 Sir coming for hypokalemia, hypokalemia potassium anything above 5 to 5.5 is hypokalemia. There is always you have to understand whenever you see a potassium you make sure there is nothing there is something called pseudo hypokalimages very very common okay when there is emolysis tying a tarnike just tying a tarnike and drawing a blood itself can cause emolysis very very simple. Lot of people will come with 5.3 unexplained or 5.5 but we just ask then the next time I ask them not to tie a tarnike and draw a blood to potassium come back to normal. So there is a serum sometime you have a doubt you can also ask for a plasma potassium. Plasma potassium is always correct you should always ask for a plasma potassium. So I need counsel more than 50,000 can cause false hyperkalemia platelets more than 7.5 lakhs or muscle activity keep on puncturing the veins couple of times you puncture and then draw the blood forcefully where the blood is not coming you keep on puncturing that severely that is sure your number will come 6.5 or 7 potassium only because it can cause lot of you know addition acrosis right anything that happen emolysis, emolysis, any tumourless syndrome all these things can cause pseudo hyperkalemia and when somebody is on metaprolol. Among all the beta blockers metaprolol we see when somebody is on metaprolol that is known to cause again pseudo hyperkalemia the less is there are other things nebulol, bisaprolol are much better. So normally somebody needs a beta blocker but metaprolol is causing that we shift on to nebulol or bisaprolol, I have done excellent. Any advanced renal failure and all these things as you know that you can always have hyperkalemia. So looking at the ECG look at the normal ECG PQRS complex when potassium is 4 this normal somewhere between 6 to 7 we can have a tall peak T waves when somebody's potassium is 7 to 8 we can have a flattened P wave a prolonged PR interval depressed ST segment thing and a peak T wave again and 8 to 9 we will have a completely absence of the P wave prolonged QRS complex and this is sine wave potassium this sine wave and harassed when the potassium goes high this is the ECG what we have to look at. So hyperkalemia ECG it is an emergency the only way to treat that will be by calcium otherwise there is no rule of calcium anywhere I will talk about this more. So in acute treatment what we have to do so IV calcium whenever you have ECG changes only then the IV calcium helps others do not treat with IV calcium gluconate unnecessarily because it is of no use it will not help to decrease the potassium at all because IV calcium gluconate is only helpful when there is ECG changes because to when it acts on the myocardium when the myocardium is involved because of hyperkalemia only then the calcium gluconate can help to reverse that but it will not bring down the potassium making calcium gluconate. Immediately you can shift the potassium into cells by using glucose and insulin or acetylene that is beta 2 agonist removing the potassium from body the only way is by what you have a calcium polystyrene or sodium polystyrene that is what you have a k-bind or what you call as a k-x that is our loop diuretics so removing the potassium only these three things can do shifting the potassium into cells only glucose insulin and acetylene can do but blocks effect of hyperkalemia not only IV calcium can do so what's the mechanism of calcium gluconate so it raises the action potential that is the reason after once it raises action potential only then it will from the resting potential then it stabilizes the myocardium that is the use of calcium gluconate so you can get calcium gluconate in 10 ml IV or 2 to 3 minutes don't wait for an infusion over 100 ml or 1 hour or something just give 10 ml calcium gluconate 10 ml IV or 2 to 3 minutes under continuous but it has to be given under continuous ECG monitoring the effect starts within 1 to 3 minutes calcium gluconate starts within 1 to 3 minutes it will last for 30 to 60 minutes in case it is not settling down don't wait keep on repeating it repeat the dose if there's no improvement in abnormal ECG you repeat the abnormal ECG requires after initial improvement then again if the ECG can go back so under continuous monitoring you have to see again if required you repeat a calcium gluconate so again I'm telling the only advantage of IV calcium is when there's ECG changes there is no rule of IV calcium to remove the potassium from the body so what is insulin dextrose do so what we do is potassium is around 6 we get a call immediately patient has to go for OT you know we can immediately want to shift then you can use insulin dextrose what we normally do is you can use 25% dextrose 50 ml or 100 ml and add 8 units or 10 units of insulin okay this can be given over 1 hour what happens is a plasma potassium drops 0.5 to 1.2 milli equivalents per litre asset begins in 10 to 20 minutes and peak at 30 to 60 somebody is going to OT we need to correct immediately we give this give acetylene send them to OT and interoperately the anesthetist will manage about it so this will last for 4 to 6 hours again it is going to bounce back again the potassium is going to go high only thing is once you get this make sure you check the sugars what I tell is after giving insulin dextrose drip you give monitor sugar every hour for 3 hours watch for iboglazemia or otherwise just give 10% dextrose at 50 to 75 ml with close monitoring