Hypokalemia

55 y/o male CC: chronic diarrhea Farmer in La Trinidad, Benguet Noted progressive weakness for the past weeks
Na Cl K Blood Test 140 meq/L 110 meq/L 2.0 meq/L

Hypokalemia
Urine potassium: 15 meq/L
pH pCO2 HCO3 Arterial Blood Gas 7.28 39 mmHg 16

Diagnostic approach to hypokalemia

Urinary K+ excretion

<15 mmol/d

>15 mmol/d

Assess acidbase status

Assess K+ secretion

Diagnostic approach to hypokalemia

Assess acidbase status

Metabolic acidosis

Metabolic alkalosis

Lower gastrointestin al K+ loss

Remove diuretic use, vomitting and K+ loss via sweat

Diagnostic approach to hypokalemia

Assess K+ secretion
Transtubular K+ concentration gradient > 4 Transtubular K+ concentration gradient < 2
Na+ wasting nephropathy, osmotic diuresis, diuretic

Acid-base status

Diagnostic approach to hypokalemia

Acid-base status

Metabolic acidosis

Metabolic alkalosis

Diabetic ketoacidosis, proximal RTA, distal RTA, amphotericin B

Hypertension?

Diagnostic approach to hypokalemia

Hypertension?

YES

NO

Mineralocorticoid excess, Liddles syndrome

Vomiting,Bartters syndrome, exclude diuretic use, hypomagnesemia

Significance of Urinary K levels

This can be established after eliminating decreased intake and intracellular shift as potential causes of hypokalemia Appropriate response to K+ depletion is to excrete less than 15 mmol/d of K+ in the urine, due to increased reabsorption and decreased distal excretion This is exemplified by the diagnostic approach shown previously

Adverse medical implications

More severe hypokalemia may lead to progressive weakness, hypoventilation (due to respiratory involvement involvement, and even complete paralysis Impaired muscle metabolism and blunted hyperemic response to exercise leads to rhabomyolysis Leads to prolonged PR interval, decreased voltage and widening of the QRS complex, with increased risk of ventricular arrhythmia

Symptoms of Hypokalemia
Palpitations Skeletal muscle weakness or cramping Paralysis, paresthesias Constipation4 Nausea or vomiting Abdominal cramping Polyuria, nocturia, or polydipsia Psychosis, delirium, or hallucinations Depression

Signs of Hypokalemia
Signs of ileus Hypotension Ventricular arrhythmias Cardiac arrest Bradycardia or tachycardia Premature atrial or ventricular beats Hypoventilation, respiratory distress Respiratory failure Lethargy or other mental status changes Decreased muscle strength, fasciculations, or tetany Decreased tendon reflexes Cushingoid appearance (eg, edema)

Treatment
ECG monitoring Establish IV access Assess respiratory status Infuse potassium chloride, since his serum potassium is < 2.5 meq/L, in other cases oral is the preferred route for potassium repletion because it is easy to administer, safe, inexpensive, and readily absorbed from the GI tract Check serum Mg levels since it is difficult to restore K if the former is low