EFFECT_of POTASSIUM

ADR:
Phlebitis / Tissue Necrosis / HYPERcalcemia

(gluconate or chloride)

45
Q

Intracellular Shift

HYPERKalemia TREATMENT

A

INSULIN +/- Glucose
glucose is given to combat hypoGlycemia

  • *10 units IV** +/- 50mL D5W
  • *10-20 min** onset // 4-6 hr duration

Beta 2 Agonist = Albuterol
10‐20 mg in 4mL saline nebulized over 10‐20 min
can lead to LOSS of B2 selectivity ->Tachycardia / Tremor

NaHCO3**
Only used for **Metabolic Acidosis

46
Q

ELIMINATION

HYPERkalemia TREATMENT

A

SODIUM POLYSTYRENE SULFONATE
= Kayexalate
Needs to be RECTALLY ELMINIATED to work + LAXATIVE

Furosemide or Thiazide
20-40 mg IV
IV to work FASTER, not good if KIDNEYS DONT WORK –>dialysis

Dialysis
only done if Bad Kidneys
Chance for REBOUND HYPERkalemia

47
Q

Sodium Polystrene Sulfonate

A

Kayexalate for HYPERkalemia Elimination Treatment

Needs to be RECTALLY ELIMINATED to work,
typically given w/ laxative

  • *15‐30 Gm PO** in 70% sorbitol - PO Onset = 2 hours
  • *30‐60 Gm PR - Rectal Onset = 1 hour**

ADRS:
COLONIC NECROSIS (drug sits in the colon –> need LAXATIVE)
HYPERnatremia
Nausea + Constipation

48
Q

Potassium Disorder
TREATMENT APPROACH

A

1) Recognize Electrolyte Abnormality = Values

2) Assess S/Sx associated w/ disorder
* *Urgent vs non-ugent** // symptoms or not

3) Treat the Underlying Cause AND:
a) Urgent –> Aggresive normalization electrolyte
b) Non-Urgent: Conservative ^
c) No symptoms = no ACTIVE intervention

4) MONITOR Electrolyte + treatment
A) Urgent = q 2-4hr
B) Non-Urgent = q12-24 hr
c) no symp= q24-72hr +

49
Q

What Chronic Electrolyte disorder leads to
HypoKalemia?

A

HypoMagnesemia

  • *Magnesium** is a cofcator for the Na+ K+ pump
  • *TREAT MAGNESIUM FIRST!**
50
Q

Which Electrolyte Disorder?

Nausea / vomiting / Tiredness

Minimal muscle weakness / Proximal muscle weakness
(lower > upper limbs)

Constipation

Rhabdomyolysis

Ascending symmetric paralysis with intact sensorium

Cardiac arrhythmias / Hypertension / Stoke

A

HypoKalemia

As Potassium DECREASES
symptoms become MORE SEVERE

MUSCLE & HEART
SIDE EFFECTS

ECG CHANGES
INVERTED T WAVE
*ALL UP

51
Q
  • *What DRUGS** are known to cause
  • *HypoKalemia**?
A
  • *DIURETICS**
  • *Loop & Thiazide Diuretics**

Insulin

B2 - Adrenergic Agonist = High Dose ALbuterol

High Dose Penicillin

HyperAldosteronism

HypoMagnesemia

52
Q
  • *You determine a DEFICIT** for
  • *which Electrolyte Disorder**?

Also ADJUST ON pH

A

HypoKalemia = POTASSIUM
First:
Adjust Based on pH
(pH) - 7.4 –> Each 0.1 = +/- 0.6 change in K+
Second:
For K+ >3.0 –> Each ↓0.1 K+ = 10 mEq Deficit
For K+ <3.0 –> Each ↓0.1 K+ = 20 mEq deficit

Goal for HT patients = K+ of 4.0

53
Q

HYPER vs Hypo K+

SYMPTOMS

A

HypoKalemia
Cardiac:
HYPERtension / Arrhythmias / INVERTED T-wave
Neuromuscular:
CONSTIPATION / Rhabdo / Paralysis
STROKE

HYPERKalemia
Cardiac:
PEAKED T-WAVE / Arrhythmias
Neuromuscular:
Twitching / Cramping / Weakness
Paraesthesias=Tingling/Prickling/Deep Tendon Reflexes

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