blood glucose to be used because when you give insulin dextrose you forget to check sugars lot of people we see having severe iboglazemia after that and hyperglazemia if somebody has 250 no need to give any high weight glucose at all directly you can give soda bicarbonate we always see in EER people a lot of people eating sodium bicarbonate please don't give there is no role of treatment of acute no role of soda bicarbonate as an acute agent only single agent in hyperglazemia so it can be in severe acidosis or hyperglazemia then we may try but you know otherwise isolated don't use soda bicarbonate at all side effect is hypernitrima in fact if you use soda bicarbonate it can cause volume overload palmedema will like will worsen palmedema and reduce anis calcium so coming to cation exchange disease like what we call as a k-bind normally we have sodium or calcium polystyrene sodium is not available anymore now so we use calcium polystyrene sulfonate that is what you get in k-bind it comes as 15 grams sachet so what happens as a 15 grams to 30 grams is every fourth hourly you have to mix it with unavailable water and you have to add a deflact syrup or sorbillin directly don't give the sorb k-bind with water alone it can cause severe constipation so whenever you get k-bind you just mix it in 15 grams one sachet and 1 ml saline of water water water and you add 10 or 20 ml of deflact or sorbillin mix everything and then you have to ask them to take it k-bind so 1 gram binds to 1 mL increments of potassium so it is a plasma potassium by 1 mL increments in 24th this is the only way to remove potassium from the body so pyrrectal also can be given where people can't take oral k-bind okay you can add 50 grams in 150 ml pyrrectal you can give like enema at least 30 to 60 minutes it has to stay then you can do it say 1 gram of pyrrectal decreases only 0.5 whereas orally decreases up to 1 mL increments so side effects you know GI irritation constipation if somebody has a bowel surgery or something be careful don't use too much of k-bind it can cause bowel necrosis or any bowel necrosis in post-operative it sometime then they use or disturb any bowel obstruction so treatment again I'm telling you IV calcium gluconate 10 ml IV push time frame is seconds to minutes glucose plays insulin 10 units plus 50% glucose 50 ml 100 ml so 5 to 10 minutes time frame 30 to 60 minutes is a action calcium polystyrene sulfonate you can add 15 grams or 30 grams you can give it can stay in the water if it doesn't respond any of those things then we do dialysis immediately it will come down so iponate trimia any sodium less than 135 is iponate trimia in treating iponate trimia don't go by the number go by what the patient whether the patient is censoring is normal or abnormal that's the most important criteria to treat iponate trimia to because I have to explain this I just go fast in this sorry if somebody sodium in the patient comes with sodium of 120 what to do is once you see the number don't go with the number then you you see the new logical assessment you talk to him look at how mentally is whether he's conscious oriented towards time place or person that is very very important because don't chase the number if you chase the number then you'll things can go pretty wrong always talk to the patient make sure clinically if his if his drowsy the treatment is different if is if a stable sensory means normal the treatment is absolutely different even if the number is 115 120 so somebody is number iponate trimia I think the number is around 120 I'll just give our number 120 he comes to you clinical assessment again iponate trimia is divided into you have to look at look at whether clinically is hyperolimic uolimic and ipo-olimic that's very very important again ipo-olimic you know then you can do all the test you know the spot sodium and all those things helping diagnosing but ipo-olimic you know again the colors of ipo-olimic is you know dehydration and any drugs which is causing or look for any drugs common is hydrochlorothiazide the most common cause of iponate trimia what this is people will be an hydrochlorothiazide or chlorthylidone ok a lot of people lot of reasons we get iponate trimia is number one is because a drug induced only so iponate trimia you have to look for those drugs if any drugs is there you please look into that you will have Telma IH and something CT so look for those drugs or any laxatives you know any sorry I am not laxative diuretics look for diuretics again those things are very important which can cause iponate trimia so clinically if somebody is dry try to fill again treat like any prerenal try to hydrate the patient sodium automatically will improve by giving just simple normal saline then if somebody is clinically uolimic that means no clinically is not dry neither is hyperolimic the JVP is ok everything then what happens is then then we look at clinically uolimia that is very important so you have something called a decreased DCF volume then we have a normal DCF volume then this is increased DCF volume so decreased I told you vomiting diarrhea and then is sweating too much of the link or look for any diuretic or salt-based thing normal volume you know what happens is you will have hyperthyroidism if hyperthyroidism is ruled out cortisol deficiency is ruled out the only condition is in causes assayage most common we see is assayage syndrome of inappropriate anti-diuretic augmentation if