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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
**Foods High in K+** Typically takes **days to increase potassium**
_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
**_ORAL Treatment Dose_** for **HypoKalemia** Most Commonly: **KCL TABLET**
**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
**Oral PROPHYLACTIC Dose** for **HypoKalemia**
**_10-20 mEq / day_** and titrate as needed ## Footnote ADRs: N/V/D Ab pain/discomfort GI ulceration / bleeding /Esophageal Irritation
28
**Parenteral Potassium Supplement DOSE** for: **Peripheral Access** or ***Non*-Cardiac Monitoring** & **MAX**
**_10 mEq/hr_** ## Footnote 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
**Parenteral Potassium Supplement DOSE** for **HypoKalemia** **_Central Access w/ Cardiac Monitoring_**
**_20 mEq/hr_** ## Footnote 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
**Parenteral Potassium SALT FORMS** ## Footnote **Chloride vs Acetate vs Phosphate**
**_K+ Chloride_** MOST COMMON **_K+ Acetate_** Use where **chloride is contraindicated** **_K+ Phosphate_** Use only in patients with **concomitant** **HypoKalemia & HypoPhosphotemia**
31
**MAX CONCENTRATION** for **_Central Access Parenteral K+ Supplement_**
**must be DILUTED** * *Central Access w Cardiac Monitoring:** * *40 mEq / 100 mL**
32
**MAX Concentration** for **PERIPHERAL Access K+ Parenteral Supplementation**
must be DILUTED * *_Continuously FLowing IV Fluids_** * *40-60 mEq / 1000mL** * *_IVPB_** * *40 mEq / 250ml**
33
**HYPERkalemia** **Level**
**\> 5 mEq/L** Susceptible Population: **Acute + Chronic RENAL DISEASE**
34
**HYPERKalemia: Etiology**
**_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
**Increase Potasium Load** HYPERkalemia Etiology
**_Dietary Source_** Various Veggies / Fruits / Salt substitutes **_PENICILLIN_** **Protein-Calorie Supplements** **Stored Blood** Increase K+ 1 mEq/L/day **Anaerobic Excercise** **Rhabdomyolysis**
36
**Transcellular Shift** HYPERkalemia Etiology
* *_HYPERosmolality_** (solute drag) * *Glucose / Mannitol** * *_Somatostatin_** * **decrease INSULIN secretion*** SuccinylCholine EXERCISE **B-Adrenergic blockers** **HYPERkalemic Periodic paralysis**
37
**_Impaired K+ Excretion_** MOST COMMON CAUSE **HYPERkalemia Etiology**
_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
**HYPERkalemia CARDIAC S/Sx**
*_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
**HYPERkalemia Neuromuscular S/Sx**
_Neuromuscular_ **Muscle TWITCHING** **Cramping** **Paraesthesias** **Generalized WEAKNESS** **Flaccid Paralysis** *Decreased or absent* **Deep Tendon Reflexes**
40
**HYPERkalemia TREATMENT ALGORITHM**
_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
**Mild HYPERkalemia** **K Level + Treatment**
**5.5 - 6.4** mEq/L ## Footnote *treat MODERATELY* **_Kayexalate_** = Sodium Polystyrene, Elimination Drug **_+/- Redistribution Drugs_** Insulin + Glucose *beta 2 agonist // NaHCO3*
42
**Moderate HYPERkalemia** ## Footnote **K+ Level // Treatment**
**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
**3 Things to Treat for** **SEVERE / LIFE THREATENING HYPERkalemia** \>8.0 Cardiac Symptoms --\> EKG Changes TALL PEAKED T-WAVE Neuromuscular --\> Cramping / Paralysis / Twitching
* *_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
**_Membrane Stabilizing_** **HYPERkalemia TREATMENT**
**_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
**_Intracellular Shift_** **HYPERKalemia TREATMENT**
**_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
**_ELIMINATION_** **HYPERkalemia TREATMENT**
**_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
**Sodium Polystrene Sulfonate**
**_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
**Potassium Disorder TREATMENT APPROACH**
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
**What Chronic Electrolyte disorder leads to HypoKalemia?**
**_HypoMagnesemia_** * *Magnesium** is a cofcator for the **Na+ K+ pump** * *TREAT MAGNESIUM FIRST!**
50
_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**
**HypoKalemia** ## Footnote As Potassium *DECREASES* symptoms become MORE SEVERE **_MUSCLE & HEART_ SIDE EFFECTS** **ECG CHANGES INVERTED T WAVE** \*ALL UP
51
* *What DRUGS** are known to cause * *HypoKalemia**?
* *_DIURETICS_** * *Loop & Thiazide Diuretics** **Insulin** **B2 - Adrenergic Agonist** = High Dose ALbuterol High Dose Penicillin **HyperAldosteronism** **HypoMagnesemia**
52
* *You determine a DEFICIT** for * *which Electrolyte Disorder**? Also **_ADJUST ON pH_**
**_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** ## Footnote Goal for HT patients = K+ of 4.0
53
**HYPER vs Hypo K+** **SYMPTOMS**
**_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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