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WHEN
EVERYTHING IS
NOT O.

Dr Rajesh Kulkarni
B.J.Medical College,Pune
MD,MRCPCH(UK)
CASE 1
Rahul a 2 year old boy with moderate VSD on Tab
Furosemide 3 mg/kg/day since last 18 months.He had
8 episodes of di...
CASE 1 CONTD..
Rahul was started on plan “B” management of
dehydration.(ORS 75 ml/kg over 4 hours)
An ECG was done(for hea...
CASE 1—CONTD..


ECG:
CASE 1 CONTD..


LAB: Na 131 mEq/L,
K 2 mEq/L



RISK FACTORS FOR HYPOKALEMIA
CASE SCENARIO 2


Vinita is a 7 year old girl, known c/o type 1
diabetes on insulin. She is admitted to the PICU
with Sev...
POTASSIUM


Most abundant cation in human body ,Normal serum
value 3.5 to 5.5 mEq/L.



Regulates intracellular enzyme f...
HOW INTRACELLULAR K+ CONTENT
IS MAINTAINED
HYPOKALEMIA
 Defined

mEq/L

as plasma concentration of K+ < 3.5

 Mild

Hypokalemia : 3.0 – 3.5 mEq/L :
asymptomatic

...
CLINICAL FEATURES


Muscle weakness and flaccid paralysis



Depressed or absent deep-tendon reflexes.





Hypoactive...
SIC WALT
FACTORS THAT DECREASE
K+LEVELS


Aldosterone (Increases sodium resorption, and
increases K+ excretion)



Insulin (Stimu...
DIAGNOSIS – ETIOLOGY


Due to



Decreased net intake :Uncommon



Shift into cells



Increased net loss



Cause is...
HISTORY
Increased excretion :
Medications (eg, diuretics,  antibiotics )
Polyuria
Vomiting or diarrhea
 Shift of potassiu...
WHAT IF CAUSE IS NOT
APPARENT??


Urinary K excretion(spot test)



ABG



TTKG=(Urine K+/Plasma K+) / (Urine Osm/Plasm...
FIRST LINE INVESTIGATIONS
Serum Electrolytes, Urinary Potassium
 ECG
Initially : flattening of t wave
depression of ST Se...
SECOND LINE TESTS
Biochemical tests
Serum renin, aldosterone, and cortisol
24-hour urine aldosterone, cortisol, sodium, an...
MANAGEMENT


Reduction of potassium losses



Replenishment of potassium stores
REDUCTION OF POTASSIUM LOSSES


Discontinue diuretics/laxatives



Use potassium-sparing diuretics like
spironolactone o...
REPLENISHMENT OF POTASSIUM
STORES


Patients who have mild or moderate hypokalemia
( 2.5-3.5 mEq/L) ;asymptomatic patient...
MANAGEMENT
•

In Severe Hypokalemia(Potassium <2) or
symptomatic patients IV Correction
required,
add: 30 meq / L of IV fl...
CAUTION!!!

Marked hypokalemia:
Monitor serum K closely
0.5-1 mEq/kg/dose given as an
infusion of 0.5 mEq/kg/hr for 1-2
ho...
REVISION—WHICH PATIENTS CAN
HAVE HYPOKALEMIA


Neuromuscular weakness (AFP) esp.if recurrent,
unable to wean off ventilat...
HYPOKALEMIA---TAKE HOME
MESSAGE


Anticipate Hypokalemia in children with
diarrhea,children on diuretics,during treatment...
HYPERKALEMIA
CASE


A 2 Year old boy was brought to hospital with h/o
loose motions and vomiting since 3 days.



He has not passed u...
HYPERKALEMIA

K+ above 5.5 mEq/L,
 Premature infants /young children upto 6.5
mEq/L normal.

FACTORS INCREASING K+


Alpha-adrenergic agents(Impairs cellular K+
uptake)



Acidosis (Impairs cellular K+ uptake)


...
CLINICAL MANIFESTATIONS
Patient may be ASYMPTOMATIC or may have
NONSPECIFIC symptoms or may present with
arrythmia/ CARDIA...
IS THIS LAB REPORT CORRECT?


Fictitious Hyperkalemia :
hemolysis,
"milking" of extremities ,
thrombocytosis or leucocyto...
TRUE HYPERKALEMIA
DECREASED EXCRETION


Most common cause is Oliguric renal failure.



Other causes include
Primary adrenal disease (e g,...
INCREASED K+ INTAKE


Intravenous or oral potassium supplementation.