somebody has a tumor anywhere in the brain or lung tumor or anywhere or any inside that is anything which can cause assayage or patient of psychiatric patients or drugs any psychiatric manifestations the most common is assayage we see in clinically uolimic condition hyperolimia again congestive heart failure liver failure nephrodic syndrome all those things you know is hyperolimic so when you have a hypernatrimia again you have to look into whether it is a clinically uolimic, hyperolimic or hyperolimic based on this only we have to treat after you do a clinical examination then you go by mental status also whether it is conscious oriented if it's conscious oriented normal talking that means it is a chronic hypernatrimia don't don't jump and treat it with 3 percent saline that's very very important the other side of extra you all know I don't need to tell about it about volume depression look for sunken eyes orthostatic hypertension flattened neck veins increase heart rate decrease urinary output and decrease body weight all those things you look for in the easier volume thing if you're not able to make up clinically then about whether it's volume status then you can do investigation ways what are the other things I'm missing hyperolimia it will be you more concentration you will have increased albumin burn creatinine ratio is more than 20 to 1 or elevated bicarbonate these are all in hyperolimia if you clinically 90 percent you can easily make out clinically still you can't make out then these are the differential things uolimia make sure uric acid is less than 5 in SIDH burn creatinine ratio will be less than 10 is to 1 bicarbonate will be slightly increasing and anion graph will be low in hyperolimia indirectly is emodulation you know the emodulation happens low albumin burn creatinine more than 20 is to 1 and elevated bicarbonate these are all only the test to make out clinically if you're not able to make out the volume status. So how do you treat hyponitrimia acute look for duration what is the somebody's sodium is 142 days ago and suddenly it is 120 that is acute acute hyponitrimia don't wait for anything is any acute we have to act immediately okay there are there are a lot of symptoms like nausea, vomiting, headache, hiccups, mental change, confusion, chronic you know even the number is 110, 105 also a lot of people will have chronically asymptomatic neurologically will be because the brain would have adapted well so chronically you do not have any symptoms. So go by thing I told you moderately severe nausea without vomiting, confusion, headache and severe you'll have vomiting even seizures, patient can if you don't treat them they can go coma. So again how do you treat them any acute hyponitrimia you think if somebody's sodium is 120 so so you send basic at least you send uric acid, urine spot sodium very important don't start any fluid without sending a urine spot sodium at least and uric acid is very very important because you know it helps us a lot once you start the treatment there's no point doing any of those tests. So what is the thumb rule to give 3% saline lot of people I see admitted in other departments you know they give you know sodium is 115 or 150 they give 5 ml of 3% saline or 10 ml per hour that is wrong. So if somebody at least I tell you how exactly you do it somebody's sodium is 120 is having little bit you know drowsy or something you don't need to at least you go by even 1 ml per kg body we can give you can give up to if somebody is 60 kg you can give up to 50 to 60 ml per hour for 2, 3 hours or 4, 5 hours then again repeat sodium don't wait for sodium doing once in 24 hours. So hyponitrimia is very very important the way you correct it but don't correct more than 10, 8 to 12, 10 to 12 millicubates in 24 hours like somebody is 115 make sure you correct rapidly means at least around 8 to 10 minutes at least by 125 to 127 you can correct in 24 hours that should be the target but don't give just 3, 5 ml per hour or 10 ml per hour or 15 ml in that way you are not sure confident about it at least start 30 ml or in a 70 kg old man you start 30 ml or 40 ml per hour but make sure you repeat every 6 hours you know the value and then you continue it otherwise just don't put on 30 ml 24 hours don't sleep on that. So if you have difficulty otherwise there is lot of formulas I don't want to tell you all the formulas because there is lot of formulas to treat hyponitrimia but at least what I tell you is at least if somebody sodium is 120 and it's acute hyponitrimia if you want to start 3 percent saline start 30 or 40 ml per hour in a elderly 70 year 70 but every after 6 hours again repeat it get the report in 1 hour again the sodium is less again you continue doing it but unless you do that don't start like that otherwise use formulas properly and then you have to treat properly but just giving 5 ml or 10 ml you know this is a common mistake we see everywhere it's not going to anywhere because in acute hyponitrimia we have treated even if 50 to 60 75 ml per hour for couple hours then we come back slowly that is how we have to treat there is a then also you can use lasix along with hypotonic saline because sodium low doesn't mean that the only the sodium is less there will be lot of water so it's basically the problem with the water so we have to excrete the water to excrete the water we have to give diuretic so lasix helps then 3 percent saline also helps along with that