Potassium


Article Author:
Moushumi Sur


Article Editor:
Shamim Mohiuddin


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
5/10/2019 8:18:06 PM

Indications

Potassium is an essential mineral constituent of the human body and is the chief cation found within the intracellular fluid of all cells. Multiple salts of potassium exist and can be used as a medication for a wide range of indications. Since potassium is an essential electrolyte usually sourced through our diet, any condition in which a patient is unable to maintain their dietary intake is an indication for exogenous replenishment of potassium. Hence, the recommendation is that potassium is included in electrolyte replacement regimens and form a part of intravenous maintenance fluids in adult as well as pediatric patients or as routine prophylaxis following surgery.

The chief indication for potassium administration is potassium deficiency or hypokalemia, a condition in which the level of serum potassium falls below a critical range. Hypokalemia can occur due to multiple reasons, mainly inadequate intake of potassium such as in the condition of malnutrition, malabsorption, debilitation, prolonged parenteral nutrition without potassium or excessive losses of potassium such as vomiting, diarrhea, excessive drainage of gastrointestinal fluids, dialysis, renal diseases, diabetic ketoacidosis, hyperadrenalism, use of diuretics, corticosteroids and amphotericin B. Hyperactivity of adrenal cortex called as Cushings syndrome is an another important causes of hypokalemia. Metabolic alkalosis can also cause hypokalemia by shifting potassium from the extracellular to the intracellular compartment.

Other recommended indications for potassium salts include:

Hypertension: Adequate intake of potassium is recommended to prevent the development of hypertension. Potassium supplements are also prescribed to improve blood pressure control in patients with known hypertension.[1]

Arrhythmia: When cardiac glycoside toxicity occurs as a result of a loss of potassium or in certain tachyarrythmias following cardiac surgery.  

Thallium toxicity: Used intravenously in a limited fashion.[2][3]

Hyperthyroidism: Potassium iodide is prescribed as an oral adjunctive medication in the immediate preoperative period for patients with hyperthyroidism undergoing thyroidectomy.[4] It is also useful as an adjunct treatment of patients critically ill with thyrotoxicosis crisis.

Radiation protection: Oral potassium iodide can be used to protect the thyroid gland by blocking thyroidal uptake of radioactive iodine isotopes either from environmental hazards or during treatment with radiopharmaceuticals.[5]

Sporotrichosis: Oral potassium iodide is considered the drug of choice for fixed cutaneous or lymphocutaneous sporotrichosis in resource-constrained countries because of its low cost.[6] However, its efficacy has not been compared to antifungals such as itraconazole and prolonged duration of therapy correlates with a high number of side effects.

Cough: Historically, potassium iodide has been used to treat symptoms of chronic cough as an expectorant of tenacious mucus. However, its efficacy in this role is not well supported.

Alkalinization: Potassium citrate is used to alkalinize urine in case of certain kinds of urinary tract calculi and management of conditions associated with chronic metabolic acidosis (chronic renal insufficiency and renal tubular acidosis). In these conditions, potassium citrate is used as an alternative to sodium citrate or sodium bicarbonate when a high amount of sodium administration is undesirable.

Antibiotics: Potassium is also used as a vehicle or compounding chemical for some antibiotic preparations (e.g., potassium benzylpenicillin, potassium penicillin V and amoxicillin-clavulanate potassium).

Mechanism of Action

In its role as a major intracellular cation, potassium acts to preserve acid-base balance and maintenance of isotonicity as well as electrodynamic cellular function. It activates many enzymatic reactions within our body and plays an essential role in the transmission of nerve impulses, contraction of cardiac muscles as well as skeletal and smooth muscles, tissue synthesis, gastric secretion and renal function. Potassium reduces mean systolic and diastolic blood pressure.[1]

Administration

Potassium administration can be in the form of multiple salts, some of which can be ingested by the oral route (potassium chloride, acetate, bicarbonate, gluconate, and citrate) and some of which are given intravenously (potassium chloride and acetate). Certain potassium–containing compounds (e.g., potassium chloride) can be injected subcutaneously (hypodermoclysis).[7] The oral route is always preferable to intravenous injection except in critical hypokalemia; this is because the relatively slow process of gastrointestinal absorption of potassium salts limits the likelihood of a sudden, large increase in serum potassium concentration.

Oral Administration

Oral potassium supplements should be administered with or after meals to reduce gastrointestinal irritation and cathartic effect.

Oral potassium salts are usually administered in 1 to 4 doses daily. With a relatively high daily dosage (greater than 20 mEq) administration should be as divided doses.

Extended-release potassium chloride preparations are useful for patients who cannot tolerate or are non-compliant with multiple daily doses of potassium preparations. 

