Potassium

Potassium Function
● The principal intracellular cation (98 % of total
body K+)
● Major affecting intracellular osmolality
● Membrane depolarization (muscle contraction)
mainly affected by the ratio IC-K+ to EC-K+
● Roles in protein metabolism, growth hormone
release and intracellular pH
 Intracellular (88.6 %) *
Exchangeable (90 %) Plasma (0.4 %)
Lymph (1.0 %)
Body potassium
Connective tissue (0.4 %)
Nonexchangeable (10 %) Bone (7.6 %)
Intracellular (2.0 %)
Total body potassium 35-50 mmol/kg
* 70 % in the skeletal muscle
 Potassium Balance
Normal serum K+
● 3.5 ~ 5.0 mmol/L
Normal plasma K+
● 3.1 ~ 4.2 mmol/L
Gastrointestinal regulation
● The daily intake : 40-150 mmol
● Normal loss : 10-15 % of the daily ingested
● Diarrhae : 10-100 mmol/L
Renal regulation
● The daily glomerular filtration : 600-900 mmol, all is
reabsorbed before reach distal segment
● Distal nephrone excretion : 10-700 mmol/day
Normal serum Potassium levels in children

Range (mEq/L or
Age
mmol/L)
Premature infant 4.0 to 6.5
Newborn 3.7 to 5.9
Infant 4.1 to 5.3
Child >1 year old 3.5 to 5
 ICF/ECF Potassium Balance (1)
● The Na/K pump driven by NaK-ATPase
● Factors stimulating entry into cell
• Hormonal : insulin, beta adrenergics, aldosteron (?)
• Physical : alkalemia
● Factors stimulating exit from cell
• Hormonal : glucagon, alpha adrenergic, beta
blockade
• Physical : acidemia, hyperosmolality
 ICF/ECF Potassium Balance (2)
● For each 0.1 unit change in blood pH, increase or
decrease plasma K+ by 0.6 mmol/L
● For each 10 mosmol/kg increase in tonicity, increase
plasma K+ by 0.1-0.6 mmol/L
● Insulin decrease ICF/ECF K+ leak and stimulate NaK-
ATPase
● Alpha adrenergic agonists increase plasma K+ by
promoting hepatic K release and reducing skeletal
muscle uptake
● Beta 2 adrenergic agonists promote cellular uptake K
by a cAMP activation of Na-K pump
Potassium imbalance
● Hypokalemia
● Hyperkalemia
Hypokalemia
 Hypokalemia
Serum K+ < 3.5 mmol/L or
Plasma K+ < 3.0 mmol/L
● An 1 meq/L decrease in serum K+ corresponds to a
loss of approximately 10- 30 % of body K+
● Severe hypokalemia/life threatening symptoms is
defined as a serum K+ of less then 2.0 mmol/L
● Daily K+ requirement 1-3 meq/kg body weight
 Major causes of hypokalemia (1)
Decreased K+ intake
Increased entry into cells
An elevation in extracellular pH
Increased availability of insulin
Elevated β-adrenergic activity - stress or administration
of beta agonists
Hypokalemic periodic paralysis
Marked increase in blood cell production
Hypothermia
Chloroquine intoxication
Increased gastrointestinal losses
Vomiting
Diarrhea
Tube drainage
Laxative abuse
 Major causes of hypokalemia (2)
Increased urinary losses
Diuretics
Primary mineralocorticoid excess
Loss of gastric secretions
Nonreabsorbable anions
Renal tubular acidosis
Hypomagnesemia
Amphotericin B
Salt-wasting nephropathies - including Bartter's or
Gitelman's syndrome
Polyuria
Increased sweat losses
Dialysis
Plasmapheresis
Bartter syndrome
Hypokalemia, hypereninemia,
hyperaldosteronism, hyperplasia of the
juxtaglomerular app, normotension, resistance
to angiotensin II, failure to thrive (chronic
hypokalemia)

Gitelman syndrome
Hypokalemia, tetany, hypomagnesemia,
hypocalciuria, normal growth
The clinical features of Hypokalemia
prolonged QRS, U-Wave, low voltage T-
wave, atrial & ventricular ectopy, increased
Cardiac
sensitivity to digitalis, ventricular & atrial
tachycardias, Torsades de pointes
weakness, hypotonicity, ascending
Skeletal muscle paralysis, ventilatory failure, cramps,
rhabdomyolysis
Gastro intestinal constipation, ileus
CNS depression, lethargy, confusion, coma
nephrogenic diabetes insipidus, metabolic
Renal
alkalosis
Endocrine glucose intolerance
 ECG in Hypokalemia

