1. Virtual Potassium for the Intern
(and other related electrolytes)
Intern Lecture Series
June 28th, 2011
Scott Pawlikowski, MD
Cardiology
Loyola University Medical Center / Hines VA
2. Goals of this Lecture
SESSION OBJECTIVES
Learn to effectively assess and manage
hyperkalemia
Learn to address various electrolyte deficiencies
(low K+, low Mg2+, low phos, low Ca2+)
Learn what serum electrolyte levels to follow in the
hospital, and how often to follow them
Apply your knowledge to real cases!
LEARNING METHODS
Lecture/material review
Interactive case scenarios
Real cases and real intern approaches to electrolyte
disorders
3. What this lecture IS:
A practical approach to handling
electrolyte disorders in MOST
hospitalized patients
A guideline for supplementing
electrolytes based on experiential
and some evidence-based medical
recommendations
Hopefully an informative and useful
tool
4. What this lecture IS NOT:
A be-all, end-all list of all the causes
of hyperkalemia, hypokalemia, etc.
A thorough review of all the large
center, prospective, randomized
controlled trials on electrolyte
replacement
There really aren’t any!!!
A complete reference that applies to
every patient you will treat
6. Hyperkalemia Overview
Commonly encountered in
hospitalized patients
Most feared consequence:
PEA
Asystole
Urgent vs. Emergent therapy?
Stepwise approach
7. Approach to Hyperkalemia: Step 1
Is it real?
Assess for/exclude pseudohyperkalemia
Hemolysis—ask RN/phlebotomist/lab tech
If suspected—order STAT repeat K+ level
Potassium infusion—ask RN
If suspected—order STAT repeat K+ level from
peripheral vein AWAY from infusion site
Check CBC (WBC > 70K, PLT > 1,000)
K+ moves out of WBC’s, PLT’s after clotting
If suspected—order STAT serum/plasma K+ levels
if serum K+ > plasma K+ by more than
0.3mEq/L, suspect pseudohyperkalemia
In any case, have low threshold to repeat labs
8. Approach to Hyperkalemia: Step 2
If real, why did it happen?
Acute or chronic renal failure
Medications (K+ sparing diuretics, ACE
inhibitors, ARB’s, BB’s, digoxin, etc.)
Endocrinopathies (hypoaldo, Addison’s)
K+ supplements or salt substitutes
K+ in IV infusions/TPN
9. Approach to Hyperkalemia: Step 3
Is this an emergency?
Did the K+ increase quickly?
If yes, treat as emergency
How high is the potassium level?
If serum K+ ≥7.0 mEq/L, treat as emergency
Any EKG changes of cardiac instability?
If yes, treat as emergency
Remember, the lack of EKG changes is NOT
always entirely reassuring
10. Approach to Hyperkalemia: Step 3
EKG assessment
Four stages of EKG changes
Peaked T waves
PR prolongation/loss of P wave (unstable)
QRS widening (unstable)
Sine waves (very unstable)
The “fifth” and final stage if
hyperkalemia not addressed…
PEA or asystole (i.e. cardiac arrest)
11. Approach to Hyperkalemia: Step 4
Emergency therapy
Part A: oppose toxic effects on cell membrane
IV calcium infusion
Chloride: 3x the elemental calcium of gluconate
Gluconate: less toxic if IV extravasates
Give 10mL ampule of 10% Calcium chloride
vs. gluconate over 2-5 minutes
Too fast—pukey pukey!!!
Can repeat in 3-5 minutes if no EKG effect
Keep EKG machine attached to patient!!!
EKG changes will diminish in 1-3 minutes
12. Approach to Hyperkalemia: Step 4
Emergency therapy
Part B: Shift K+ into cells
Will buy you 1-4 hours before direct
elimination methods “kick-in”
Insulin/dextrose therapy
Regular insulin10 units IV push
50% Dextrose (“D50”) 1 ampule IV push
Adjuncts (usually not necessary)
Albuterol nebulizer (continuous neb)
Sodium bicarbonate 1 ampule IV push
Only really helpful with coexistant acidosis
Beware rebound hyperkalemia!!!
