Here are the key steps in approaching hypokalemia:
1. Determine if the hypokalemia is caused by redistribution or depletion. Redistribution occurs with insulin, beta-agonists, alkalosis etc. and replacement may cause overshoot hyperkalemia. Depletion is more common, due to GI losses, diuretics, medications etc.
2. Estimate the potassium deficit based on how low the serum potassium is. A deficit of 100-250 mEq is suggested for levels of 3.5-3 mEq/L.
3. Choose oral replacement whenever possible over IV, as oral is safer and better tolerated. Only use IV if patient cannot take oral or deficit is severe.
4
This lecture is based on National guidelines(Sri Lanka) and guidelines by NHS UK. all the materials used to prepare the lecture are trusted and high in quality. also the books referred are internationally recognized. both hyper and hypokalemia management included in the lecture. lecture is free and you can even download. i kept no copy rights. i appreciate your support, comments and suggestions. also i would be grateful if you can make these lectures popular. wishing your success.
A simple presentation on hypokalemia. The most common electrolyte disorder in the Critical Care practice.The presentation is based on a mortality and morbidity case report and discussion. It covers all the basic aspects of understanding the causes of hypokalemia in ICU and its management. Target audience are residents ICU and ER but all health care workers can benefit.
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
This lecture is based on National guidelines(Sri Lanka) and guidelines by NHS UK. all the materials used to prepare the lecture are trusted and high in quality. also the books referred are internationally recognized. both hyper and hypokalemia management included in the lecture. lecture is free and you can even download. i kept no copy rights. i appreciate your support, comments and suggestions. also i would be grateful if you can make these lectures popular. wishing your success.
A simple presentation on hypokalemia. The most common electrolyte disorder in the Critical Care practice.The presentation is based on a mortality and morbidity case report and discussion. It covers all the basic aspects of understanding the causes of hypokalemia in ICU and its management. Target audience are residents ICU and ER but all health care workers can benefit.
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
Fluid and electrolyte balance Dr Reshma Gafoorreshm007
FLUID AND ELECTROLYTE BALANCE IN ORAL AND MAXILLOFACIAL SURGERY
BRIEF DISCUSSION OF FLUID REPLACEMENT THERAPY
END PARAMETERS AND GOALS OF FLUID REPLACEMENT
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
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Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
9. SOME IMPORTANTSOME IMPORTANT
TERMINOLOGIESTERMINOLOGIES
OSMOLARITYOSMOLARITY : amount of solute dissolved in: amount of solute dissolved in
solution (measured in volume).solution (measured in volume).
Expressed as mOsm/LExpressed as mOsm/L
OSMOLALITYOSMOLALITY : amount of solute dissolved in: amount of solute dissolved in
solvent(measured in KG)solvent(measured in KG)
expressed as mOsm/KGexpressed as mOsm/KG
Osmolality is more accurate than Osmolarity.Osmolality is more accurate than Osmolarity.
9
10. PLASMA OSMOLALITYPLASMA OSMOLALITY
Largely determined by sodium salts
Normal 275 – 295mOsm/kg
Plasma
osmolality
EFFECTIVE OSMOLALITY
UREA being lipid soluble crosses freely cell membrane
and does not contribute to EFFECTIVE OSMOLALITY
Under normal circumstances glucose accounts for only 5 mOsm/kg
in effective osmolality. So plasma sodium concentration is the
primary determinant of plasma osmolality.
2 x Na + glucose mg/dl+ BUN mg/dl
18 2.8
10
26. Maintenance fluidMaintenance fluid
For first 10 kg body weight 4ml /kg /hour
For 10 – 20 kg body weight 2ml / kg /hour
For >20 kg body weight 1ml /kg /hour
For 60 kg body weight
Per hour fluid requirement is 40 +20 + 40 ml=100ml
26
36. RESPONSE TO WATER DEFICITRESPONSE TO WATER DEFICIT
a)Water intake is regulated by thirst, stimuli for which are
Dehydration
Fall in BP
Increased osmolality
b)Water excretion is regulated by ADH
Regulation: water deficit increases serum osmolality or
decreases circulating blood volume which stimulates
hypothalamus for ADH.ADH acts on distal tubules and collecting
ducts to increase the water permeability and decrease the urine
output.
