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

2. 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

3. 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

4. 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 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.

5. 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

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

7. 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
mEq/l/h

8. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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
mmol/day : if there is continued potassium loss

17. Selection of Appropriate Rate of Administration
mmol/l after mmol
mmol/l after mmol
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

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