Hypokalemia: Difference between revisions

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'''Original Editors '''- Kara Lawless [[Pathophysiology of Complex Patient Problems|from Bellarmine University's Pathophysiology of Complex Patient Problems project.]]  
'''Original Editors '''- Kara Lawless [[Pathophysiology of Complex Patient Problems|from Bellarmine University's Pathophysiology of Complex Patient Problems project.]]  


'''Lead Editors'''    [[Physiopedia:Editors|Read more.]]  
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== Introduction ==
One of the most common [[Electrolytes|electrolyte]] disturbances seen in clinical practice is hypokalemia. Hypokalemia is an [[Electrolytes|electrolyte]] imbalance that is lower than normal level of potassium in the bloodstream.<ref name=":0">Castro D, Sharma S. [https://www.ncbi.nlm.nih.gov/books/NBK482465/ Hypokalemia]. 2018 Available: https://www.ncbi.nlm.nih.gov/books/NBK482465/<nowiki/>(accessed 18.9.2021)</ref>The most common cause is excessive potassium loss in [[urine]] due to [[diuretics]], often prescribed for people who have [[hypertension]] or [[Heart Failure|heart disease]]<ref name=":2">Mayo clinic Hypokalemia Available:https://www.mayoclinic.org/symptoms/low-potassium/basics/causes/SYM-20050632?p=1 (accessed 3.6.2022)</ref>.


<ref name="clincal key">Hypokalemia [Internet]. 2012 [cited 2013 March 27] Available from:https://www.clinicalkey.com/topics/nephrology/hypokalemia.html</ref>  
* A normal blood potassium is 3.6 to 5.2 mmol/L.
* Severe and life threatening hypokalemia level is known as &lt;2.5mmol/L. <ref name="mayo">Low Potassium(hypokalemia)[Internet]. 2012 August 10 [cited 2013 March 27] Available from:http://www.mayoclinic.com/health/low-potassium/MY00760</ref>


== Definition/Description  ==
Potassium helps carry electrical signals to cells in your body. It is critical to the proper functioning of [[Neurone|nerve]] and [[Muscle Cells (Myocyte)|muscles cells]], particularly [[Muscle: Cardiac|heart muscle cells]]<ref name=":2" />.


Hypokalemia is known as a electrolyte imbalance that is lower than normal level of potassium in your bloodstream. A normal blood potassium is 3.6 to 5.2 mmol/L. Severe and life threatening hypokalemia level is known as &lt;2.5mmol/L. Since potassium is critical to the proper functioning of nerve and muscle fibers, hypokalemia can require urgent medical attention. <ref name="mayo">Low Potassium(hypokalemia)[Internet]. 2012 August 10 [cited 2013 March 27] Available from:http://www.mayoclinic.com/health/low-potassium/MY00760</ref>  
Few people meet the daily recommended potassium intake (3,400 mg for men and 2,600 mg for women), however hypokalemia is rarely caused by dietary deficiency alone. It can be caused by a number of factors, including fluid loss, [[malnutrition]], [[shock]], using certain medications, and medical conditions eg [[Chronic Kidney Disease|kidney failure]].<ref name=":1">Healthline Hypokalemia Available: https://www.healthline.com/nutrition/potassium-deficiency-symptoms#bottom-line (accessed 3.6.2022)</ref>


== Prevalence<br>  ==
== Etiology ==
Potential etiologies resulting in hypokalemia are put into the following categories:


Hypokalemia&nbsp;is more common in hospitalized patients,&nbsp;up to 15%,&nbsp;as a result of other pathologies. While only 3% of the outpatient population is found to have Hypokalemia.&nbsp;There has been no significant&nbsp;difference in prevalence between gender and race. <ref name="clinical">Hypokalemia [Internet]. 2012 [cited 2013 March 27] Available from:https://www.clinicalkey.com/topics/nephrology/hypokalemia.html#720089</ref>
# Decreased potassium intake
# Transcellular shifts (increased intracellular uptake)
# Increased potassium loss ([[skin]], gastrointestinal, and [[Kidney|renal]] losses)<ref name=":0" />
Certain illnesses or other factors more likely the cause of hypokalemia, these include:


== Characteristics/Clinical  ==
* Chronic diarrhea.
* Certain medications. eg diuretics, beta 2-agonists, theophylline, [[insulin]], [[Corticosteroid Medication|corticosteroids]], and [[antibiotics]]
* Eating disorders. eg [[Anorexia Nervosa|anorexia nervosa,]] refeeding syndrome, purging, laxative abuse.
* [[Cushing's Syndrome|Cushing’s syndrome]]
* Hyperaldosteronism.
* Kidney failure and Kidney disorders.
* [[Hypomagnesemia]].
* Overconsumption of licorice
* Excessive sweating


An individual with Hypokalemia may exhibit signs of the following:
== Signs and Symptoms ==
[[File:Blood test.jpg|thumb|Blood test]]
In most cases, low potassium is found by a [[Blood Tests|blood test]] that is done because of an illness, or because of diuretics use. It is rare for low potassium to cause isolated symptoms.


*Abnormal heart rhythyms
Hypokalemia symptoms may include:
*Constipation
*Fatigue
*Muscle Damage
*Muscle Weakness or spasms
*Paralysis<ref name="mayo" />
*Nausea and vomiting
*Polyuria, nocturia or polydipsia
*Altered mental status
*Signs of Ileus
*Hypotension
*Cardia arrest
*Bradycardia or Tachycardia
*Premature atrial or ventricular beats
*Hypoventilation/Respiratory distress
*Respiratory failure
*Lethargy
*Edema (Cushingoid appearance)<ref name="medscape">Garth D.,Schraga E.Hypokalemia in emergency medicine.[homepage on the Internert]2012 April 13 [cited 2013 March 27] Available from: http://emedicine.medscape.com/article/767448-overview</ref>


== Associated Co-morbidities  ==
* Weakness


Hypokalemia may present as a result of:
* Fatigue
* Muscle cramps
* Constipation


*Chronic Kidney Failure
Abnormal heart rhythms ([[Heart Arrhythmias: Assessment|arrhythmias]]) are the most worrisome complication of very low potassium levels, particularly in people with underlying heart disease<ref>Mayo Clinic [https://www.mayoclinic.org/symptoms/low-potassium/basics/when-to-see-doctor/sym-20050632 Hypokalemia] Available: https://www.mayoclinic.org/symptoms/low-potassium/basics/when-to-see-doctor/sym-20050632 (accessed 19.9.2021)</ref>.
*Diabetic Ketoacidosis
*Diarrhea/Vomiting
*Excessive Sweating
*Excessive use of laxatives
*Prescription Diuretic Pills
*Primary Aldosteronism <ref name="mayo" />
*Liddle Syndrome
*Cushing Syndrome
*Bartter Syndrome
*Fanconi Syndrome
*Bulimia <ref name="medline">Hypokalemia [Internet]. 2013 March 22 [cited 2013 March 27] Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000479.htm</ref>
*Eating large amounts of licorice, herbal teas or chewing tobacco
*Magnesium Deficiency
*Glue Sniffing
*Alcoholism (poor appetite and/or vomiting)  
*Amphotericin B therapy
*Hypothermia <ref name="clinical" />


== Medications <br> ==
== Diagnosis ==
[[File:Hypokalemia.png|alt=|thumb|ECG Pattern Of Hypokalemia]]Hypokalemia is commonly found in a blood test, with &lt;3.5mmol/L as mild hypokalemia and &lt;2.5mmol/L as severe hypokalmia.<ref name="mayo" />  