36
37. Response to water excessResponse to water excess
1)
2)
3) Decreased ADH
When amount of water in body increases, secretion of ADH
decreases so water absorption by collecting ducts decreases and
urine output increases
2) Increase in ANP
Volume expansion will increase the secretion of ANP which
promotes diuresis and natriuresis.
4)
37
38. ECFVOLUME EXCESSECFVOLUME EXCESS
Can be divided into two groups
1) Water and salt excess
2) Predominantly water excess (water intoxication)
Water and salt excess
Frequently encountered disorder
ETIOLOGY
SYSTEMIC ILNESS: CHF, cirrhosis, nephrotic syndrome, acute or
chronic renal failure, or hypoproteinaemia
IATROGENIC
Excessive and prolonged administration of saline in traumatic and
post operative patients.
38
39. ..
CLINICAL FEATURES
Weight gain Oedema
Raised JVP with hepatojugular reflex
Tachycardia with bounding pulse
Increase in systolic BP Ascites
Bilateral basal crepitation's
Raised CVP Pulmonary oedema
TREATMENT
§ Treatment of underlying aetiology
§ Water restriction, salt restriction, and diuretics
§ Pulmonary oedema needs extensive treatment i.e. propped up
position, O2 inhalation, i.v aminophylline, nitro-glycerine
infusion and in non responsive patients phlebotomy, dialysis
or ultrafiltration 39
40. PREDOMINANTLYWATER EXCESSPREDOMINANTLYWATER EXCESS
§ Water intoxication, over hydration or dilutional
syndrome
§ Usually iatrogenic disorder
§ ETIOLOGY
§ Absorption of irrigating fluid in TURP
§ Excessive administration of dextrose in patients with high
ADH secretion
§ Correction of salt and water loss solely by 5% dextrose
solution
§ SIADH
§ Psychogenic polydipsia
40
41. CLINICAL FEATURESCLINICAL FEATURES
Predominantly neurological due to hyponatremia, hypoosmolality
and increased ICT due to brain cell swelling
Confusion , loss of attention ,altered behaviour, drowsiness,
nausea and vomiting. In severe cases convulsions and coma
On investigations urine is diluted with low specific gravity and
serum sodium and osmolality are low.
TREATMENT
§ Fluid restriction
§ For symptomatic patients vigorous treatment with hypertonic
saline and furosemide
§ Correction of hyponatremia should be done slowly do avoid
cerebral pontine syndrome
§ If patients undergoing TURP show signs of intoxication,
procedure should be terminated and treated promptly.
41
42. ECF VOLUME DEFICITECF VOLUME DEFICIT
§ Severe fluid deficit if untreated can be lethal
Can be divided into two groups
1)Isotonic volume depletion
2)Pure water depletion
Isotonic volume depletion
§ Combined loss of water and salt leading to hypovolemia
§ Causes; diarrhoea, vomiting, excess diuresis
§ Normal or low sodium
§ Reduction only in ECF volume leading to hypotension and
reduction in tissue perfusion
Dry tongue tachycardia postural hypotension
Dizziness oliguria and azotaemia with disproportionate elevation in
BUN
Cold extremities ,shrunken eyes and poor or absent peripheral pulses and
hypotension 42
43. Pure water depletionPure water depletion
§ Pure water loss leads to dehydration
§ Causes: poor oral intake and DI
§ Characterised by hypernatremia
§ Proportionate reduction in total body water
§ Features : excessive thirst and CNS manifestations secondary to
hypernatremia
§ Blood pressure and tissue perfusion are better maintained
43
51. administration of hypotonic maintenance
intravenous fluids
Infants who may have been given inappropriate
amounts of free water
bowel preparation before colonoscopy or
colorectal surgery
51
56. DIAGNOSISDIAGNOSIS
Three important diagnostic tests 1) plasma osmolality 2) urinary
osmolality 3) urinary sodium concentration
If plasma osmolality is normal or high, rule out
pseudohyponatremia
Oedematous patient rule out CHF ,cirrhosis, nephrotic
syndrome
Urinary sodium >20mEq/l renal loss of sodium
Urinary sodium<20mEq/l diarrhoea , vomiting, burns
Associated hyperkalemia, renal insufficiency or adrenal
insufficiency with hypoaldosteronism
Associated with hpokalemia and metabolic alkalosis, vomiting or
diuretic theraphy
SIADH –most common cause of euvolemic hyponatremia (high
urinary sodium in spite of low serum sodium)
56
57. TREATMENTTREATMENT
Treatment must be individualised acc.To etiology, acute/chronic, severity
and signs and symptoms
Hyponatremia which develops quickly, should be treated fast where as
which develops slowly should be corrected slowly
Hypovolumic hyponatremia;;salt and water supplementation (.9% NaCl)
Hypervolumic hyponatremia :: salt and water restriction and loop
diuretics
Normovolumic hyponatremia :: water restriction
Patients with severe hyponatremia are at risk of developing severe and
potentially irreversible neurological demage and sometimes death. On
the other hand rapid correction can produce central pontine myelinosis
or osmotic demyelination syndrome.