Packed RBCs (PRBCs)transfusion
TRANSCELLULAR SHIFTS


Acidosis most common cause



Process that leads to cellular injury or death (eg,
Tumor lysis syn...
INVESTIGATIONS
FIRST LINE:
 Serum electrolyte tests.
 Serum BUN and creatinine tests
 Urinalysis (UA),ECG,TTKG<6 s/o re...
ECG CHANGES


Tall Peaked T waves (K 6.5)



Prolonged PR, Flat or absent P waves(K 7.5)
ECG CHANGES


Widened QRS (>0.12 Sec) ,



Sine wave pattern(S and T waves merging) (K
8.5)
ECG CHANGES


Bradycardia, Ventricular Tachycardia (K 9.0)
MANAGEMENT


Immediately discontinue any IV potassium
containing fluid/any drugs that may cause
hyperkalemia.
STABILIZE MYOCARDIUM


IV Calcium Gluconate (10 %) 0.5 mL/kg IV
over 2-4 min,monitor for bradycardia.May
repeat.Has trans...
SHIFT K INTO CELL


Regular insulin and glucose IV
2ml/kg 50% dextrose (1g/kg) and 0.1units/kg of
regular Insulin over 5-...
SHIFT K INTO CELLS CONTD…


Sodium bicarbonate(7.5%) IV
2 cc / kg slowly ,?Efficacy, repetition not
recommended.



A Co...
INCREASE K EXCRETION


Loop or thiazide diuretics work well if
kidneys are functioning normally.



Kayexalate(Cation Ex...
INCREASE K EXCRETION CONTD..


Hemodialysis
Definitive method ,used in cases of severe
hyperkalaemia or when other treatm...
C BIG K DROP


C : Calcium Gluconate



B: Bicarbonate



I,G : Insulin and Glucose



K: Kayexelate



D: Diuretics ...
REVISION—AT RISK CHILDREN FOR
HYPERKALEMIA


Children with low or absent urine output
,hypertension ( ARF)



Children o...
HYPERKALEMIA-TAKE HOME
MESSAGE


Acute Renal Failure is most common cause of
hyperkalemia.



Uncommon causes like adren...
REFERENCES


Clinical manifestations and treatment of
hypokalemia .David Mount.Avaialble from
http://www.uptodate.com/con...
CASE HISTORY


A six month old boy was admitted to our hospital
with cough and fever for 4 days, repeated
vomiting and se...
CASE CONTD..


After vigorous fluid resuscitation he was
haemodynamically stabilized. Abdomen,
genitalia and nervous syst...
CASE CONTD..
His urine electrolytes revealed increased
excretion of sodium, potassium and chloride.
TTKG>4
His subsequent ...
THANK YOU
ALTERNATIVE APPROACH TO
HYPOKALEMIA


Investigations Required

Urine Potassium
ABG
Urine chloride
Renin/Aldosterone
Hypokalemia and hyperkalemia indore pedicon 2014 final
Hypokalemia and hyperkalemia indore pedicon 2014 final
Hypokalemia and hyperkalemia indore pedicon 2014 final
Hypokalemia and hyperkalemia indore pedicon 2014 final
Hypokalemia and hyperkalemia indore pedicon 2014 final
Hypokalemia and hyperkalemia indore pedicon 2014 final
Hypokalemia and hyperkalemia indore pedicon 2014 final
Hypokalemia and hyperkalemia indore pedicon 2014 final
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POTASSIUM DISTURBANCES,HYPOKALEMIA,HYPERKALEMIA,CHILDREN

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Hypokalemia and hyperkalemia indore pedicon 2014 final