In order to correct Hypokalemia, potassium supplements can be administered orally or intervenously.&nbsp;&nbsp;&nbsp;  
In severe cases, a&nbsp;12-lead [[electrocardiogram]] may be necessary if to check&nbsp;for [[Heart Arrhythmias|cardiac arrythymias]]. Findings such as T-wave flattening or prominent U waves will result in hospital admission.<ref name="clinical">Hypokalemia [Internet]. 2012 [cited 2013 March 27] Available from:https://www.clinicalkey.com/topics/nephrology/hypokalemia.html#720089</ref> Other tests may include:
*[[Arterial Blood Gases|Arterial blood gas]]
*Basic or comprehensive metabolic panel


Oral preparations of potassium include:  
Blood tests will also be administered&nbsp;to check the following: glucose; magnesium; calcium; sodium; phosphorus; thyroxine; aldosterone levels.<ref name="medline">Hypokalemia [Internet]. 2013 March 22 [cited 2013 March 27] Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000479.htm</ref>
== Management ==
[[File:Magnesium Sulfate IV 1.jpg|thumb|Magnesium Sulfate IV]]
The overarching goals of therapy for hypokalemia are to prevent or treat life-threatening complications, replace the potassium deficit, and to diagnose and correct the underlying cause.<ref name=":0" />


*8m Eq KCl slow release tablets
Management of the underlying disease or contributing factors constitutes the cornerstone of therapeutic approach. Potassium should be gradually replaced, preferably by oral administration if clinically feasible. In cases of severe/symptomatic hypokalemia and cardiac complications, i.v. administration with continuous ECG monitoring is recommended. In some patients, such as in [[Endocrine Disorders|endocrine]] related hypokalemia cases, multidisciplinary diagnostic and therapeutic approach is needed.<ref>Kardalas E, Paschou SA, Anagnostis P, Muscogiuri G, Siasos G, Vryonidou A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881435/ Hypokalemia: a clinical update. Endocrine connections]. 2018 Apr 1;7(4):R135-46. Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881435/ (accessed 18.9.2021)</ref>
*20 mEq KCl elixir
*20 mEq KCl powder
*25mEq KCl tablet


If the patient has severe hypokalemia (&lt;2.5mmol/L) up to 40 m Eq/h of IV preparation will be administered. Close follow-up care is necessary with continuous ECG monitoring and serial potassium level cheacks. If higher amounts of potassium is administered, cardiac complication risks may increase. Thus, many insttitutions have set up policies that limit the amount of potassium that can be given per hour. Potassium levels must be measured every 1-3 hours.<ref name="medscape" />  
* Though diet alone usually will not resolve hypokalemia, it’s still beneficial to increase intake of potassium-rich foods, like fruits, vegetables, beans, and nuts<ref name=":1" />.
* The majority of patients who are treated for hypokalemia have a good outcome but those who remain untreated are at a risk for arrhythmias which may be fatal.<ref name="medline" />


== Diagnostic Tests/Lab Tests/Lab Values  ==
== Physical Therapy Management ==
Hypokalemia is not managed primarily by a physical therapist. Physical therapists should be mindful of common signs of symptoms of hypokalemia when working with patients.


Hypokalemia is commonly found in a blood test, with &lt;3.5mmol/L as mild hypokalemia and &lt;2.5mmol/L as severe hypokalmia.<ref name="mayo" />
* Potassium levels &lt; 3.2 mEq/L&nbsp;is contraindicated for physical therapy intervention due to the potential for arrhythmia . Due to muscle weakness and cramping, [[Therapeutic Exercise|exercise]] is not effective during the state of hypokalemia.
 