Normal rhythm strip

Prominent U waves
 Hypokalaemia

ECG : Sinus rhythm, normal axis, narrow QRS complex, ST depression V3-V5,
prolonged QT interval, T-waves unseparable from giant U-waves seen V2–6
ECG in various level of Hypokalemia
 Management Hypokalemia
● Identify the cause of hypokalemia
● Estimate the defisit
● Administer K+ salts
● Administer the iv replacement carefully
● Monitor the serum level
 Oral administration of Potassium
● Mild hypokalemia
● Safest, although solutions may cause diarrhea
● K+ salts (chloride, bicarbonate/citrate)
● Dosage : 2-4 meq/kg body weight in divided doses
● The K+ content : bananas, 7-8 meq/100 g; orange
juice, 5 meq/100 g; meat, 10 meq/100 g
Indication of iv Potassium administration

● Serum K+  2.5 meq/L

● EKG changes
● Muscle weakness
Intra venous Potassium administration
● Peripheral: do not exceed 40-50 mEq
● Delivery rate : 10-40 mEq/hour; avoid temptation
to rapidly bolus
● Central: 0.5 -1 mEq/kg over 1-3 hours, depending
on severity
● Severe hypokalemia : > 40 mEq/hour, split into
two portions and administer via two separate lines
● Close monitoring of serum K+ level
● Replace magnesium also (25-50 mg/kg MgSO4) if
low
Hyperkalemia
 Hiperkalemia
Serum Potassium >5.5 mEq/L
● Can cause lethal cardiac arrhythmia
● One of the most serious electrolyte
disturbances
 Major causes of hyperkalemia (1)
Increased K+ release from cells
Pseudohyperkalemia
Metabolic acidosis
Insulin deficiency, hyperglycemia, and hyperosmolality
Increased tissue catabolism
Beta blockers
Exercise
Hyperkalemic periodic paralysis
Other
Overdose of digitalis or related digitalis glycosides
Red cell transfusion
Succinylcholine
Arginine hydrochloride
Activators of ATP-dependent K+ channels (eg, calcineurin
inhibitors, diazoxide, minoxidil, and some volatile
anesthetics)
 Major causes of hyperkalemia (2)
Reduced urinary K+ excretion
Reduced aldosterone secretion
Reduced response to aldosterone
Reduced distal sodium and water delivery
Effective arterial blood volume depletion
Acute and chronic kidney disease
Other
Selective impairment in K+ secretion
Gordon's syndrome
Ureterojejunostomy
 Causes of hyperkalemia in children
based on pathophysiology (1)
Category Cause
Exposure to high K+ loads in
Increased K+ intake (rare intravenous fluids or medications
cause of hyperkalemia with Exposure to K+ containing
the exception of children medications
with chronic kidney disease) Massive transfusions of stored
blood
Structural cellular damage :
Hemolysis , Rhabdomyolysis,
Tumor lysis
Transcellular K+ movement No structural cellular injury :
Metabolic acidosis , Diabetic
ketoacidosis , Hyperkalemia
periodic paralysis
 Causes of hyperkalemia in children
based on pathophysiology (2)
Category Cause
Decreased effective circulating vol
Decreased RAAS activity : Adrenal
hyperplasia, Adrenal insufficiency,
Drugs (ACE inhibitor/ARB, eplere-
none, spironolactone, or aliskiren)
Significant renal impairment with
Abnormal renal K+ excretion either acute or chronic loss of GFR
Impaired tubular K+ secretion :
Reflux nephropathy, Obstructive
uropathy, Sickle cell nephropathy,
Drug effect (amiloride,
triamterene), Hypoaldosteronism
(type IV renal tubular acidosis)
Hemolyzed specimen
Pseudohyperkalemia
Leukocytosis or thrombocytosis
 · Hemolysis or tissue ischemia during phlebotomy
Pseudo
· Thrombocytosis or leukocytosis (affects serum K+ but not
plasma K+)

· Blood transfusion (increasing risk with duration of cell storage)

Increased
· Intravenous (IV) or oral potassium
intake
· Maintenance K+ in IVF or oral solutions combined with
decreased renal function

