1-2 DHE: POTASIO

Desequilibrios del potasio

Por: Dra. Paola Morales, R4 de Medicina Interna

Regulación

3.5 - 5.0 mEq/L

• Regulador principal: riñón.
• Mecanismos de "regulación interna"

• Principal catión intracelular.
• Ayuda a mantener el potencial de membrana --> función celular

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Hipokalemia

Hiperkalemia

• Concentraciones < 3.5 mEq/L
• 15% de población. general.
• 20% de pacientes hospitalizados

• [K+] > 5.0 mEq/L.
• Grave: > 6.0 mEq/L
• 2-4% población general.
• 10-55% pacientes hospitalizados.
• 73% de ERC
• 40% de falla cardiaca

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Cambios electrocardiográficos

• 5.5 - 6.5 mmol/L = ondas T picudas, de base estrecha, predominio en precordiales.
• 6.5 - 8.0 mmol/L = ondas T picudas, intervalo PR prolongado, disminución de la amplitud de ondas P, prolongación del complejo QRS.
• > 8 mmol/L = ausencia de onda T, bloqueos, ensanchamiento del QRS, patrones de "onda sinusal", VF, asistolia.

Clase, C. M., Carrero, J. J., Ellison, D. H., Grams, M. E., Hemmelgarn, B. R., Jardine, M. J., Kovesdy, C. P., Kline, G. A., Lindner, G., Obrador, G. T., Palmer, B. F., Cheung, M., Wheeler, D. C., Winkelmayer, W. C., Pecoits-Filho, R., & Conference Participants (2020). Potassium homeostasis and management of dyskalemia in kidney diseases: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney international, 97(1), 42–61. https://doi.org/10.1016/j.kint.2019.09.018

Cambios electrocardiográficos

• < 3.5 mmol/L = aplanamiento o inversión de las ondas T.
• < 3.0 mmol/L = prolongación del QT, aparición de onda "U", disminución en la amplitud de ondas P, aplanamiento de ondas T, depresión del intervalo ST, bloqueo AV (prolongación del intervalo PR), extrasístoles ventriculares.
• < 2.5 mmol/L = FA, taquicardias multifocales, contracciones atriales y ventriculares prematuras, bradicardia, Torsade de Pointes, FV.

Krogager, M. L., Kragholm, K., Thomassen, J. Q., Søgaard, P., Lewis, B. S., Wassmann, S., Baumgartner, I., Ceconi, C., Schmidt, T. A., Kaski, J. C., Drexel, H., Semb, A. G., Agewall, S., Niessner, A., Savarese, G., Kjeldsen, K. P., Borghi, C., Tamargo, J., & Torp-Pedersen, C. (2021). Update on management of hypokalaemia and goals for the lower potassium level in patients with cardiovascular disease: a review in collaboration with the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. European heart journal. Cardiovascular pharmacotherapy, 7(6), 557–567. https://doi.org/10.1093/ehjcvp/pvab038

Acidosis metabólica por aniones inorgánicos

VS

Acidosis metabólica por Acidosis orgánica

Tratamiento

Reponer el potasio

• Hipokalemia leve: aumentar ingesta de potasio en los alimentos o suplementar.
• Consumo recomendado: 4.7 mg/día (120 mmol/Día).
• Hipokalemia moderada: suplementación oral
• 10 mmol de KCL = î 0.1 mmol/L
• Hipokalemia grave: suplementación parenteral con monitorización ECG continua.
• Riesgo de disrritmias: máximo 20 mEq/h.