* Patients should be monitored for potassium levels in order to determine the appropriate time to participate in Physical Therapy.<ref name="Goodman">Goodman CC. Fuller KS. In K Falk editor. Pathology: Implications for the Physical Therapist. St. Louis: Saunders Elsevier; 2009. pp.150, 157, 187-189, 480, 558, 927, 1243, 1640-1641</ref>
In severe cases, a&nbsp;12-lead electrocardiogram may be necessary if to check&nbsp;for cardiac arrythymias. Findings such as T-wave flattening or prominent U waves will result in hospital admission.<ref name="clinical" />
 
Other tests may include:
 
*&nbsp;arterial blood gas
*basic or comprehensive metabolic panel
 
Blood tests will also be administered&nbsp;to check the following:
 
*glucose
*magnesium
*calcium
*sodium
*phosphorus
*thyroxine
*aldosterone levels.<ref name="medline" />
 
== Etiology/Causes  ==
 
Low potassium has many causes with the most common being excessive loss in urine or from the digestive tract. Very seldom it may be caused by&nbsp;not consuming&nbsp;enough potassium in your diet.<ref name="mayo" />&nbsp;
 
Other causes include excessive sweating or overuse of laxatives, diuretics, and alcoholism.<ref name="mayo" />Certain medications (penicillin, nafcillin, cerbencillin, gentamicin, amphotericin B, foscarnet) are known to be possible causes, as well.Pathologies such as Cushing syndrome, Liddle Syndrome, Barrtter Syndrome and Fanconi Syndrome can all potentially casue low potassium levels.<ref name="medline" />
 
== Systemic Involvement  ==
 
{| style="width: 586px; height: 323px" border="1" cellspacing="1" cellpadding="1" width="586"
|+ Systems Affected
|-
| Systems
| Impairments
|-
| Cardiovascular
| Cardiac Arrythmias, Hypotension, Premature Artrial or Ventricular Contractions, Bradycardia/Tachycardia/3
|-
| Pulmonary
| Respiratory Failure or complete paralysis in cases &lt;2.5mmol/L
|-
| Musculoskeletal
|
Muscle weakness, cramping or paralysis.
 
|-
| Genitourinary
| Polyuria or sexual dysfunction.<ref name="mayo" />
|}
 
== Medical Management (current best evidence)  ==
 
Severe hypokalmeia levels that cause ECG changes such as T-wave flattening or prominent U waves require hospital admission. Mild hypokalemia (&lt;3.5mmol/L) can&nbsp;be treated by taking potassium supplements by mouth, while severe cases (&lt;2.5mmol/L)&nbsp;may need to receive potassium intravenously. Potassium supplements usually corrects the problem, however if hypokalemia is not addressed it may lead to serious heart problems that can be fatal.&nbsp;&nbsp;<ref name="clinical" />
 
== Physical Therapy Management (current best evidence)  ==
 
Potassium levels &lt; 3.2 mEq/L&nbsp;is contraindicated for physical therapy intervention due to the potential for arrhythmia . Due to muscle weakness and cramping, exercise is not effective during the state of hypokalemia. Patients should be monitored for potassium levels in order to determine the appropriate time to participate in Physical Therapy.<ref name="Goodman">Goodman CC. Fuller KS. In K Falk editor. Pathology: Implications for the Physical Therapist. St. Louis: Saunders Elsevier; 2009. pp.150, 157, 187-189, 480, 558, 927, 1243, 1640-1641</ref>
 
Thus, hypokalemia is not managed primarily by a physical therapist. Physical therapists should be mindful of common signs of symptoms of hypokalemia when working with patients.
 
== Alternative/Holistic Management (current best evidence)  ==
 
Consuming foods high in potassium may help avoid the risk of hypokalemia. These foods include:
 
*avocados
*bananas
*bran
*carrots
*kiwi
*lima beans
*milk
*molasses
*peanut butter
*seaweed
*spinach
*tomatoes
*oranges
*wheat germ <ref name="medline" />


