HIPOKALEMIAS

hypokalemia in adults
Author: David B Mount, MD
Section Editors: Richard H Sterns, MD Michael Emmett, MD
Deputy Editor: John P Forman, MD, MSc
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2020. | This topic last updated: Dec 02, 2019.
Función

´ Es la generación del potencial de reposo de la membrana celular,

siendo particularmente importante en el proceso de excitabilidad
del tejido nervioso, corazón y músculos (liso y esquelético).
´ The daily minimum requirement of potassium is considered to be
approximately 1600 to 2000 mg (40-50 mmol or mEq).
Regulación Normal del Potasio

´ El potasio es el principal catión intracelular y el segundo más importante

del cuerpo.
´ Valor normal en suero de 3,5 a 5,0 mEq/L.
´ La proporción entre la concentración de potasio intracelular y extracelular
es de 35:1
´ Está dada por la presencia de la bomba sodio potasio ATPasa en la
membrana celular que introduce potasio a la célula y saca sodio de ella;
este intercambio determina un potencial eléctrico a través de la
membrana y es el responsable de la iniciación y la transmisión de los
impulsos eléctricos en los nervios musculoesqueléticos y el miocardio .
´ La ingestión normal en un sujeto occidental es de aproximadamente 0,75 a
1,25 mEq/Kg de peso día.

´ En circunstancias normales, el 90% del potasio ingerido cada día se elimina

por el riñón, variando entre 40-120mEq/día.

´ Menos del 15% del potasio ingerido se excreta por las heces y un pequeño
porcentaje por sudor.

´ El 90% del potasio es intracelular y la mayoría está dentro del musculo (60-
75% del potasio corporal total), el 5% a 10% restante es extracelular es el que
medimos clínicamente.
HIPOCALEMIA

´ Es un desorden potencialmente mortal, ya que la concentración

intracelular de potación es mucho mayor que la extracelular.

La hipocalemia la podemos dividir en 3:

´ Falsa hipocaliemia
´ Hipocaliemia por redistribución transcelular
´ Depleción verdadera de potasio
HIPOCALEMIA

- Falsa hipocaliemia

Se asocia a leucocitosis (100.000-250.000) en pacientes leucémicos, cuyas muestras

dejadas al ambiente hacen que capten el potasio del plasma y en los conteos se
detecte un valor falsamente bajo;
cuando se deja la muestra en frio ocurre lo contrario (sale el potasio de la célula).
 HIPOCALEMIA
Hipocaliemia por redistribución transcelular

1. la alcalosis, ya sea metabólica o respiratoria, genera hipocaliemia, la cual es mayor

en la alcalosis metabólica que en la respiratoria.
Acidosis stimulates cellular efflux of potassium from cells, resulting in hyperkalemia,
whereas alkalosis stimulates influx of potassium, resulting in hypokalemia

2. Insulina: especialmente cuando se sobre dosifica. Esta sobredosificación ocurre en 2

situaciones: en pacientes con función pancreática normal a quienes se les administra
equivocadamente insulina o expuestos a una carga muy alta de glucosa o en
pacientes diabéticos con dosis altas mayores de su requerimiento de insulina.
 HIPOCALEMIA
Hipocaliemia por redistribución transcelular

3. Agonistas beta-adrenérgicos: los niveles altos de estos promueven la captación

celular de potasio por efecto beta 2 selectivo.
(eg, decongestants and bronchodilators). A standard dose of nebulized albuterol
reduces serum potassium by 0.2 to 0.4 mmol/L. A second dose administered within 1 hour
reduces it by approximately 1 mmol/L.2
β2-Blockade, on the other hand, increases serum potassium.

4. El incremento en la liberación de catecolaminas endógenas que acompañan a una

variedad de condiciones patológicas general una hipocaliemia transitoria.
HIPOCALEMIA

Deplesión verdadera de potasio

´ Es útil dividirla en pérdidas de origen renal ( diureticos tiazidicos) y pérdidas
de origen extra renal, teniendo como parámetro la excreción urinaria de
potasio.
´ Es muy importante, también, tener en cuenta el estado acido básico del
paciente.
Causas mas importantes :

Potential causes include

´ diuretic therapy,
´ inadequate dietary potassium intake,
´ high dietary sodium intake,
´ and hypomagnesemia .
´ In most cases, hypokalemia is secondary to drug treatment, particularly
diuretic therapy
ETIOLOGIA EXTRARRENAL

Depleción de potasio

Etiología extrarrenal

pH normal pH variable Acidosis metabólica

ingestión inadecuada
Adenoma velloso Diarrea
Anorexia nerviosa
Dieta de té y galletas rectal Fístulas
Incremento de masa muscular
gastrointestinales
Geofagia y abuso de laxantes
Ayuno
Sintomas