13. Approach to Hyperkalemia: Step 5
Direct elimination of K+ from body
Usually takes 4-6 hours to work
Kayexalate (K+ binding resin/laxative combo)
Give 30-60 gm
PO if patient can tolerate
PR (retention enema) if upper GI problems
Patient needs to have a colon for this to work!
Lasix?
Works best when volume overloaded
Hemodialysis (always discuss with renal fellow)
Last resort or in severe cases
14. Approach to Hyperkalemia: Step 6
Housekeeping/Follow Up
Try to reverse/prevent/treat the cause
Treatment of acute kidney injury
Medication adjustment
Monitor and reassess closely
Should check serum K+ 4-8 hours after Rx initiated
Beware of rebound hyperkalemia, especially if
cellular shift Rx used!!
ALWAYS discuss digitalis-toxicity associated
hyperkalemia with your senior resident!!!
Calcium infusion can potentiate the toxicity!!!
15. Hypokalemia Overview
Occurs in over 20% of hospitalized patients
Dangers
Arrhythmia
Rhabdomyolysis
Paralysis
Usually does NOT require emergency
supplementation over minutes to hours
16. Approach to Hypokalemia: Step 1
Redistribution or depletion?
Redistribution causes (cellular shift)
Insulin therapy (usually in DKA)
Beta 2 agonists (e.g. albuterol)
Metabolic alkalosis
Replacing K+ in these settings may
cause overshoot and hyperkalemia
17. Approach to Hypokalemia: Step 1
Redistribution or depletion?
Depletion causes (common)
GI tract losses (diarrhea, vomiting)
Loop/thiazide diuretic therapy
Other medications (e.g. amphotericin B)
Osmotic diuresis (DKA)
Refeeding syndrome (NEVER underestimate!)
Endocrinopathies (Conn’s syndrome, e.g.)
Salt wasting nephropathies/RTA’s
Magnesium deficiency (NEVER overlook!)
18. What is Refeeding Syndrome?
Spectrum of electrolyte/volume disorders
Occurs when previously malnourished patients are
fed carbohydrate loads (PO or IV!)
Triggered by intense insulin secretion
Low phos/K+/Mg2+ (sometimes low blood sugar)
Severe cases with unexplained CHF-like picture
First identified/described in liberated POW’s,
concentration camp survivors from WWII
19. Approach to Hypokalemia: Step 2
Estimate the deficit
For every 100 mEq below normal,
serum K+ usually drops by 0.3 mEq/L
Highly variable from patient to patient,
however!!
Dr. Popli’s estimation scheme
For every 10 mEq below normal, serum
K+ usually drops by 0.1 mEq
20. Approach to Hypokalemia: Step 3
Choose route to replace K+
In nearly all situations, ORAL
replacement PREFERRED over IV
Oral is quicker
Oral has less side effects (IV burns!)
Oral is less dangerous
Choose IV therapy ONLY in patients
who are NPO (for whatever reason) or
who have severe depletion
21. Approach to Hypokalemia: Step 4
Choose K+ preparation
Oral therapy
Potassium Chloride is PREFERRED AGENT
Especially useful in Cl-responsive metabolic
alkalosis
Potassium Phosphate useful when
coexistant phosphorus deficiency
Often useful in DKA patients
Potassium bicarbonate, acetate,
gluconate, or citrate useful in metabolic
acidosis (“-ate” = bicarb former)
22. Approach to Hypokalemia: Step 4
Choose K+ preparation
IV therapy
Adjunct to maintenance fluids (10-20 mEq/L)
“The surgical intern’s way”
Try to avoid using it!!!
you often forget it’s there
hyperkalemia can then develop, especially in
patients that get ARF in the hospital
IV rider/”piggyback” (+/- lidocaine)
Generally 40-60 mEq
KCl is PREFERRED AGENT again
Can also use KPhos, Kbicarb, etc.
