POTASSIUM HOMEOSTASIS Mohammed Almeziny BsPharm R,Ph. Msc PhD Clinical Pharmacist.
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Transcript of POTASSIUM HOMEOSTASIS Mohammed Almeziny BsPharm R,Ph. Msc PhD Clinical Pharmacist.
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POTASSIUM HOMEOSTASIS
Mohammed Almeziny BsPharm R,Ph. Msc PhD
Clinical Pharmacist
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Introduction
POTASSIUM is required for neuromuscular
tissues.
intracellularly (98%).
approximately 3500 mmol.
50 mmol is located in extracellular.
(Hak & Dunham, 1983; Scribner et al, 1956).
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Protective effect of potassium
An antihypertensive effect.
Inhibitory effect on free radical formation.
Reduce the relative risk of stroke mortality.
Offer a protective effect on renal arterioles
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Daily requirement
1-2 mmol/kg. (1mmol =1mEq 39.1 mg)
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HYPOKALEMIA
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DEFINITION
Hypokalemia is defined as a serum
potassium concentration less than 3.5
mmol/L. Normal levels range from 3.5 to 5
mmol/L
(Young & Koda-Kimble, 1988)
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CAUSES
The most common cause of hypokalemia is drug therapy.
Shifting of potassium from extracellular to intracellular.
Reduction in potassium intake (Lindman, 1976; Lawson et al, 1979; Nardone et al, 1978;
AMA, 1983)
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Blood pH effect
0.1 unit potassium of approximately 0.6 mmol/L;
0.1 unit corresponds to slightly less 0.6mmol/L.
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Clinical presentation
Usually are asymptomatic between 3.5-3 mmol/l
Malaise, weakness, fatigue and myalgia.
Renal tubular disorders, myocardial excitability, and metabolic abnormalities
(AMA, 1983; Stanaszek & Romankiewicz, 1985)
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Calculate adult K deficit in hypokalemia
1 mmol/L fall in serum potassium from 4 to 3 mmol/L =200 mmol.
< 3mmol/L, = 200 to 400 mmol for each 1 mmol/L
*After correct acid-base status of measured serum level.
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June 1, 1998, Volume 55, Issue 11
Most hospitals removing KCl concentrate from patient units
, ISMP reports
Institute for Safe Medication Practices (ISMP).
JAMA / volume:280 (page: 1444)Promoting Patient Safety by Preventing Medical Error Lucian L. Leape, MD; et al October 28, 1998
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Treatment and Prevention
Correct coexisting magnesium depletion.
Give potassium salts, primarily by the oral
route.
POTASSIUM CHLORIDE is the
supplement of choice
(Stanaszek & Romankiewicz, 1985; Beck et al, 1982).
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Intravenous indication
Intravenous potassium chloride is
indicated primarily when oral therapy is
not feasible.
Also indicated for the treatment of
DIGITALIS-induced arrhythmias.
(Cohen, 1979; McCarron, 1975).
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INTRAVENOUS.
POTASSIUM CHLORIDE MUST BE DILUTED BEFORE INFUSION.If serum potassium is > 2.5 mmol/L and neuromuscular and cardiac abnormalities are minimal (and renal function is not impaired),concentrations not exceeding 40 mmol/L and at a rate of 10 to 15 mmol/hour. Doses should not exceed 100 to 300 mmol/day (AMA, 1983).
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INTRAVENOUS. Cont’d
If serum potassium is < 2 mmol/L and muscle paralysis or cardiac abnormalities are present.
Concentrations not exceeding 60 mmol/L at a rate of 40 mmol/hour. Doses should not exceed 400 mmol/day (AMA, 1983).
Administration of potassium in high concentration should be given after strict evaluation.
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Intravenous Rate of Administration
Should be kept within 10 to 20 mmol/hour. Frequent biochemical and ECG monitoring is necessary when rates >10 mmol/hour.The faster rates should be continued for only short periods of time
(Lawson, 1976; Lawson & Henry, 1977; van der Linde et al, 1977; Porter, 1976; Beeson et al, 1958; Schwartz, 1976; Dipiro et al, 1989).