´ los sintomas generalmente no comienzan hasta que el potasio no esta por

debajo de 3 meq/l
´ la debilidad muscular o rabdomiolisis usualmente no ocurren hasta que el k
esta debajo de 2,5 meq/l inicia en las extremidades inferiores y asciende
hasta el tronco, extremidades superiores y puede empeorar hasta el
punto de la paralisis.
´ la deplesión de potasio puede causar calambres musculares, rabdomiolisis
y myoglobinuria.
Sintomas

Otras manifestaciones musculares son :

´ debilidad muscular respiratoria que puede llevar a falla respiratoria y

muerte

´ ileo- distension- anorexia- nauseas y vomitos.

Anormalidades EKG

´ latidos ventriculaes prematuros

´ bradicardia sinusal
´ taquicardia axial paroxistica
´ bloqueo atrioventricular
´ taquicardia ventricular o fibrilacion.
´ depresion del segmento st
´ disminucion de la amplitud de la onda t
´ prolonga el intervalo qt
´ ondas u visibles de v4 a v6
Que empeora la situación???

´ la liberacion de epinefrina como respuesta al estrés como en las isquemias

coronarias lleva el k dentro de la celula y empeora la hipok pre-existente.
un efecto similar lo tienen los broncodilatadores con agonista beta
adrenergico.

´ la hipok tambien puede estar asociada a deplesion de magnesio por

diarreas o diureticos, pues la caida del magnesio y potasio promueve
Torsade de pointes. Esta puede ser :
- diarreas
- diureticos
Manejo : General

El objetivo de la terapia es:

´ prevenir y tratar las complicaciones que comprometen la vida ,

´ reemplazar el k y corregir las causas subyacentes.
´ tener en cuenta que el riesgo de arritmias es mas alto en pctes mayores,
con enfermedad cardiaca , pctes con arritmias o con digoxina.
Estimación del déficit de Potasio

´ The potassium deficit varies directly with the severity of hypokalemia.

´ In different studies, the serum potassium concentration fell by
approximately 0.27 mEq/L for every 100 mEq reduction in total body
potassium stores.
´ In chronic hypokalemia, a potassium deficit of 200 to 400 mEq is required to
lower the serum potassium concentration by 1 mEq/L .
´ However, these estimates are only an approximation of the amount of
potassium replacement required to normalize the serum potassium
concentration and careful monitoring is required.
Preparaciones de Potasio

´ Potassium can be administered as

´ potassium chloride,
´ potassium phosphate,
´ potassium bicarbonate or its precursors (potassium citrate, potassium
acetate) or potassium gluconate .
The choice among these preparations varies with the clinical setting:
´ Potassium bicarbonate or its precursors are preferred in patients with
hypokalemia and metabolic acidosis (eg, renal tubular acidosis or
diarrhea) . Only potassium acetate is available for intravenous use.
Cual es el preferido ?

Potassium chloride is preferred in all other patients for two major reasons :

´ Patients with hypokalemia and metabolic alkalosis are often chloride

depleted due, for example, to diuretic therapy or vomiting.
´ Potassium chloride raises the serum potassium concentration at a faster
rate than potassium bicarbonate.
Primera Opción: Terapia Oral

´ Oral potassium chloride can be given in crystalline form (salt substitutes), as

a liquid, or in a slow-release tablet or capsule.
´ Salt substitutes contain 50 to 65 mEq per level teaspoon; they are safe, well
tolerated, and much less expensive .
Terapia Oral y Dieta

´ Increasing the intake of potassium-rich foods, such as oranges and

bananas is less effective, in part because dietary potassium is
predominantly in the form of potassium phosphate or potassium
citrate which, as mentioned earlier in this section, results in the retention of
only 40 percent as much potassium

´ It would take two to three bananas to provide 40 mEq.

Terapia Intravenosa

´ Potassium chloride can be given intravenously to patients who are unable

to take oral therapy or as an adjunct to oral replacement in patients who
have severe symptomatic hypokalemia.
Manejo según la Severidad

´ Hipokalemias Moderadas y Leves

Most hypokalemic patients have a serum potassium concentration of 3.0 to 3.4

mEq/L. This degree of potassium depletion usually produces no symptoms.

Su Manejo depende de la causa desencadenante de la hypokalemia y el estado acido

basico.
Hipokalemias Moderadas y Leves

´ Patients with gastrointestinal losses are treated with potassium chloride if they
have metabolic alkalosis (as usually seen with vomiting) or a normal serum
bicarbonate concentration.