== Differential Diagnosis  ==
== Differential Diagnosis  ==


*&nbsp;Emesis
* Bartter syndrome
*Nasogastric suctioning
* [[Hyperthyroidism]] and thyrotoxicosis
*Pyloric stenosis
* [[Hypocalcemia]]
*Diarrhea&nbsp;
* Hypochloremic alkalosis
*Malabsorption
* [[Hypomagnesemia]]
*Villous adenoma&nbsp;
* Iatrogenic [[Cushing's Syndrome|Cushing syndrome]]
*Renal losses
* Metabolic alkalosis<br>
*Electrolyte abnormalities&nbsp;
*Hypomagnesemia
*Endocrine abnormalities
*Cushing disease or syndrome  
*Congenital adrenal hyperplasia&nbsp;
*Hyperaldosteronism&nbsp;
*High renin states
*Increased mineralocorticoid –&nbsp; chewing tobacco, licorice&nbsp;
*Intrinsic renal abnormalities
*Bartter’s Syndrome
*Gitelman’s Syndrome&nbsp;
*Renal tubular acidosis, types I or II <ref name="pediatrics">Alessandro D. Alessandro M. What is the differential diagnosis of hypokalemia? [Internet] 2006 February 6. [cited 2013 April 4] Available from:http://www.pediatriceducation.org/2006/02/06/what-is-the-differential-diagnosis-of-hypokalemia/</ref><br>
 
== Case Reports/ Case Studies  ==
 
''The syndrome of refractory watery diarrhea and hypokalemia in patients with a non-insulin—secreting islet cell tumor ☆: A further case study and review of the literature&nbsp; ''http://www.sciencedirect.com/science/article/pii/0002934362901882<br>--Summary: Surgical removal of islet cell adenoma results in a decrease of severe diarrhea and a reduced risk of hypokalemia.
 
<br>
 
''Hypokalemic nephropathy in anorexia nervosa ''http://connection.ebscohost.com/c/case-studies/67145420/hypokalemic-nephropathy-anorexia-nervosa
 
--summary: 25 year old female that has a history of multiple hospital admissions due to hypokalemia caused by chronic purging.
 
== Resources <br>  ==
 
http://www.mayoclinic.com/health/low-potassium/MY00760
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
 
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]  
<div class="researchbox">
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1NGmwZeh8JwVIzrKgHG1LrDm0izTr7ViJiDkSYAY2BW5hiXsx0|charset=UTF-8|short|max=10</rss>
</div>
<br>  


== References  ==
== References  ==

Latest revision as of 05:44, 3 June 2022

Original Editors - Kara Lawless from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Kara Lawless, Elaine Lonnemann, Lucinda hampton, Admin, Kim Jackson, Wendy Walker and WikiSysop  

Introduction[edit | edit source]

One of the most common electrolyte disturbances seen in clinical practice is hypokalemia. Hypokalemia is an electrolyte imbalance that is lower than normal level of potassium in the bloodstream.[1]The most common cause is excessive potassium loss in urine due to diuretics, often prescribed for people who have hypertension or heart disease[2].

  • A normal blood potassium is 3.6 to 5.2 mmol/L.
  • Severe and life threatening hypokalemia level is known as <2.5mmol/L. [3]

Potassium helps carry electrical signals to cells in your body. It is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells[2].

Few people meet the daily recommended potassium intake (3,400 mg for men and 2,600 mg for women), however hypokalemia is rarely caused by dietary deficiency alone. It can be caused by a number of factors, including fluid loss, malnutrition, shock, using certain medications, and medical conditions eg kidney failure.[4]

Etiology[edit | edit source]

Potential etiologies resulting in hypokalemia are put into the following categories:

  1. Decreased potassium intake
  2. Transcellular shifts (increased intracellular uptake)
  3. Increased potassium loss (skin, gastrointestinal, and renal losses)[1]

Certain illnesses or other factors more likely the cause of hypokalemia, these include:

Signs and Symptoms[edit | edit source]

Blood test

In most cases, low potassium is found by a blood test that is done because of an illness, or because of diuretics use. It is rare for low potassium to cause isolated symptoms.

Hypokalemia symptoms may include:

  • Weakness
  • Fatigue
  • Muscle cramps
  • Constipation

Abnormal heart rhythms (arrhythmias) are the most worrisome complication of very low potassium levels, particularly in people with underlying heart disease[5].