Avoid dextrose solution (trigger insulin, shift K+)
23. Approach to Hypokalemia: Step 5
Choose dose/timing
Mild/moderate hypokalemia
3.0 to 3.5 mEq/L
60-80 mEq PO (or IV) QDay divided doses
Sometimes will require up to 160 mEq per
day (refeeders, lots of diarrhea, IV
diuretics)
Avoid too much PO at once
GI upset or just poor response
Usually divide as BID or TID dosing
24. Approach to Hypokalemia: Step 5
Choose dose/timing
Severe hypokalemia (< 3.0 mEq/L)
Can use combination of IV and PO, again
with PO preferred if at all possible
Avoid more than 60-80 mEq PO in a
single dose
Avoid IV infusion rates >20 mEq/hour
Can cause arrhythmia!!!
Most RN protocols won’t allow >10 mEq/hour
rates on the floors (ICU’s too?)
25. Approach to Hypokalemia: Step 6
Monitor/reassess
Severe hypokalemia, DKA patients
Reassess labs Q4-6 hours
Moderate hypokalemia, IV diuresis
patients
Reassess labs BID to TID as needed
Mild hypokalemia
Reassess labs QDay or less as needed
26. Approach to Hypokalemia: Step 7
Housekeeping/Follow Up
BE AGGRESSIVE in DKA patients and IV
diuresis patients
“Moran’s Rule” for cardiac patients: keep
K+ > 4.0 or even 4.5 mEQ/L
BE GENTLE in patients with acute or chronic
renal failure, and monitor very closely
Cut dose in half
Double dosing interval
Do not replace at all
NEVER forget to check for and treat
hypomagnesemia in refractory hypokalemia!!!
27. Hypomagnesemia Overview
Most of total body magnesium is intracellular
Serum levels may NOT reflect intracellular status
Low intracellular Mg2+ can occur in the setting of
low, normal, and high serum magnesium levels
Highest risk patients for hypomagnesemia
Alcoholics
Diabetics
Critically ill patients
Refeeding syndrome patients
Rare symptoms (most patients asymptomatic)
Neurologic
Muscular
Cardiac
28. Causes of Hypomagnesemia
Poor PO intake and malabsorptive syndromes
Alcohol ingestion (renal losses)
Thiazide/loop diuretic administration
Amphotericin administration
Acute/chronic diarrhea
DKA
Refeeding syndrome
Inadequate TPN dosing
Diabetes mellitus? (at least an association)
29. Approach to Hypomagnesemia
Unlike potassium replacement,
magnesium replacement usually
involves IV replacement
All PO magnesium salts are all poorly
absorbed
High doses of PO magnesium usually
leads to diarrhea
Conversion rule: 8 mEq of
magnesium sulfate equals 1 gram of
magnesium sulfate (Hines CPRS)
30. Approach to Hypomagnesemia
Rx in hospitalized patients
1.6-2.0 mg/dL
Give 2-4 gram IVPB (16-32 mEq)
Usually infused at 1 gram/hour
1.0-1.6 mg/dL
Give 4-8 gram IVPB (32-64 mEq), usually
in divided doses BID to TID
<1.0 mg/dL
Can give up to 8-12 gram IVPB (64-96
mEq) in a single day, would divide into
three-four doses
31. Approach to Hypomagnesemia
Treating chronic low Mg2+ patients
Give oral magnesium salt daily
Sulfate, oxide, hydroxide, citrate, lactate,
chloride, and gluconate available
Gluconate less likely to cause diarrhea
Periodic IM/IV dosing if/when needed
My approach: Magnesium Oxide 420mg
PO QDay to TID, based on level and
tolerability
32. Approach to Hypomagnesemia
Housekeeping/Follow Up
BE AGGRESSIVE in DKA patients and IV
diuresis patients
“Moran’s Rule” for cardiac patients: keep
Mg2+ > 2.0 or even 2.5 mEQ/L
BE GENTLE in patients with acute or chronic
renal failure, and monitor very closely
Cut dose in half
Double dosing interval
Do not replace at all
33. Hypophosphatemia Overview
Phosphorus is a critically important
element in every cell
Remember what the “P” stands for in
ATP?