IV Infusion

Administration of potassium containing infusions must be by slow intravenous infusion, including boluses of potassium for hypokalemia (rate of administration generally should not exceed 20 mEq/hour). When including potassium in long term or maintenance fluid administration, concentration should not exceed 40mEq/L (exceptions may be severe hypokalemia associated with cardiac arrhythmias or in diabetic ketoacidosis where higher concentrations of 60 to 80 mEq/L may be used with caution). Continuous ECG monitoring and serial measurements of plasma potassium concentrations are essential during IV administration of potassium, particularly when the rate of administration is greater than 20 mEq/hour.

Potassium IV solutions should be administered only in patients who are well-hydrated and with adequate urine flow (especially in post-surgical patients).

Selection of potassium dosages requires caution in patients with renal impairment and geriatric patients.[8]

Potassium acetate, potassium chloride, and potassium phosphate are available as concentrated solutions that should be diluted before intravenous administration. Local vascular intolerance may be a limiting factor in the ability to administer concentrated solutions. Ideally, potassium infusion administration should be via a large, high-flow vein (e.g., femoral vein), or administration of solutions of lower concentration may be in divided doses via peripheral veins. 

Dosage

The calculated dosage of potassium supplements is usually as mEq of potassium. Depending on the potassium supplement in use, the amount of oral supplement that will provide a particular dosage of potassium in mEq will vary. 

Normal adult daily potassium requirement and usual dietary intake of potassium is 40 to 80 mEq; infants and children require 2 to 3 mEq/kg or 40 mEq/m daily.

Adverse Effects

Hyperkalemia is the most common and life-threatening adverse effect of potassium administration and can develop rapidly.[9] This condition can manifest as potentially fatal bradycardia, asystole, and ventricular fibrillation.  

Gastrointestinal side effects occur commonly with enteral preparations, such as nausea, emesis, diarrhea and abdominal pain.

Extravasation, local irritation, and phlebitis may occur due to improper dilution of intravenous preparations or administration through a peripheral vein.

Hypersensitivity reactions occur from the use of potassium iodide as well as chronic iodine poisoning (iodism).

Contraindications

Hyperkalemia is an absolute contraindication for potassium replacement. Inadequate or absent urine output and severe renal impairment are relative contraindications. Systemic acidosis and states of dehydration require correction before potassium administration. Potassium should be administered cautiously in states of significant tissue breakdown (e.g., burns or post-operative conditions), adrenal insufficiency, and with concomitant administration of potassium-sparing diuretics. Oral forms of potassium supplements should be used cautiously in patients who have delayed gastrointestinal transit due to structural or functional causes.

Potassium iodide should not be used in patients with known sensitivity to iodides.

Monitoring

Fluid balance, hydration and acid-base status need to be monitored periodically during potassium replacement. Serum potassium levels require frequent monitoring in patients with renal impairment or with intravenous bolus potassium replacement. Frequent potassium checks are also needed when patients are receiving drugs that increase the risk of hyperkalemia (e.g., ACE inhibitors, potassium-sparing diuretics).

Toxicity

Hyperkalemia is the most prevalent and life-threatening hazard of potassium therapy. ECG changes are the most critical indicator of silent potassium toxicity and include tall, peaked T waves, ST-segment depression,  disappearance of the P wave, QT interval prolongation and widening of the QRS complex with slurring. Clinical signs and symptoms of hyperkalemia include paresthesias, drowsiness, mental confusion, flaccid paralysis, gray pallor, cold skin, peripheral vascular collapse with fall in blood pressure, critical cardiac arrhythmias and heart block.

Treatment of hyperkalemia is dependant on its severity and there are multiple regimens available.[9] However, rapid lowering of plasma potassium concentrations in digitalized patients can result in cardiac glycoside toxicity. Administration of potassium-rich foods and potassium-sparing diuretics require prompt discontinuation. In patients with severe hyperkalemia, immediate measures which allow an intracellular shift of potassium (administration of sodium bicarbonate, a calcium salt, and/or insulin-dextrose), have been recommended. Patients whose ECGs demonstrate absent P waves or a broad QRS complex and who are not receiving cardiac glycosides should immediately be given calcium gluconate or another calcium salt IV with continuous ECG monitoring to antagonize the cardiotoxic effects of potassium. If abnormalities on the ECG persist, repeated doses of the calcium salt may be given. 

When the ECG normalizes, next efforts should point toward the removal of potassium from the body. Some adsorption of potassium can be accomplished by administration of sodium polystyrene sulfonate orally or as an enema. Hemodialysis or peritoneal dialysis will reduce plasma potassium concentrations and can be necessary for patients with renal insufficiency.  