57
58. Osmotic demyelination syndromeOsmotic demyelination syndrome
Occurs after the rapid correction of chronic hyponatremia
Characterised by dysarthria, dysphasia, flaccid paresis and coma
Diagnosis is confirmed by CT or more accurately by MRI
58
59. GENERAL GUIDLINESGENERAL GUIDLINES
FOR TREATMENT
Chronic asymptomatic hyponatremia
Targeted rate of plasma sodium correction should not be greater
than .5 to 1 mEq/l/hour
Raise the plasma sodium by less than 10- 12 mEq/l on the first day
and less than 18 mEq/l over first two days
If the rate of correction is faster or rise in serum sodium is >25
mEq/48 hours, there is high risk of ODS
Acute hyponatremia with severe neurological symptoms
Require rapid correction with hypertonic saline
Initial rise should be 1.5 – 2 mEq/l/hour for first 3-4 hours or until
the symptoms improve
Besides the initial rapid correction rise in plasma sodium
concentration should not exceed 10-12 mEq in first 24 hours
59
60. WHEN TO STOPWHEN TO STOP
qPatients symptoms are abolished
q
qSafe plasma sodium 120-125 mEq/l is achieved
q
qA total magnitude of correction of 20 mEq/l is achieved.
q
.9% saline and 3% hypertonic saline are only two
routinely used fluids for hyponatremia
60
61. CALCULATIONCALCULATION
Change in serum infusate Na/L –serum NaChange in serum infusate Na/L –serum Na
sodium conc. Total body water + 1sodium conc. Total body water + 1
Total body water ::Total body water ::
children and non elderly men 0.6xBW kgchildren and non elderly men 0.6xBW kg
elderly men and non elderly women .5xBW kgelderly men and non elderly women .5xBW kg
elderly women .45xBW kgelderly women .45xBW kg
e.g. 45 year male with 60 kg wt with serum sodium of 110 mEq/le.g. 45 year male with 60 kg wt with serum sodium of 110 mEq/l
infusion of 3% NaClinfusion of 3% NaCl
change in Na conc. = 513 – 110 /.6x60 +1change in Na conc. = 513 – 110 /.6x60 +1
= 403/36+1= 403/36+1
=10.9mEq/l=10.9mEq/l
to raise 4 mEq/l in initial 4 hours we need to transfuse 4/10.9x 1000to raise 4 mEq/l in initial 4 hours we need to transfuse 4/10.9x 1000
=366 ml=366 ml 61
64. Free water deficitFree water deficit
Free water deficit = total body water x (serum Na -140)
140
Half of deficit is corrected over first 24 hours
Rate of correction should not exceed .5 – 1 mEq/l
64
67. Metabolic acidosis increases the serum potassiumMetabolic acidosis increases the serum potassium
level where as metabolic alkalosis decreases thelevel where as metabolic alkalosis decreases the
serum potassium level.serum potassium level.
unlike sodium, absorption of potassium is neverunlike sodium, absorption of potassium is never
complete, about 20 mEq of K are lost daily even incomplete, about 20 mEq of K are lost daily even in
absence of K intake.absence of K intake.