· Metabolic acidosis
· Acute tubular necrosis
· Electrical burns
· Thermal burns
· Cell depolarization
Transcellular
Hyperkalemia shift
· Congenital adrenal hyperplasia
· Head trauma
· Rhabdomyolysis
· Digitalis toxicity
· Tumor lysis syndrome
· Succinylcholine use in a child with neuromuscular disease,
prolonged bedrest (including patients in ICUs), or more
than 24 hours after crush or burn injury
· Acute renal failure
· Primary adrenal disease
Decreased
· Hyporeninemic hypoaldosteronism
excretion
· Renal tubular disease
· Medications (eg, potassium sparing diuretics, ACE inhibitors,
angiotensin II blockers)
 Clinical features of hyperkalemia
· Signs and symptoms are uncommon and tend to
occur only when the serum K+ > 7.0 meq/L;
· Symptoms can include muscle weakness and
ventricular arrhythmias
· Pseudohyperkalemia, due to hemolysis of the blood
specimen, is the most common cause of a reported
elevation in serum K+ and must be excluded; does
not reflect true hyperkalemia and does not produce
ECG changes
 Symptoms/Signs of Hyperkalemia
● Depend on the degree of hyperkalemia
● Primarily relate to cardiac conduction
● High serum levels interfere cellular membrane
repolarization
● Mild: asymptomatic, nausea, vomiting, and paresthesias
(eg, tingling)
● Severe: EKG changes (peaked T-wave, increased P-R
interval, widened QRS, depressed ST segment, AV or
intraventricular heart block, ventricular flutter, fibrillation,
cardiac arrest)
● Respiratory failure and weakness that progresses to
paralysis
 ECG manifestations in hyperkalemia
· Large interpatient variability exists in the relationship
between the serum K+ and ECG changes
· ECG changes are more common with acute elevations
and less common with chronic elevations (eg, chronic
kidney disease)
· Careful cardiac monitoring and serial ECGs are essential
· ECG findings commonly progress as follows:
· Peaked T waves
· Prolonged PR and QRS intervals, and small P waves
· Loss of P wave, further prolongation of QRS interval
("sine wave" pattern), and conduction delay that can
manifest as bundle branch or AV nodal block
· Ventricular fibrillation or asystole can result
ECG changes in Hyperkalemia
● Peaked T waves, that progress to
● Widening of the QRS, and then to
● Sine wave pattern
ECG in various level of Hyperkalemia
 ECG in moderate hyperkalaemia

ECG : absence of the p-wave, widened QRS complex, peaked

T-waves V3-V4
 ECG in severe hyperkalaemia

ECG : absence of the P-wave, extremely bizarre widened QRS

complexes, (sine wave appearance)
Ventricular fibrillation
 Laboratory evaluation
● All patients with true hyperkalemia should have the
following tests obtained:
● Blood urea nitrogen (BUN)
● Creatinine
● Blood glucose
● Serum electrolytes
● Urine specific gravity, pH, and electrolytes
● In cases where rhabdomyolysis is suspected, the following
studies are also indicated:
● Serum creatine kinase and lactic dehydrogenase
● Urine for myoglobin
● Blood gas
● In cases where adrenal insufficiency is suspected,
additional testing includes: Serum cortisol and ACTH (prior
to administration of exogenous corticosteroids)
 Initial diagnostic studies to assess
unexplained hyperkalemia in a child (1)
NOTE : No obvious risk factor for hyperkalemia and normal volume
status ~ Repeat testing of serum/plasma K+ to differentiate from
pseudohyperkalemia

Diagnostic studies To assess

Complete blood count, Blood dyscrasia or hemolysis
platelets, and serum lactic
dehydrogenase (LDH)
Serum creatine kinase (CK) Muscle injury
Blood electrolytes (Na+, K+, Other electrolyte
bicarbonate, chloride) abnormalities (i.e. metabolic
acidosis
Serum creatinine and blood Renal function
urea nitrogen
 Initial diagnostic studies to assess
unexplained hyperkalemia in a child (2)
NOTE : No obvious risk factor for hyperkalemia and normal volume
status ~ Repeat testing of serum/plasma K+ to differentiate from
pseudohyperkalemia

Diagnostic studies To assess

Urinalysis (Urine chemistries ,
Urine K+, Urine Na+
Renal disease :
K+ values should be > than 20
mEq/L
Na+ values < than 20 mEq/L
suggest increased proximal Na+
absorption and a decrease in Na+
delivery in the distal tubule
resulting in impaired K+ excretion
due to limited availability of Na+
for exchange