Krogager, M. L., Kragholm, K., Thomassen, J. Q., Søgaard, P., Lewis, B. S., Wassmann, S., Baumgartner, I., Ceconi, C., Schmidt, T. A., Kaski, J. C., Drexel, H., Semb, A. G., Agewall, S., Niessner, A., Savarese, G., Kjeldsen, K. P., Borghi, C., Tamargo, J., & Torp-Pedersen, C. (2021). Update on management of hypokalaemia and goals for the lower potassium level in patients with cardiovascular disease: a review in collaboration with the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. European heart journal. Cardiovascular pharmacotherapy, 7(6), 557–567. https://doi.org/10.1093/ehjcvp/pvab038Piner, A., & Spangler, R. (2023). Disorders of Potassium. Emergency medicine clinics of North America, 41(4), 711–728. https://doi.org/10.1016/j.emc.2023.07.005

Cuadro Clínico

"Leve" = asintomático manifestaciones > 7 mEq/L

Rosano, G. M. C., Tamargo, J., Kjeldsen, K. P., Lainscak, M., Agewall, S., Anker, S. D., Ceconi, C., Coats, A. J. S., Drexel, H., Filippatos, G., Kaski, J. C., Lund, L., Niessner, A., Ponikowski, P., Savarese, G., Schmidt, T. A., Seferovic, P., Wassmann, S., Walther, T., & Lewis, B. S. (2018). Expert consensus document on the management of hyperkalaemia in patients with cardiovascular disease treated with renin angiotensin aldosterone system inhibitors: coordinated by the Working Group on Cardiovascular Pharmacotherapy of the European Society of Cardiology. European heart journal. Cardiovascular pharmacotherapy, 4(3), 180–188. https://doi.org/10.1093/ehjcvp/pvy015Jeremy Pinnell, Simon Turner, Simon Howell, Cardiac muscle physiology, Continuing Education in Anaesthesia Critical Care & Pain, Volume 7, Issue 3, June 2007, Pages 85–88, https://doi.org/10.1093/bjaceaccp/mkm013

Encontrar la causa

Kim, M. J., Valerio, C., & Knobloch, G. K. (2023). Potassium Disorders: Hypokalemia and Hyperkalemia. American family physician, 107(1), 59–70.

Tratamiento

Estabilizar membrana cardiaca, Mover y eliminar

• Calcio: estabilización de la membrana.
• Cloruro de calcio (1 g) 3:1 Gluconato de calcio (1 g).
• Dosis: repetir hasta normalización de EKG.
• 1-2 g de cloruro de calcio al 10%
• 2-3 g de gluconato de calcio al 10%
• Insulina: ¿10 UI o 5UI de IAR? ¿en dextrosa al 50% o se puede al 10%?
• Agonistas B adrenérgicos: salbutamol 10-20 mg
• ¿Bicarbonato?
• Diuréticos de asa: Furosemide

Yang, I., Smalley, S., Ahuja, T., Merchan, C., Smith, S. W., & Papadopoulos, J. (2020). Assessment of dextrose 50 bolus versus dextrose 10 infusion in the management of hyperkalemia in the ED. The American journal of emergency medicine, 38(3), 598–602. https://doi.org/10.1016/j.ajem.2019.09.003Krogager, M. L., Kragholm, K., Thomassen, J. Q., Søgaard, P., Lewis, B. S., Wassmann, S., Baumgartner, I., Ceconi, C., Schmidt, T. A., Kaski, J. C., Drexel, H., Semb, A. G., Agewall, S., Niessner, A., Savarese, G., Kjeldsen, K. P., Borghi, C., Tamargo, J., & Torp-Pedersen, C. (2021). Update on management of hypokalaemia and goals for the lower potassium level in patients with cardiovascular disease: a review in collaboration with the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. European heart journal. Cardiovascular pharmacotherapy, 7(6), 557–567. https://doi.org/10.1093/ehjcvp/pvab038Piner, A., & Spangler, R. (2023). Disorders of Potassium. Emergency medicine clinics of North America, 41(4), 711–728. https://doi.org/10.1016/j.emc.2023.07.005 Jaber, S., Paugam, C., Futier, E., Lefrant, J. Y., Lasocki, S., Lescot, T., Pottecher, J., Demoule, A., Ferrandière, M., Asehnoune, K., Dellamonica, J., Velly, L., Abback, P. S., de Jong, A., Brunot, V., Belafia, F., Roquilly, A., Chanques, G., Muller, L., Constantin, J. M., … BICAR-ICU Study Group (2018). Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet (London, England), 392(10141), 31–40. https://doi.org/10.1016/S0140-6736(18)31080-8 Garcia, J., Pintens, M., Morris, A., Takamoto, P., Baumgartner, L., & Tasaka, C. L. (2020). Reduced Versus Conventional Dose Insulin for Hyperkalemia Treatment. Journal of pharmacy practice, 33(3), 262–266. https://doi.org/10.1177/0897190018799220 Patel, S., & Dillon, R. (2022). Evaluation of Peripheral Administration of 10% Calcium Chloride in a Retrospective, Single-Center Electronic Health Record Cohort. Journal of emergency nursing, 48(4), 484–491. https://doi.org/10.1016/j.jen.2021.12.005 Bulloch, M.N., Cardinale-King, M., Cogle, S. et al. Correction of Electrolyte Abnormalities in Critically Ill Patients. Intensive Care Res (2024). https://doi.org/10.1007/s44231-023-00054-3