Whenever body K increases, serum K risesWhenever body K increases, serum K rises
proportionately. But when there is deficit in serum K,proportionately. But when there is deficit in serum K,
reduction in serum K is not proportionate as it isreduction in serum K is not proportionate as it is
compensated by shift from intra cellularcompensated by shift from intra cellular
compartment.compartment. 67
71. Approach to HypokalemiaApproach to Hypokalemia
Step 1:Step 1: Redistribution or depletionRedistribution or depletion??
Redistribution causesRedistribution causes
Insulin therapy – DKAInsulin therapy – DKA
Beta 2 agonists - SalbutomolBeta 2 agonists - Salbutomol
Metabolic alkalosisMetabolic alkalosis
Beta 2 adrenergic stimulationBeta 2 adrenergic stimulation
increased cell proliferation – Rx ofincreased cell proliferation – Rx of
megaloblatic anaemiamegaloblatic anaemia
Barium poisoiningBarium poisoining
Replacement of potassium in these settings may lead toReplacement of potassium in these settings may lead to
overshoot & hyperkalemiaovershoot & hyperkalemia
71
72. Approach to HypokalemiaApproach to Hypokalemia
Step 1: Redistribution or depletion?
Depletion causes (common)
GI tract losses (diarrhea, vomiting)
Loop/thiazide diuretic therapy
Other medications (e.g. amphotericin B)
Osmotic diuresis (DKA)
Refeeding syndrome
Endocrinopathies (mineralocorticoid excess)
Salt wasting nephropathies/RTA’s
Magnesium deficiency 72
73. Approach to Hypokalemia
Step 2: Estimate the deficit
For every 100 mEq below normal, serum K+ usually drops by 0.3
mEq/L
Highly variable from patient to patient, however!!
TOTAL 125 -250 250-400 300-600 500 -750
K deficit
(mEq/L,70 kg)
S.K 3.5 3 2 <2
(mEq/L)
73
74. Approach to Hypokalemia
Step 3: Choose route to replace K+
In nearly all situations, ORAL replacement is PREFERRED over IV
replacement
Oral is quicker
Oral has less side effects (IV burns!)
Oral is less dangerous
Choose IV therapy ONLY in patients who are NPO (for whatever reason) or
who have severe depletion
I V POTASSIUM
Avoid I v K till urine output is established
Don’t give >10-20mEq/hour
Don’t give >40/l
Don’t give >240/day
Never give inj. KCL directly I v causes sudden hyperkalemia and instant
death
Don’t use D5 as diluent as it aggravates hypokalaemia
74
75. Approach to Hypokalemia
Step 4: Choose K+ preparation
Oral therapy
Potassium Chloride is PREFERRED AGENT
Especially useful in Cl-responsive metabolic alkalosis
⇑ in ECF K quicker with KCl compared to other salts
Potassium Phosphate useful when co existant
phosphorus deficiency
Often useful in DKA patients
Potassium bicarbonate, acetate, gluconate, or
citrate useful in metabolic acidosis
ORAL POTTASIUM CHLORIDE SOLUTION
15 ML = 20 mEq/L
10 ml ampoule of 15% kcl = 19.5 mEq 75
76. Approach to Hypokalemia
Step 5: Choose dose/timing
Mild/moderate hypokalemia
3.0 to 3.5 mEq/L
60-80 mEq PO (or IV) in divided doses
Sometimes will require up to 160 mEq per
day (refeeders, lots of diarrhea, IV diuretics)
Avoid too much PO at once
GI upset or just poor response
Usually divide as BID or TID dosing 76
77. Approach to Hypokalemia
Step 5 (con’t): Choose dose/timing
Severe hypokalemia (< 3.0 mEq/L)
Can use combination of IV and PO, again with PO
preferred if at all possible
Avoid more than 60-80 mEq PO in a single dose
Avoid IV infusion rates faster than 20 mEq/hour—can
cause arrhythmia!!!
Most protocols won’t allow more than 10 mEq/hour rates on the
floors (ICU’s too?)