  1. 1. WHEN EVERYTHING IS NOT O. Dr Rajesh Kulkarni B.J.Medical College,Pune MD,MRCPCH(UK)
  2. 2. CASE 1 Rahul a 2 year old boy with moderate VSD on Tab Furosemide 3 mg/kg/day since last 18 months.He had 8 episodes of diarrhea since today morning and was brought to the ED. On examination,the pediatric resident noted “some”dehydration.He also noted abdominal distension with sluggish bowel sounds.
  3. 3. CASE 1 CONTD.. Rahul was started on plan “B” management of dehydration.(ORS 75 ml/kg over 4 hours) An ECG was done(for heart disease) and routine tests including electrolytes were ordered.
  4. 4. CASE 1—CONTD..  ECG:
  5. 5. CASE 1 CONTD..  LAB: Na 131 mEq/L, K 2 mEq/L  RISK FACTORS FOR HYPOKALEMIA
  6. 6. CASE SCENARIO 2  Vinita is a 7 year old girl, known c/o type 1 diabetes on insulin. She is admitted to the PICU with Severe DKA and given IV fluids and insulin as per hospital protocol.  Her initial investigations show K of 4.4 mEq/L and the on duty resident feels she might get hyperkalemia if he adds more potassium to the fluids  After 4 hours she c/o severe weakness and inability to move her limbs. Her DTR are absent.
  7. 7. POTASSIUM  Most abundant cation in human body ,Normal serum value 3.5 to 5.5 mEq/L.  Regulates intracellular enzyme function and helps to determine neuromuscular & cardiovascular tissue excitability. 90 % of total body K+ : Intracellular ( predominantly in muscle )  10 % : Extracellular fluid   < 1 % : Plasma
  8. 8. HOW INTRACELLULAR K+ CONTENT IS MAINTAINED
  9. 9. HYPOKALEMIA  Defined mEq/L as plasma concentration of K+ < 3.5  Mild Hypokalemia : 3.0 – 3.5 mEq/L : asymptomatic  Hypokalemia 2.5 to 3.0 mEq/L : Moderate, may be symptomatic  Hypokalemia symptomatic < 2.5 mEq/L : Severe, may be
  10. 10. CLINICAL FEATURES  Muscle weakness and flaccid paralysis  Depressed or absent deep-tendon reflexes.   Hypoactive bowel sounds or ileus,constipation Severe hypokalemia : Bradycardia with cardiovascular collapse, cardiac arrhythmias and acute respiratory failure from muscle paralysis
  11. 11. SIC WALT
  12. 12. FACTORS THAT DECREASE K+LEVELS  Aldosterone (Increases sodium resorption, and increases K+ excretion)  Insulin (Stimulates K+ entry into cells by increasing sodium efflux)  Beta-adrenergic agents(Increases skeletal muscle uptake of K+ )  Alkalosis (Enhances cellular K+ uptake)
  13. 13. DIAGNOSIS – ETIOLOGY  Due to  Decreased net intake :Uncommon  Shift into cells  Increased net loss  Cause is usually apparent on HISTORY and physical examination.
  14. 14. HISTORY Increased excretion : Medications (eg, diuretics,  antibiotics ) Polyuria Vomiting or diarrhea  Shift of potassium into the intracellular space Recurrent episodes of paralysis Use of high doses of insulin High-dose beta-agonist therapy (e.g, for Asthma) 
  15. 15. WHAT IF CAUSE IS NOT APPARENT??  Urinary K excretion(spot test)  ABG  TTKG=(Urine K+/Plasma K+) / (Urine Osm/Plasma Osm) Hypokalemia with extra renal losses,TTKG is <2 (kidney conserves K+) Hypokalemia with high TTKG suggests renal loss (Not accurate if urine dilute or urine sodium <25 mmol/L)
  16. 16. FIRST LINE INVESTIGATIONS Serum Electrolytes, Urinary Potassium  ECG Initially : flattening of t wave depression of ST Segment development of prominent u waves  Severe hypokalemia : increased amplitude of p wave increased QRS duration 
  17. 17. SECOND LINE TESTS Biochemical tests Serum renin, aldosterone, and cortisol 24-hour urine aldosterone, cortisol, sodium, and potassium Serum anion gap Drug screen in urine and/or serum  Hormones Thyroid Function Tests  Radiology Pituitary imaging to evaluate for Cushing syndrome Adrenal imaging to evaluate for adenoma Evaluation for renal artery stenosis 
  18. 18. MANAGEMENT  Reduction of potassium losses  Replenishment of potassium stores
  19. 19. REDUCTION OF POTASSIUM LOSSES  Discontinue diuretics/laxatives  Use potassium-sparing diuretics like spironolactone or amiloride if diuretic therapy is required (e.g, severe heart failure)  Treat diarrhea or vomiting