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Potassium infusion I.V. order
I.V fluid Concentration mmol/L
Rout of infusion
Peripheral/ Central
Infusion rate mmol/h
Ward ECG monitoring Yes/no
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ORAL
Liquid, enteric-coated, and slow release preparation.Slow release:
1) Sugar-coated (slow-K) or film coated (K-Tab) tablets;
2) KCL incorporated into wax matrix, controlled release tablets (K-Dur)
3) A gelatin capsule containing microencapsulated KCL crystals that are coated with a water polymer
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Food, Standard Amount Potassium (mg)
Calories
Sweetpotato, baked, 1 potato (146 g) 694 131
Tomato paste, ¼ cup 664 54
Beet greens, cooked, ½ cup 655 19
Potato, baked, flesh, 1 potato (156 g) 610 145
White beans, canned, ½ cup 595 153
Yogurt, plain, non-fat, 8-oz container 579 127
Tomato puree, ½ cup 549 48
Clams, canned, 3 oz 534 126
Yogurt, plain, low-fat, 8-oz container 531 143
Prune juice, ¾ cup 530 136
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Food, Standard Amount Potassium (mg) Calories
Carrot juice, ¾ cup 517 71
Blackstrap molasses, 1 Tbsp 498 47
Halibut, cooked, 3 oz 490 119
Soybeans, green, cooked, ½ cup 485 127
Tuna, yellowfin, cooked, 3 oz 484 118
Lima beans, cooked, ½ cup 484 104
Winter squash, cooked, ½ cup 448 40
Soybeans, mature, cooked, ½ cup 443 149
Rockfish, Pacific, cooked, 3 oz 442 103
Cod, Pacific, cooked, 3 oz 439 89
Bananas, 1 medium 422 105
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Food, Standard Amount Potassium (mg) Calories
Spinach, cooked, ½ cup 419 21
Tomato juice, ¾ cup 417 31
Tomato sauce, ½ cup 405 39
Prunes, stewed, ½ cup 398 133
Peaches, dried, uncooked, ¼ cup 398 96
Pork chop, center loin, cooked, 3 oz 382 197
Milk, non-fat, 1 cup 382 83
Apricots, dried, uncooked, ¼ cup 378 78
Rainbow trout, farmed, cooked, 3 oz 375 144
Pork loin, center rib (roasts), lean, roasted, 3 oz
371 190
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Food, Standard Amount Potassium (mg) Calories
Buttermilk, cultured, low-fat, 1 cup 370 98
Cantaloupe, ¼ medium 368 47
1%-2% milk, 1 cup 366 102-122
Lentils, cooked, ½ cup 365 115
Honeydew melon, 1/8 medium 365 58
Kidney beans, cooked, ½ cup 358 112
Plantains, cooked, ½ cup slices 358 90
Split peas, cooked, ½ cup 355 116
Orange juice, ¾ cup 355 85
Yogurt, plain, whole milk, 8 oz container
352 138
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Continuous Subcutaneous Infusion
Effective in elderly patients who do not need acute potassium repletion.
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Monitoring Parameters
Should be monitored at least every two weeks in ambulatory patients with mild deficiencies and in patients requiring prophylactic.
After a pattern is established, monitoring every 3 to 6 months is adequate (Stanaszek & Romankiewicz, 1985).
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HYPERKALEMIA
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Introduction
Hyperkalemia is a potentially life-
threatening illness, which can be
difficult to diagnose clinically because
of paucity of reliable signs and
symptoms.
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Definition
Hyperkalemia is defined as a serum potassium concentration greater than 5.5 mmol/LSome hospitals > 5mmol/L
(Cox, 1981).
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Clinical Manifestation
cardiac excitability, possibly
progressing to ventricular fibrillation
and asystole.
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Mortality/Morbidity
Reported death rates rate range up to 67% if
severe hyperkalemia is untreated.
Gender: Male = Female
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Causes Decreased or impaired potassium excretion.
Acute or chronic renal failure (most common).
Potassium sparing diuretics.Urinary obstruction. Sickle cell disease. Addison disease.Systemic lupus erythematosus (SLE).
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Causes cont’d
Additions of potassium into extracellular space:
potassium supplements (eg, PO/IV
rhabdomyolysis,
hemolysis (eg, venipuncture, blood transfusions,
burns, tumor lysis).