Serum aldosterone and Clinical concern for

plasma renin activity endocrinopathy
 Treatment of hyperkalemia
Antagonism of membrane actions of K+
Calcium
Drive extracellular K+ into the cells
Insulin and glucose
Sodium bicarbonate, primarily if metabolic acidosis
β2-adrenergic agonists
Removal of K+ from the body
Loop or thiazide diuretics
Cation exchange resin
Dialysis, preferably hemodialysis if severe
 Hyperkalemia management
· Confirm the patient is truly hyperkalemic (ie, exclude
pseudohyperkalemia)
· Obtain electrocardiogram and, if signs of hyperkalemia
are seen, place patient on cardiac monitor
· Stabilize cardiac membranes with calcium: give only
for hyperkalemia with significant ECG findings (eg,
widening of the QRS complex or loss of P waves, but
not peaked T waves alone) or severe arrhythmias
thought to be caused by hyperkalemia
· Shift K+ into cells: give insulin and glucose; Beta 2
agonist; Sodium bicarbonate
· Remove Potassium : cation exchange resin (sodium
polystyrene sulfonate); loop or thiazide diuretic;
hemodialysis
 Hyperkalemia management
Time to
Drugs Dose Note
onset
Calcium Adults : Ca chloride 500 to immediate May be repeated after 5
1000 mg (5 to 10 mL of minutes if ECG changes
10 % solution) by IV persist;
infusion slowly over 2 to 3 Patient must be on
minutes, preferably via a cardiac monitor;
central line; or calcium can exacerbate
Ca gluconate 1000 mg (10 digoxin toxicity
mL of 10 percent solution) Since the effect is
infused slowly; may be transient, patients also
given peripherally in large require treatments to
vein; Children : Ca shift K+ into cells and to
gluconate (10 % solution) remove K+
0.5 mL/kg
 Hyperkalemia management
Time to
Drugs Dose Note
onset
Insulin and IV bolus of regular insulin 10 to 20 Give to patients with
glucose 10 U with 50 mL of a 50 minutes ECG changes OR serum
% glucose solution; K+ ≥6.5 to 7 meq/L
Children : regular insulin after insulin and glucose
0.2 U per gram of glucose; start dextrose infusion;
glucose 1 g/kg monitor fingerstick
glucose closely
Beta 2 10 to 20 mg in 4 mL saline 20 to 30 IV albuterol or
agonist nebulized over 10 minutes minutes epinephrine are
albuterol (metered dose inhaler); alternatives
pediatric dose 0.1 to 0.3
mg/kg;
Sodium 150 meq in one liter of - provides minimal effect,
bicarbonate D5W at 250 mL/hour; do treat-ments to remove
not give Ca in same IV K+ are also required
 Hyperkalemia management
Time to
Drugs Dose Note
onset
Cation 15 to 30 grams (without 1 to 2 Sorbitol can cause
exchange sorbitol) orally; hours intestinal necrosis;
resin (sodium Pediatric : 1 g/kg; may Do not give sodium
polystyrene repeat after 4 to 6 hours polystyrene sulfonate or
sulfonate) based upon serum K+ sorbitol to post-
May be given as a operative or renal
retention enema (dose is transplant patients
50 g) without sorbitol
Loop or furosemide 20 to 40 mg - Limited short-term
thiazide IV; pediatric : 1 to 2 effect; fluid losses must
diuretic: mg/kg IV; higher dose be replaced unless the
may be required with patient is volume
renal insufficiency expanded
Hemodialysis If the conservative measures fail, hyperkalemia is severe, renal
failure, marked tissue breakdown releasing large amounts of K+
 Treatment of hyperkalemia in children (1)
Agent Dose Onset of action
Stabilization of cardiac myocardial membrane in setting of
hyperkalemia-associated abnormal ECG or arrhythmia
0.5 to 1 mL/kg IV
over 5 to 15 min (50
to 100 mg/kg calcium
Calcium gluconate, 10
gluconate, maxiumum Immediate
percent*
dose 3 grams)
Repeat after 10
minutes, if needed
Movement of extracellular K+ into the cells
IV administration of
glucose 0.5
g/kg (equal to 2
mL/kg of a 25 percent
Glucose and insulin 30 minutes
dextrose solution)
IV administration of
insulin 0.1 units/kg
over 30 min
 Treatment of hyperkalemia in children (2)
Agent Dose Onset of action
Movement of extracellular K+ into the cells
Inhaled beta-agonists
0.1 to 0.3 mg/kg 30 minutes
(albuterol)
IV administration of 1
mEq/kg over 10 min
Sodium bicarbonate 15 minutes
(maximum dose of 50
mEq per hour)
Removal of K+
Sodium polystyrene 1 g/kg PO or PR with
1 to 2 hours
sulfonate sorbitol
IV administration of 1
to 2 mg/kg with
Furosemide 1 to 2 hours
replacement of fluid
loss
Hemodialysis
Note :
● Calcium administered in a larger vein or central line (irritant)
● Sodium bicarbonate not introduced into the line (precipitation)
 Hyperkalemia

►
True?

No (Pseudo) Yes

►
Serum
No treatment potassium?

< 6 mEq/L > 6 mEq/L > 6.5 mEq/L

Asymptomatic? Symptomatic, with EKG changes?

►

►
Kayexalate 0.5-1.0 g/kg PO/PR in 5ml 20% Sorbitol Calcium 100 mg/kg slow IV
►

►
Monitor K+ Na Bic 1-2 mEq/kg IV

►
Glucose 1-2 g/kg as D25 4-8 ml/kg IV bolus followed by continuous
infusion of D15 0.2 % NS + 4 U regular Insulin/100 ml, at infusion
rate = patient’s fluid requirements

►
Monitor K+

►
Consider peritoneal or hemodialysis for refractory/
renal failure cases