A 50-year-old male patient was admitted with generalized weakness and abdominal distension. On examination, he was found to be alert and hemodynamically stable. Neurological examination revealed quadriparesis. Abdominal examination revealed distension with sluggish bowel sounds. His serum potassium level was 2 mEq/L.

Disorder of potassium balance—both hypoand hyperkalemia—is a common finding in the ICU. These abnormalities might be subtle requiring minimal intervention or life-threatening requiring urgent measures. A methodological approach is warranted to manage this problem.

Step 1: Initial resuscitation

•Patients should be resuscitated, as mentioned in Chap. 78.

•Patients with quadriparesis need to be assessed for airway protection and if needed should be intubated or ventilated.

•Circulatory status needs to be maintained with intravenous fluids as hypokalemic patients are usually volume depleted.

Step 2: Assess severity of hypokalemia

•After initial resuscitation, the patient should be assessed for urgency of correction of hypokalemia.

S. Todi, M.D., M.R.C.P. (*)

Critical Care & Emergency, A.M.R.I. Hospital, Kolkata, India e-mail: drsubhashtodi@gmail.com

R. Chawla, M.D., F.C.C.M.

Department of Respiratory, Critical Care & Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India

e-mail: drchawla@hotmail.com

Step 4: Replace intravenous potassium chloride

Peripheral route

It is safe

It is used in mild-to-moderate hypokalemia (3–3.5 mEq/L)

20–40 mEq/L of KCl is added to each liter of fluid given over 4–6 h

A saline rather than dextrose solution should be used. Half-strength saline with 20 mEq of KCl makes the solution isotonic and suitable for peripheral use

Do not use high concentrations over 60 mEq/l; it can lead to pain and sclerosis of peripheral vein Volume overload is a potential risk in susceptible subjects

Central route

Prepare 20 mEq KCl in 100 mL normal or half-strength saline

5–20 mEq/h (through syringe pump) can be safely given by central route (preferably femoral vein)

Life-threatening arrhythmias

Up to 40 mEq/h of KCl can be given for few hours

No other infusion should be going through the same catheter

Avoid blood sampling and flushing the catheter

Frequently monitor potassium till 3–3.5 mEq/L

Continuous ECG monitoring is required

Step 5: Replace intravenous magnesium

•Hypomagnesemia is usually concurrently present with hypokalemia and needs to be corrected.

Step 6: Ascertain the cause of hypokalemia and manage specifically (Table 57.2)

•Detailed history and physical examination should be performed to look for systemic causes of hypokalemia.

•History of increased urinary or gastrointestinal loss of fluid (vomiting, diarrhea, polyuria) should be taken.

•Detailed drug history to rule out drug-induced hypokalemia should also be taken.

•Urinary potassium level of more than 30 mEq/day is a feature of loss of potassium in the urine.

Step 7: Send investigation

•Complete blood count

•Na, K, Ca, Mg, PO4, HCO3

•Urea, creatinine

•Creatine phosphokinase (CPK)

•Arterial blood gas analysis

•ECG