  20. 20. REPLENISHMENT OF POTASSIUM STORES  Patients who have mild or moderate hypokalemia ( 2.5-3.5 mEq/L) ;asymptomatic patients: ORAL THERAPY PREFERRED POTCHLOR STRENGTH: 20 ml=15 mEq KESOL 5 ml= 13 mEq Dose : 0.5-2 mEq/kg PO q12hr (How to give?)
  21. 21. MANAGEMENT • In Severe Hypokalemia(Potassium <2) or symptomatic patients IV Correction required, add: 30 meq / L of IV fluid 40 meq / L of IV fluid 50 meq / L of IV fluid 60 meq / L of IV fluid 70 meq / L of IV fluid  ECG monitoring  Frequent testing I.V.KCL K+ is 2 mEq/ml (RECHECK!!!)
  22. 22. CAUTION!!! Marked hypokalemia: Monitor serum K closely 0.5-1 mEq/kg/dose given as an infusion of 0.5 mEq/kg/hr for 1-2 hour BOLUS OF KCL I.V. SHOULD NOT BE GIVEN
  23. 23. REVISION—WHICH PATIENTS CAN HAVE HYPOKALEMIA  Neuromuscular weakness (AFP) esp.if recurrent, unable to wean off ventilator.  Unexplained abdominal distension,constipation  Children with Asthma , Heart disease and children on medications that cause polyuria or loss of K in urine  Children who have rhythm abnormalities( Bradycardia,hypotension,low volume pulse)
  24. 24. HYPOKALEMIA---TAKE HOME MESSAGE  Anticipate Hypokalemia in children with diarrhea,children on diuretics,during treatment of DKA.  Uncommon causes like Bartter syndrome,RTA should be considered –look for clues in history,examination and investigations.  Oral route is safe and effective,IV only if K is less than 2.5 or symptoms present.  DOUBLE CHECK IV Potassium prescriptions
  25. 25. HYPERKALEMIA
  26. 26. CASE  A 2 Year old boy was brought to hospital with h/o loose motions and vomiting since 3 days.  He has not passed urine since 24 hours.  BUN 160 mg/dl ,Creatinine 5.4 mg/dl  Na 123 mEq/L ,K 7.5 mEq/L
  27. 27. HYPERKALEMIA K+ above 5.5 mEq/L,  Premature infants /young children upto 6.5 mEq/L normal. 
  28. 28. FACTORS INCREASING K+  Alpha-adrenergic agents(Impairs cellular K+ uptake)  Acidosis (Impairs cellular K+ uptake)  Cell damage (Intracellular K+ release)  Hypoaldosteronism
  29. 29. CLINICAL MANIFESTATIONS Patient may be ASYMPTOMATIC or may have NONSPECIFIC symptoms or may present with arrythmia/ CARDIAC ARREST Respiratory failure and weakness that progresses to paralysis.  Nausea, vomiting, and paresthesias (eg, tingling). 
  30. 30. IS THIS LAB REPORT CORRECT?  Fictitious Hyperkalemia : hemolysis, "milking" of extremities , thrombocytosis or leucocytosis.
  31. 31. TRUE HYPERKALEMIA
  32. 32. DECREASED EXCRETION  Most common cause is Oliguric renal failure.  Other causes include Primary adrenal disease (e g, Addison disease, salt-wasting forms of congenital adrenal hyperplasia), Hyporeninemic hypoaldosteronism, Renal tubular disease (pseudohypoaldosteronism I[or II), or Medications (e g, ACE inhibitors, angiotensin II blockers, spironolactone or other potassiumsparing diuretics).
  33. 33. INCREASED K+ INTAKE  Intravenous or oral potassium supplementation.  Packed RBCs (PRBCs)transfusion
  34. 34. TRANSCELLULAR SHIFTS  Acidosis most common cause  Process that leads to cellular injury or death (eg, Tumor lysis syndrome, massive hemolysis) can cause hyperkalemia  Other causes include propofol ("propofol infusion syndrome"),toxins (digitalis intoxication), succinylcholine, beta-adrenergic blockade, strenuous or prolonged exercise, insulin deficiency, malignant hyperthermia, and hyperkalemic periodic paralysis.
  35. 35. INVESTIGATIONS FIRST LINE:  Serum electrolyte tests.  Serum BUN and creatinine tests  Urinalysis (UA),ECG,TTKG<6 s/o renal cause SELECTED CASES  ABG,Serum Uric Acid, CPK and calcium measurements),CBC,Urine electrolytes  Urine myoglobin test ,Specific drug level tests for suspected toxicity
  36. 36. ECG CHANGES  Tall Peaked T waves (K 6.5)  Prolonged PR, Flat or absent P waves(K 7.5)
  37. 37. ECG CHANGES  Widened QRS (>0.12 Sec) ,  Sine wave pattern(S and T waves merging) (K 8.5)
  38. 38. ECG CHANGES  Bradycardia, Ventricular Tachycardia (K 9.0)