Low phos commonly encountered in
hospitalized patients
Feared complication of severe
deficiency is rhabdomyolysis
35. Approach to Hypophosphatemia
Rx in hospitalized patients
Mild to moderate hypophosphatemia
1.5 -2.4 mg/dL
Give phosphorus in the form of K+ or Na+
salts PO BID to TID as needed
Usually given as 1-2 packets of “neutraphos” BID
to TID
Severe deficiency
<1.5 mg/dL
Give IVPB in the form of sodium or
potassium phosphate
Usually given as 20-40 mEq/mmol rider infused
over 2-4 hours
Reasess labs QDay to TID as needed
36. Hypocalcemia Overview
Hypocalcemia in hospitalized
patients is usually spurious and/or
DOES NOT need to be treated
Aggressive management of
hypocalcemia is usually ONLY
indicated in “symptomatic” patients
Active or latent tetany
Cardiac dysrhythmia/prolonged QT
37. Hypocalcemia Overview
Spurious hypocalcemia: low albumin
Corrected Ca2+ = measured Ca2+ + [(normal
albumin - measured serum albumin) x 0.8]
Works well unless albumin < 2 mg/dL
Hypocalcemia due to hyperphosphatemia
from CKD/ESRD
Aggressive calcium replacement is DANGEROUS
—serum/tissue precipitation!!!
Treat high phos and calcium level will improve
Renal consults/senior resident can help with
phosphate binder dosing/orders
38. Hypocalcemia Overview
IV Calcium infusion can cause skin and
muscle necrosis if it extravasates from IV
May threaten limb or necessitate skin
grafting!!!
If replacement is needed, can usually give
TUMS PO
Severe depletion: discuss IV dosing with
senior resident or endo consults
Maintenance calcium replacement in TPN
usually handled by nutrition support team
39. Recap of Major Learning Points
Hyperkalemia
Make sure it’s real
Determine emergent or not
Rate of rise, degree of hyperkalemia, EKG
Treat emergent cases with calcium
gluconate, insulin, dextrose, and
kayexalate +/- dialysis/lasix
Monitor closely for response to
treatment—watch for rebound
Fix the cause if possible
40. Recap of Major Learning Points
Hypokalemia
PO almost always preferred over IV
KCl is preferred preparation
Don’t give too much too quickly
Be aggressive in DKA and IV diuresis
patients
Be gentle in renal failure patients
Don’t forget to check magnesium levels
in refractory patients
41. Recap of Major Learning Points
Hypomagnesemia
IV almost always preferred over PO
Give IVPB in 2 gram increments
Be aggressive in DKA patients, IV
diuresis patients, and alcoholics
Be gentle in renal failure patients
PO does not work well and in high
doses causes diarrhea
42. Recap of Major Learning Points
Hypophosphatemia
Can be treated with neutraphos packets PO
BID/TID in mild cases
Can be treated with sodium or potassium
phosphate IVPB’s in severe cases
Hypocalcemia
Usually spurious or does not require Rx
Avoid calcium replacement in CKD/ESRD
patients with hyperphosphatemia
Avoid IV calcium whenever possible
Call for help if hypocalcemia really needs IV Rx
43. Getting Labs on Patients
BMP
QDay or Qother day on most hospitalized patients,
especially if they have PO intake issues or are on
maintenance fluids
BMP with Mg levels
QDay-BID on cardiology patients, alcoholics, and
patients on amphotericin B
BMP with Mg/Phos levels
QDay-TID on tube feeding patients, DKA patients,
or patients with suspected refeeding syndrome
BMP with Ca/Mg/Phos levels
QDay-4x/Day on TPN patients, AKI/CKD/ESRD
patients, oncology patients (chemo/TLS),
pancreatitis patients, critically ill patients
44. Ok, You Think You Got It???
Let’s try it out on some cases
3 Real cases from real patients at Hines
Figure out what you would do...
…then I’ll show you what the intern
actually DID and what actually
happened!
45. Case #1
A 56 y/o male presents due to increased swelling
in his face, legs, and abdomen, as well as
increasing SOB and DOE. He is volume
overloaded on exam. His labs are listed below.
His serum albumin is 2.5 g/dL. Would you
replace or treat anything?