Enhancing Healthcare Team Outcomes

Managing potassium overdose requires an interprofessional team of healthcare professionals that includes a nurse, laboratory technologists, pharmacist and a number of physicians in different specialties. Without prompt and proper management, the morbidity and mortality from potassium overdose is high. Cardiovascular mortality from hyperkalemia especially increases in patients with chronic kidney disease and those on dialysis.[10] (Level I).As soon as it is apparent that hyperkalemia may have ensued as a result of potassium administration, the patient requires ICU admission for monitoring and treatment. Care coordination is provided by the ICU clinician including the following:

  • Ordering serial potassium levels in blood 
  • Monitor the patient for signs and symptoms of cardiac arrhythmias, and continuous EKG monitoring
  • Performing various maneuvers to help limit absorption of the drug in the body
  • Rapid administration of sodium bicarbonate and calcium gluconate or calcium chloride to limit cardiotoxicity
  • Consult with the pharmacist about the use of Polystyrene sulfonate and glucose-insulin
  • Consult with a nephrologist on further management, which may include dialysis
  • Consult with a cardiologist for management of life-threatening arrhythmias

Existing treatment protocols for critical hyperkalemia resulting from potassium administration has no support by strong evidence and appear to be institution-specific.[11] (Level III) Definitive clinical trials are needed to fill knowledge gaps of when to treat and how to treat.[11] The management of potassium overdose does not stop with the resolution of hyperkalemia. Once the patient is stabilized, one has to determine how and why the patient became hyperkalemic. The nursing and pharmacy sections of the team can help identify whether the intended dose was being administered or whether a medical error resulted in the potassium toxicity. The nephrologist can detect whether there is baseline decreased renal function contributing to the resultant hyperkalemia. Only by working as an interprofessional team can the morbidity and mortality of inadvertent potassium overdose be decreased. 


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Potassium - Questions

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Which of the following is a normal potassium level?



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Which of the following electrolytes is found in greater amounts inside the cell than outside?



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A 65-year-old patient with grand mal epilepsy is well controlled on phenytoin. He has recently started taking laxatives for constipation. He presents to the emergency department with muscle cramps and fatigue. His blood tests reveal a potassium level of 2.3 mEq/L. What is the correct dose and mode of administration of potassium chloride for this patient?



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Potassium is:



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What is the normal serum potassium concentration?



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Which method of supplementing potassium is contraindicated?



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Hypokalemia and hyperkalemia are common. Which of the following can affect serum potassium levels? Select all that apply.



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Potassium - References

References

Whelton PK,He J,Cutler JA,Brancati FL,Appel LJ,Follmann D,Klag MJ, Effects of oral potassium on blood pressure. Meta-analysis of randomized controlled clinical trials. JAMA. 1997 May 28;     [PubMed]
Malbrain ML,Lambrecht GL,Zandijk E,Demedts PA,Neels HM,Lambert W,De Leenheer AP,Lins RL,Daelemans R, Treatment of severe thallium intoxication. Journal of toxicology. Clinical toxicology. 1997;     [PubMed]
Bank WJ,Pleasure DE,Suzuki K,Nigro M,Katz R, Thallium poisoning. Archives of neurology. 1972 May;     [PubMed]
Bahn Chair RS,Burch HB,Cooper DS,Garber JR,Greenlee MC,Klein I,Laurberg P,McDougall IR,Montori VM,Rivkees SA,Ross DS,Sosa JA,Stan MN, Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid : official journal of the American Thyroid Association. 2011 Jun;     [PubMed]
Becker DV,Braverman LE,Dunn JT,Gaitan E,Gorman C,Maxon H,Schneider AB,Van Middlesworth L,Wolff J, The use of iodine as a thyroidal blocking agent in the event of a reactor accident. Report of the Environmental Hazards Committee of the American Thyroid Association. JAMA. 1984 Aug 3;     [PubMed]
Sterling JB,Heymann WR, Potassium iodide in dermatology: a 19th century drug for the 21st century-uses, pharmacology, adverse effects, and contraindications. Journal of the American Academy of Dermatology. 2000 Oct;     [PubMed]
Rochon PA,Gill SS,Litner J,Fischbach M,Goodison AJ,Gordon M, A systematic review of the evidence for hypodermoclysis to treat dehydration in older people. The journals of gerontology. Series A, Biological sciences and medical sciences. 1997 May;     [PubMed]
Rastegar A,Soleimani M, Hypokalaemia and hyperkalaemia. Postgraduate medical journal. 2001 Dec;     [PubMed]
Alscher MD, [     [PubMed]
Hoppe LK,Muhlack DC,Koenig W,Carr PR,Brenner H,Schöttker B, Association of Abnormal Serum Potassium Levels with Arrhythmias and Cardiovascular Mortality: a Systematic Review and Meta-Analysis of Observational Studies. Cardiovascular drugs and therapy. 2018 Apr;     [PubMed]
Rossignol P,Legrand M,Kosiborod M,Hollenberg SM,Peacock WF,Emmett M,Epstein M,Kovesdy CP,Yilmaz MB,Stough WG,Gayat E,Pitt B,Zannad F,Mebazaa A, Emergency management of severe hyperkalemia: Guideline for best practice and opportunities for the future. Pharmacological research. 2016 Nov;     [PubMed]

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