  39. 39. MANAGEMENT  Immediately discontinue any IV potassium containing fluid/any drugs that may cause hyperkalemia.
  40. 40. STABILIZE MYOCARDIUM  IV Calcium Gluconate (10 %) 0.5 mL/kg IV over 2-4 min,monitor for bradycardia.May repeat.Has transient effect. Indicated in all cases of severe hyperkalemia (ie, >7 mEq/L), especially when accompanied by ECG changes
  41. 41. SHIFT K INTO CELL  Regular insulin and glucose IV 2ml/kg 50% dextrose (1g/kg) and 0.1units/kg of regular Insulin over 5-10 minutes (mixed in same syringe) ,can be repeated after 30 min. Rapid action,Monitor sugar post insulin  Beta-adrenergic agents, such as salbutamol neb. 2.5-5 mg or Epinephrine (0.05 µg/kg per minute by intravenous infusion)
  42. 42. SHIFT K INTO CELLS CONTD…  Sodium bicarbonate(7.5%) IV 2 cc / kg slowly ,?Efficacy, repetition not recommended.  A Cochrane review suggests that Dextrose/Insulin and salbutamol are the first line therapies most supported by evidence, and that a combination of the two therapies may be more effective than either alone. (Mahoney BA, et al. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev 2005;(2):CD003235.)
  43. 43. INCREASE K EXCRETION  Loop or thiazide diuretics work well if kidneys are functioning normally.  Kayexalate(Cation Excange Resin): exchanges Na for k. Dose: 1gm/kg/dose every 6 to 8 hrly PO/PR.
  44. 44. INCREASE K EXCRETION CONTD..  Hemodialysis Definitive method ,used in cases of severe hyperkalaemia or when other treatments have failed. K can be lowered by 1-1.5mmol/l for every hour of dialysis
  45. 45. C BIG K DROP  C : Calcium Gluconate  B: Bicarbonate  I,G : Insulin and Glucose  K: Kayexelate  D: Diuretics and Dialysis
  46. 46. REVISION—AT RISK CHILDREN FOR HYPERKALEMIA  Children with low or absent urine output ,hypertension ( ARF)  Children on drugs (K sparing diuretics,ACE inhibitors)  Children who have rhythm disturbances –always check K+
  47. 47. HYPERKALEMIA-TAKE HOME MESSAGE  Acute Renal Failure is most common cause of hyperkalemia.  Uncommon causes like adrenal insufficiency, aldosterone deficiency should be kept in mind.  Always take hyperkalemia seriously (potentially fatal).  Calcium gluconate ,Glucose insulin therapy and salbutamol neb can be lifesaving in hyperkalemia.
  48. 48. REFERENCES  Clinical manifestations and treatment of hypokalemia .David Mount.Avaialble from http://www.uptodate.com/contents/clinical-manifestations-and-t .  Pediatric Hypokalemia Treatment and Management . Michael J Verive.Available from http://emedicine.medscape.com/article/907757-treatment.  Mahoney BA, et al. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev 2005; (2):CD003235.
  49. 49. CASE HISTORY  A six month old boy was admitted to our hospital with cough and fever for 4 days, repeated vomiting and severe dehydration. Within the past three months he had suffered three similar episodes warranting hospitalization and IV fluids, but was normal between episodes and prior to onset.  Antenatal,perinatal and postnatal period was uneventful with normal development  On admission, he was in hypovolemic shock with tachycardia
  50. 50. CASE CONTD..  After vigorous fluid resuscitation he was haemodynamically stabilized. Abdomen, genitalia and nervous system appeared normal.  His CBC, blood urea, and creatinine were normal but despite serum sodium being normal (135meq/l), potassium (2.5meq/l) and chloride (92meq/l) were low. His arterial blood gas revealed metabolic alkalosis with a pH of 7.56
  51. 51. CASE CONTD.. His urine electrolytes revealed increased excretion of sodium, potassium and chloride. TTKG>4 His subsequent ultrasound scan of abdomen was normal.  Serum renin was markedly elevated (11.99ng/ml/hr) [normal range 0.15-2.33]. DIAGNOSIS
  52. 52. THANK YOU
  53. 53. ALTERNATIVE APPROACH TO HYPOKALEMIA  Investigations Required Urine Potassium ABG Urine chloride Renin/Aldosterone
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