Diagnosis[edit | edit source]

ECG Pattern Of Hypokalemia

Hypokalemia is commonly found in a blood test, with <3.5mmol/L as mild hypokalemia and <2.5mmol/L as severe hypokalmia.[3]

In severe cases, a 12-lead electrocardiogram may be necessary if to check for cardiac arrythymias. Findings such as T-wave flattening or prominent U waves will result in hospital admission.[6] Other tests may include:

Blood tests will also be administered to check the following: glucose; magnesium; calcium; sodium; phosphorus; thyroxine; aldosterone levels.[7]

Management[edit | edit source]

Magnesium Sulfate IV

The overarching goals of therapy for hypokalemia are to prevent or treat life-threatening complications, replace the potassium deficit, and to diagnose and correct the underlying cause.[1]

Management of the underlying disease or contributing factors constitutes the cornerstone of therapeutic approach. Potassium should be gradually replaced, preferably by oral administration if clinically feasible. In cases of severe/symptomatic hypokalemia and cardiac complications, i.v. administration with continuous ECG monitoring is recommended. In some patients, such as in endocrine related hypokalemia cases, multidisciplinary diagnostic and therapeutic approach is needed.[8]

  • Though diet alone usually will not resolve hypokalemia, it’s still beneficial to increase intake of potassium-rich foods, like fruits, vegetables, beans, and nuts[4].
  • The majority of patients who are treated for hypokalemia have a good outcome but those who remain untreated are at a risk for arrhythmias which may be fatal.[7]

Physical Therapy Management[edit | edit source]

Hypokalemia is not managed primarily by a physical therapist. Physical therapists should be mindful of common signs of symptoms of hypokalemia when working with patients.

  • Potassium levels < 3.2 mEq/L is contraindicated for physical therapy intervention due to the potential for arrhythmia . Due to muscle weakness and cramping, exercise is not effective during the state of hypokalemia.
  • Patients should be monitored for potassium levels in order to determine the appropriate time to participate in Physical Therapy.[9]

Differential Diagnosis[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Castro D, Sharma S. Hypokalemia. 2018 Available: https://www.ncbi.nlm.nih.gov/books/NBK482465/(accessed 18.9.2021)
  2. ↑ 2.0 2.1 Mayo clinic Hypokalemia Available:https://www.mayoclinic.org/symptoms/low-potassium/basics/causes/SYM-20050632?p=1 (accessed 3.6.2022)
  3. ↑ 3.0 3.1 Low Potassium(hypokalemia)[Internet]. 2012 August 10 [cited 2013 March 27] Available from:http://www.mayoclinic.com/health/low-potassium/MY00760
  4. ↑ 4.0 4.1 Healthline Hypokalemia Available: https://www.healthline.com/nutrition/potassium-deficiency-symptoms#bottom-line (accessed 3.6.2022)
  5. ↑ Mayo Clinic Hypokalemia Available: https://www.mayoclinic.org/symptoms/low-potassium/basics/when-to-see-doctor/sym-20050632 (accessed 19.9.2021)
  6. ↑ Hypokalemia [Internet]. 2012 [cited 2013 March 27] Available from:https://www.clinicalkey.com/topics/nephrology/hypokalemia.html#720089
  7. ↑ 7.0 7.1 Hypokalemia [Internet]. 2013 March 22 [cited 2013 March 27] Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000479.htm
  8. ↑ Kardalas E, Paschou SA, Anagnostis P, Muscogiuri G, Siasos G, Vryonidou A. Hypokalemia: a clinical update. Endocrine connections. 2018 Apr 1;7(4):R135-46. Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881435/ (accessed 18.9.2021)
  9. ↑ Goodman CC. Fuller KS. In K Falk editor. Pathology: Implications for the Physical Therapist. St. Louis: Saunders Elsevier; 2009. pp.150, 157, 187-189, 480, 558, 927, 1243, 1640-1641

see adding references tutorial. 

 
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