Management of Hyperkalemia & Hypokalemia

1. Management of
Hyperkalemia and
Hypokalemia
Dr. Tehzeeb Sialvi

2. Points to cover:
› Potassium as an electrolyte
› Definitions of Hypo and Hyperkalemia
› Causes
› Clinical Manifestations
› Management

3. Potassium (K+)
› Potassium is an alkaline element in group I of the
periodic table.
› It is predominantly an intracellular electrolyte; 98%
is present in the IC space , while only 2% is present
extracellularly.
› Normal serum levels of K+ are 3.5-5 mEq/L.
› Daily K intake of atleast 90 mmol/L (3510 mg/day) is
recommended by WHO.

4. Functions of K+:
• Regulates intracellular osmolality
• Helps in contraction of smooth and
skeletal muscles
• Maintains normal cardiac rhythm

5. Hypokalemia:
› It refers to serum potassium <3.5 mmol/L.
Causes:
› Redistribution into cells:
1. Alkalosis
2. Hyperinsulinemia
3. Beta-2 agonists & Alpha antagonists

6. › Gastrointestinal losses:
With alkalosis:
1. Vomiting
2. NG aspiration
With acidosis:
1. Diarrhea
2. Laxative abuse
3. Villous adenoma of rectum
4. Bowel obstruction / fistula

7. › Renal losses:
1. Diuretics (loop or thiazide)
2. DKA
3. Hyperaldosteronism
4. Decreased circulatory volume
5. Hypomagnesemia

8. Clinical Features:
› Fatigue
› Muscular cramps
› Ascending paralysis / Respiratory muscle weakness
› Abdominal distension due to paralytic ileus
› Hypotension/ Hyporeflexia
› Paresthesia
› Cardiac arrhythmias (atrial, ventricular ectopic
beats)

9. ›ECG Findings:
1. Flattened T- waves
2. U- wave
3. ST- depression

10. Treatment:
› Treat the underlying disorder.
› Oral and/or IV potassium replacement.
Calculating K+ Deficit:
0.4 x Body weight (in kgs) x (Normal K+ limit –
Serum K+)
Maintenance dose:
1 mEq = 1 kg
K+ replacement:
K+ deficit + Maintenance dose

11. Hyperkalemia:
› It refers to serum potassium >5 mmol/L.
Causes:
› Decreased excretion:
1. Renal insufficiency
2. Drugs (ACEIs, ARBs, K+ sparing diuretics,
NSAIDs)
1. Hypoaldosteronism
2. Type IV Renal Tubular Acidosis

12. › Redistribution out of cells:
1. Tissue injury (Rhabdomyolysis)
2. Insulin deficiency
3. Drugs (Digoxin, Beta- blockers)
4. Resorption of blood (Hematomas, GI bleed)
5. Hyperosmolarity of ECF

13. › Spurious:
1. Hemolysis of blood samples
2. Fist clenching during blood draws
3. Thrombocytosis
4. Leucocytosis

14. Clinical features:
› Nausea, vomiting and intestinal colic
› Muscular weakness
› Flaccid paralysis
› Cardiac conduction abnormalities
› Cardiac arrhythmias

15. › ECG Findings:
1. Tall, peaked T- waves
2. Wide QRS complex
3. PR prolongation
4. Loss of P- waves
5. Can progress to V-Fib and cardiac arrest

16. Treatment:
• Urgent treatment is required if:
 Acute onset
 Severe hyperkalemia (>6.5-7 mmol/L)
Step 1: Stabilize cell membrane potential:
 IV calcium gluconate
 10% of 1o ml solution over 2 minutes

17. Step 2: Shift K+ into cells:
 IV glucose and insulin
 Inhaled beta-2 agonist (Salbutamol)
 IV sodium bicarbonate (if acidosis present)
Step 3: Remove K+ from body:
 IV furosemide and normal saline
 Ion-exchange resin (sodium polystyrene sulfonate/
Kayexalate) orally or rectally
 Dialysis (in renal failure or severe, refractory cases)

18. Thank you!