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Causes cont’d
Transmembrane shifts
Acidosis.
Medication effects (eg, acute digitalis
toxicity, beta-blockers, succinylcholine).
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Causes cont’d
Pseudohyperkalemia: Improper blood collection (eg, ischemic
blood draw from venipuncture technique)Laboratory errorLeukocytosisThrombocytosis.
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Classification of Hyperkalemia
Serum sodium is usually decreased, and acidosis is usually present.
The relationship between serum potassium and symptoms is not consistent.
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Classification of Hyperkalemia cont’d
MINIMAL TOXICITY - < 6.5 mmol/L. MODERATE TOXICITY - 6.5-8 mmol/L give lassitude, fatigue, and weakness.SEVERE TOXICITY - >8 mmol/L, complete neuromuscular paralysis may dominate the clinical picture. Death from cardiac arrest occurs usually at 10 to 12 mmol/L. It may occur at lower levels if cellular potassium is severely depleted.
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Treatment
Urgency of therapy depends on EKG findings and level of serum potassium.
If serum K is greater than 8 mmol/L. If the EKG shows the changes of
hyperkalemia.If the patient is extremely symptomatic.
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Goal of therapy
stabilizing the myocardium
Shifting potassium from the extracellular to the intracellular compartment.
Promoting the renal excretion and GI loss of potassium.
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CALCIUM
The first drug to be used for severe hyperkalemia (> 7.0 mmol/L) when the ECG also manifests significant abnormalities.
Antagonizes cardiac toxicity.
onset < 5 min and lasts 30-60 min.
Calcium chloride is the preferred salt.
Calcium chloride is very irritating, and should only be given via a central venous catheter.
Enhance the effects of the cardiac glycoside by causing arrhythmias
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SODIUM BICARBONATE
Shift potassium intracellularly.
Onset of action is within minutes and lasts approximately 15-30 min.
Blood pH should be monitored to avoid excess alkalosis.
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INSULIN/DEXTROSE
Enhances intracellular potassium shift.
This regimen will lower serum potassium by 1 to 2 mmol/L within 30 to 60 minutes with the decrease lasting for several hours (Saxena, 1989).
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ADULT DOSE
Administer 25 g of dextrose (250 ml of a 10% solution) I.V + 10 units of regular insulin over 30 minutes, and then continue the infusion at a slower rate. (Saxena, 1989).
Or, 50 ml of a 50% dextrose solution with 5 to 10 units of regular insulin may be administered I.V over 5 minutes.
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PEDIATRIC DOSE
0.5 to 1 g/kg/dose followed by 1 unit of regular insulin intravenously for every 4 grams of glucose infused; may repeat every 10 to 30 minutes (Barkin, 1986).
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HYPEROSMOLARITY
It must be remembered that 50% dextrose (2525 mOsm/L) , and even 25% dextrose (1330 mOsm/L) , are very hyperosmolar and may be sclerosing to peripheral veins (Chameides, 1988).
Peripheral veins can tolerate up to (900 mOsm/L).
Administration of hypertonic solutions via central lines is preferred, if possible.
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SODIUM POLYSTYRENE SULFONATE
SPS is a cation exchange resin.
Onset 2-12 h, (longer when administered rectally).
SORBITOL is added to combat the constipating effect of the cation-exchange resin (Gilman et al, 1990)
Multiple doses of SPS are usually necessary.
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BETA-2-AGONIST
Appears to be a safe and reasonably effective means of treatment while waiting for dialysis or other potassium removing therapies to be initiated.
Use with caution in hyperthyroidism, diabetes mellitus, or cardiovascular disorders.
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Diuretics
Effects of diuretics are slow and frequently take an hour to begin.
Avoid use in patients with anuria
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HEMODIALYSIS
Peritoneal and hemodialysis are effective methods.
Slow to be practical in treatment of acute poisoning.
Patients who cannot tolerate fluids or have kidney dysfunction may benefit from dialysis (Ellenhorn & Barceloux, 1988).
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Summary
Chronic Vs Acute
Symptomatic Vs Asymptomatic
Level
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Questions?