77
78. Approach to Hypokalemia
Step 6: Monitor/reassess
Severe hypokalemia, DKA patients
Reassess labs 4-6 hourly
Moderate hypokalemia, IV diuresis patients
Reassess labs BID to TID as needed
Mild hypokalemia
Reassess labs OD or less as needed
78
86. Treatment of hypocalcemiaTreatment of hypocalcemia
Acute management
10-20 ml of 10% ca. glu i.v over 10 min followed by infusion of 60
ml of ca glu in 500 ml of d5
If I.v calcium does not relieve tetany rule out hypomagnesemia
Long term management
Oral elemental calcium 1 to 3 grams per day
Vitamin d (calcitriol)
86
87. Treatment of hypercalcemiaTreatment of hypercalcemia
ü Measures to increase urinary excretion
0.9% NaCl for volume expansion and natriuresis
furosemide
hemodialysis
ü Measures to inhibit bone resorption
bisphosphonates like pamidronate
calcitonin
Measures to decrease intestinal absorption
glucocorticoids
oral phosphate
98. Due to dilution of serum bicarbonate. Many argue that in acidotic pts
body offloads O2 from Hb better than in alkalosis, atleast to a milder
degree.
98
100. PLASMA-LYTEPLASMA-LYTE
Balanced crystalloid containing additional electrolytes such as
acetate and gluconate.
Chloride level is lower
Also contains magnesium.
Safe in priming of extracorporeal circulation pumps, cold ischemia,
circulatory arrest, organ transplantation, and organ preservation.
100
122. 122
DR
DROP RATE/MIN VOLUME TO BE INFUSED IN ML
DURATION OF INFUSION IN HRS X 4
Suppose 500 ml of NS is to be infused over 3 hrs
500/3x4 = 500/12 = 40 drops per min
129. Potassium is avoided in first twoPotassium is avoided in first two
post op days why????post op days why????
q Oliguria or azotemia unless urine output is established K is risky
q
q Tissue trauma releases K from intracellular stores __ hyperkalaemia
q
q Intra or imm. post op blood transfusions add large amount of K
q Post op metabolic acidosis will shift K extracellular
q Body has large stores of K intracellular so hypokalaemia will not occur 129
131. General PrinciplesGeneral Principles
>10% total BSA - IV fluid resuscitation & urinary>10% total BSA - IV fluid resuscitation & urinary
catheter.catheter.
In major injury - nasogastric tube toIn major injury - nasogastric tube to
decompress the stomach.decompress the stomach.
During transport - maintain body temperature.During transport - maintain body temperature.
132. Fluid ResuscitationFluid Resuscitation
§ Burn leads to intravascular volume depletion
§ Major losses occur during the first 24 hrs – crystalloids used.
§ Myocardial depression - 24-“36 hrs after injury.
§ The goal of resuscitation is to maintain adequate intravascular
volume to support tissue perfusion and thereby preserve organ
function.
§ The adequacy of resuscitation - based on observation of blood
pressure, heart rate, and urine output.
§ Fluid to maintain normal blood pressure, heart rate, and hourly
urine output of 1 mL/kg/hr in the infant and young child and 0.5
mL/kg/hr in the child >12 years of age or >50 kg in weight.
133. Parkland formula - crystalloid-based formula - with
RL - based on the BSA of burn and the patient's body
weight.
Maintenance fluids (5% dextrose in lactated
Ringer solution)
= (4ml/kg+ BSA of burn) + Maintainance fluids
(For adults and children who weigh >40 kg,
maintenance fluids are not included in the estimate of
fluid requirements.)
Half of this - in the first 8 hrs after injury, and other
half is given in the following 16 hrs.
134. After the first 24 hrs, - maintenance requirements + to
replace ongoing losses.
The hourly evaporative fluid loss from wounds can be
estimated as:
= ( 25 + Burn surface area) x total BSA
The evaporative losses are primarily free water.
However, to avoid rapid changes in sodium concentration
in children, this loss is replaced with - 5% dextrose in 0.2%
normal saline.
loss of serum protein occurs in > 40% BSA burns.
When the injury is larger, the loss is replaced in the second
24 hrs after injury with 5% albumin.
135. Ultimate goal – to maintain normal blood
pressure,
heart rate, urine output, and serum
sodium