´ and with potassium bicarbonate (or potassium citrate or acetate) in the presence of
metabolic acidosis (as seen with diarrhea or renal tubular acidosis). Treatment is
usually started with 10 to 20 mEq of potassium given two to four times per day
(20 to 80 mEq/day), depending upon the severity of the hypokalemia.
 Hipokalemias severas o Sintomaticas:

´ Potassium must be given more rapidly to patients with hypokalemia that is

severe (serum potassium less than 2.5 to 3.0 mEq/L) or symptomatic
(arrhythmias, marked muscle weakness, or rhabdomyolysis).

´ Potassium therapy can be initiated with repeated monitoring of the serum

potassium every four to six hours initially.
Severas pero toleran via oral y Aun sin
sintomas
´ The serum potassium concentration can transiently rise by as much as 1 to 1.5
mEq/L after an oral dose of 40 to 60 mEq.
´ And by as much as 2.5 to 3.5 mEq/L after 135 to 160 mEq .
´ The serum potassium concentration will then fall back toward baseline over a
few hours, as most of the exogenous potassium is taken up by the cells .
´ A patient with a serum potassium concentration of 2.0 mEq/L, for example:
may have a 400 to 800 mEq potassium deficit .
potassium chloride can be given orally in doses of 40 mEq three to four
times per day.
or, particularly in patients also treated with intravenous potassium, 20 mEq every
two to three hours.
Controles

´ We suggest that the serum potassium should initially be measured every

two to four hours to ascertain the response to therapy.

´ If tolerated, this regimen should be continued until the serum potassium

concentration is persistently above 3.0 to 3.5 mEq/L and symptoms or signs
attributable to hypokalemia have resolved.
Solución salina Vs Solución Dextrosa

´ A saline rather than a dextrose solution should be used for initial therapy
since the administration of dextrose stimulates the release of insulin which
drives extracellular potassium into the cells.
´ This can lead to a transient 0.2 to 1.4 mEq/L reduction in the serum
potassium concentration, particularly if the solution contains only 20 mEq/L
of potassium
´ Insulin therapy should be delayed until the serum potassium is above
3.3 mEq/L to avoid possible complications of hypokalemia such as cardiac
arrhythmias, cardiac arrest, and respiratory muscle weakness.
Efectos Adversos del Potasio
Intravenoso
´ Pain and phlebitis can occur during parenteral infusion of potassium into a
peripheral vein.

´ This primarily occurs at rates above 10 mEq/hour, but can be seen at

lower rates.

´ Rapid infusion of 40 to 60 mEq of potassium can result in severe

hyperkalemia. ( Bombas de Infusión).
Recomendaciones

´ For patients with severe hypokalemia due to gastrointestinal or renal losses,

the recommended maximum rate of potassium administration is 10 to 20
mEq/hour in most patients.
´ However, initial rates as high as 40 mEq/hour have been used for life-
threatening hypokalemia .
´ Rates above 20 mEq/hour are highly irritating to peripheral veins. Such high
rates should be infused into a large central vein or into multiple peripheral
veins.
´ To decrease the risk of inadvertent administration of a large absolute
amount of potassium, we suggest the following maximum amounts of
potassium that should be added to each particular sized infusion container:
 Recomendaciones

´ In any 1000 mL-sized container of appropriate non-dextrose fluid, we suggest a

maximum of 60 mEq of potassium.

´ In a small-volume mini-bag of 100 to 200 mL of water that is to be infused into a

peripheral vein, we suggest 10 mEq of potassium.

´ In a small-volume mini-bag of 100 mL of water that is to be infused into a large

central vein, we suggest a maximum of 40 mEq of potassium.
 Recomendaciones

´ Intravenous potassium is most often infused in a peripheral vein at concentrations of

20 to 60 mEq/L in a non-dextrose-containing saline solution.

´ Use of an infusion pump is preferred to prevent overly rapid potassium administration

in any intravenous container with more than 40 mEq of potassium or if the desired rate
of potassium administration is more than 10 mEq/hour.

´ For patients with severe hypokalemia, administration in a large central vein is

preferred if this access is available.
Monitoreo continuo

Careful monitoring of the physiologic effects of severe hypokalemia

´ ECG abnormalities, muscle weakness, paralysis is essential.

´ Continuous ECG monitoring or telemetry is warranted in patients with

arrhythmias caused by hypokalemia, prolonged QT and/or other ECG
abnormalities
Monitoreo continuo

´ We suggest that the serum potassium should initially be measured every

two to four hours to ascertain the response to therapy.
´ If tolerated, this regimen should be continued until the serum potassium
concentration is persistently above 3.0 to 3.5 mEq/L and symptoms or signs
attributable to hypokalemia have resolved.
´ Thereafter, the dose and frequency of administration can be reduced to
that used in mild to moderate hypokalemia since aggressive repletion is no
longer required and gastric irritation can be avoided.