McDonough, A. A., & Fenton, R. A. (2022). Potassium homeostasis: sensors, mediators, and targets. Pflugers Archiv : European journal of physiology, 474(8), 853–867. https://doi.org/10.1007/s00424-022-02718-3

Encontrar la causa

Potasio urinario: 15 mEq/L

Clase, C. M., Carrero, J. J., Ellison, D. H., Grams, M. E., Hemmelgarn, B. R., Jardine, M. J., Kovesdy, C. P., Kline, G. A., Lindner, G., Obrador, G. T., Palmer, B. F., Cheung, M., Wheeler, D. C., Winkelmayer, W. C., Pecoits-Filho, R., & Conference Participants (2020). Potassium homeostasis and management of dyskalemia in kidney diseases: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney international, 97(1), 42–61. https://doi.org/10.1016/j.kint.2019.09.018

Catecolaminas

Insulina

Palmer B. F. (2015). Regulation of Potassium Homeostasis. Clinical journal of the American Society of Nephrology : CJASN, 10(6), 1050–1060. https://doi.org/10.2215/CJN.08580813

Cuadro Clínico

"Leve" = asintomático

Krogager, M. L., Kragholm, K., Thomassen, J. Q., Søgaard, P., Lewis, B. S., Wassmann, S., Baumgartner, I., Ceconi, C., Schmidt, T. A., Kaski, J. C., Drexel, H., Semb, A. G., Agewall, S., Niessner, A., Savarese, G., Kjeldsen, K. P., Borghi, C., Tamargo, J., & Torp-Pedersen, C. (2021). Update on management of hypokalaemia and goals for the lower potassium level in patients with cardiovascular disease: a review in collaboration with the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. European heart journal. Cardiovascular pharmacotherapy, 7(6), 557–567. https://doi.org/10.1093/ehjcvp/pvab038Jeremy Pinnell, Simon Turner, Simon Howell, Cardiac muscle physiology, Continuing Education in Anaesthesia Critical Care & Pain, Volume 7, Issue 3, June 2007, Pages 85–88, https://doi.org/10.1093/bjaceaccp/mkm013

Regulación renal

Principal, aunque más tardada

• Filtración "libre" a través del glomérulo.
• Reabsorción: 90% en túbulo proximal y asa de Henle.
• < 10% llega hasta nefrona distal.
• Secreción: cominza en túbulo contorneado distal y aumenta hacia el túbulo colector.
• Potasio urinario: secundario a secreción electrogénica de K+ mediada por las células principales en túbulo colector.
• Reabsorción: en casos de depleción de potasio --> túbulo colector.

Palmer B. F. (2015). Regulation of Potassium Homeostasis. Clinical journal of the American Society of Nephrology : CJASN, 10(6), 1050–1060. https://doi.org/10.2215/CJN.08580813