Therapeutic Approach to Hyperkalemia Nephron 2002 :92(suppl 1):33-40

Benign to lethal arrhythmias : unpredictable, w/o warning Pseudohyperkalemia Release of K in the process of drawing blood or from lysis of cells in blood prior to assay Leukocytosis (>70,000/cm3), thrombocytosis(>1,000,000/cm3) EKG Peaked T waves Decresed or absence of P waves Prolonged PR interval Widened QRS complex Sine wave Finally asystole Benign to lethal arrhythmias : unpredictable, w/o warning

The three main approahes for acute therapy of hyperkalemia Antagonize the membrane toxic effects of potassium Promote cellular uptake of potassium Remove potassium directly from the body

Opposing the Direct Toxic Effects IV of calcium (Ca 2+) EKG changes can be seen within 1-3min of infusion, with the effect lasting for 30-60 min. IV Ca salt can be repeated, if no effect is seen within 5-10 min. 1-2 10ml amplues of 10% Ca gluconate : over 2-5 min with continous EKG monitoring for the resolution or recurrence of hyperkalmic changes. Treated with digoxin : Ca added to 100ml of 5% dextrose in water should be given slowly over 20-30min with extreme caution since Ca potentiates the myocardial toxicity of digoxin.

Shifting Potassium into Cells Insulin Onset less than 20 min with a peak effect between 30 and 60min Bolus infusion of 10 units of insulin Followed by bolus infusion of 50 ml of 50% glucose The effect lasts 4-6h Without simultaneous administration of glucose in hyperglycemic pts ( 250mg%glucose level) Adrenergic Agents 10-20mg of albuterol was given in the same nebulizer

Shifting Potassium into Cells NaHCO3 Should not be used as a single agent Combined Therapies Insulin with glucose + B2 agonist Insulin with glucose + NaHCO3

Direct Elimination from Body Renal Route Increase urine flow and sodium delivery Furosemide (40-80mg IV), ethacrynic acid(50-100mg IV) Gastrointestinal Route 1g of sodium polystylene sulfonate : remove about 0.5-1mEq of potassium Requiring approximately 4-6hr for a full effect The mixture of the resin with sorbitol Dialysis Hemodialysis is the most efficient way 1.2-1.5 mEq/l/h

Medications NSAID Heparin B- adrenergic antagonists(propanolol) Andiotensin-converting enzyme inhibiotrs (enalapril, captopril) Angiotensin II receptor antagonists(losartan, irbesartan) Mineralocorticoid receptor antagonist (spironolactone) Amiloride, triamterene, trimethoprim, pentamidine, cyclosporine

Therapeutic Approach to Hypokalemia Nephron 2002 :92(suppl 1):28-32

Potassium Replacement Indication K has been lost, either in urine or stool Hypokalemic periodic paralysis Uncorrected preoperative hypokalemia(<3.5mmol/l) : increase perioperative arrhythimia and the need for cardiopulmonary resuscitation The entire K deficit is not corrected immediately to avoid the potential risk of hyperkalemia

Estimation of the Potassium Deficit Monitoring of the EKG and muscle strength Administered in a moderate dose by mouth over a period of days to weeks to correct deficits fully

Selection of the Appropriate Preparation Potassium chloride Crystalline form, liquid, slow release tablet or capsule Cl-depleted metabolic alkalosis Potassium bicarbonate (citrate, acetate, or gluconate) Mild degree of hypokalemia and metabolic acidosis Potassium phosphate Replace phosphate losses Orange juice or bananas is less desirable

Selection of Appropriate Route of Administration Oral KCl replacement is the prefered method. IV K replacement when the pt. cannot take oral medicines when the K deficit is very severe and is acutely causing cardiac arrhythmias, quadriplegia, respiratory failure, or rhabdomyolysis

Selection of Appropriate Route of Administration In a non-dextrose-containing solution In a concentration of 40mmol/l No more than 60mmol/l should be given through a peripheral vein

Selection of Appropriate Rate of Administration Mild to moderate hypokalemia (3.0~3.5 mmol/l) Well tolerated in the absence of digitalis therapy or severe hepatic disease Treatment is not urgent Oral KCL at an initial dose of 60-80mmol/day 100-150 mmol/day : if there is continued potassium loss

Selection of Appropriate Rate of Administration 1.0-1.5mmol/l after 40-60 mmol 2.5-3.5 mmol/l after 135-160mmol These maximum effects are transient, since most of the administered potassium will enter the cells to repair the cell deficit. IV not excedd 10-20mmol/h Emergent therapy : 5-10mmol over 15-20min, repeated as needed 40-100mmol/h : paralysis of repisatory m. or life threatening of ventricular arrhythmias

Potassium chloride Potassium citrate Potassium phosphate 케이콘틴 서방정(KCL), 8mEq/T Potassium citrate 유로시트라씨산 (UROCIT) Potassium phosphate 포스텐주 (7PHOS) , 20mEq