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
133 5.5 101 18 51 9.5 83 8.2 2.1 6.0
47. Case #1 (continued)
Here’s what the intern did…
Gave 30gm Kayexalate PO
Appropriate
Gave lasix for volume overload, attempt at diuresis
and potassium lowering
Appropriate
No insulin/dextrose/calcium gluconate
Probably appropriate
Gave phosphate binders for high phosphorus and
DID NOT Rx low calcium (corrected calcium 9.4 mg/
dL--normal)
Very appropriate
Discussed possible hemodialysis with senior
Appropriate
48. Case #1 (continued)
Here’s what the intern did…
Rechecked K+ 12 hours later, still 5.5
mEq/L
Could have rechecked a little sooner
Therfore gave another 30gm of
Kayexalate PO
Appropriate
Rechecked K+ 8 hours later, down to
5.1 mEq/L
49. Teaching Points
Know the systematic approach to
assessing and treating
hyperkalemia
Avoid unnecessary correction of low
serum calcium values, especially
when they are spuriously low
50. Case #2
A 31 y/o male with a h/o severe HTN and
resultant CKD and diastolic dysfunction/CHF
presents with hypertensive urgency and CHF
exacerbation. He is started on IV lasix and BP
meds in the ED. His admission labs are below
(taken prior to any medication administration).
Would you replace or treat anything?
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
137 3.5 100 26 25 2.8 125 9.1 1.9 3.5
51. Case #2 (continued)
Here’s what the intern(s) did…
No initial Rx for low normal K+ or Mg2+
in the setting of CKD
Probably appropriate, though could have
given a little K+ PO (20 mEq) or Mg2+ IV
(2 grams), given plans for IV lasix
Repeated BMP and Mg2+ level in 12
hours
Appropriate
52. Case #2 (continued)
The patient is responding to IV diuretics
in terms of volume status and BP. His
repeat labs are below (bottom row).
What would you do now?
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
137 3.5 100 26 25 2.8 125 9.1 1.9 3.5
139 5.4 106 29 23 2.4 102 1.9
54. Case #2 (continued)
Here’s what the intern did…
Did NOT bother to notice that hemolysis was
noted on the lab report
Ooops!
Did NOT repeat BMP values before deciding
treatment
Ooops!
Gave 15gm Kayexalate PO
Big Ooops!
Repeated BMP and Mg2+ level in 8 hours
Appropriate, though intervention is suspect…
55. Case #2 (continued)
The patient experienced 3-4 loose, watery
BM’s and is now very frustrated. He is
still receiving high dose IV diuretics. His
repeat labs are listed below (bottom row).
What would you do now?
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
137 3.5 100 26 25 2.8 125 9.1 1.9 3.5
139 5.4 106 29 23 2.4 102 1.9
142 3.3 105 29 25 2.7 115 2.0
56. Case #2 (continued)
Here’s what the intern(s) did…
Gave 20mEq KCl PO and 20mEq KCl
IVPB
Most likely needed only PO potassium
therapy, low dose probably appropriate,
given CRI
Repeated BMP and Mg2+ level in 12
hours
Probably appropriate
57. Case #2 (continued)
The patient complains bitterly about the IV
potassium infusion burning his arm. He’s still
mad about the diarrhea from last night. He
threatens to leave AMA and requires three
separate MD conferences to keep him in the
hospital! Repeat labs listed below (bottom row).
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
137 3.5 100 26 25 2.8 125 9.1 1.9 3.5
139 5.4 106 29 23 2.4 102 1.9
142 3.3 105 29 25 2.7 115 2.0
139 3.6 102 29 24 2.6 96 2.1
58. Teaching Points
Consider “staying ahead” of potassium
and magnesium depletion in IV diuresis
patients with replacement for low-normal
values
Suspect pseudohyperkalemia when things
“just don’t add up”
Be gentle in CKD patients
PO potassium is PREFERRED over IV
potassium in most situations
59. Case #3
A 56 y/o male with a h/o chronic alcoholism and
chronic dysphagia from prior CVA presents due to
heavy drinking with nausea and vomiting at home.
Patient is a poor historian and is VERY CACHECTIC on
exam. He is placed on dextrose-containing IV fluids
and made NPO. His labs are listed below. His serum
albumin is 3.2 g/dL. Would you replace or treat
anything?
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
140 4.7 99 29 11 1.1 89 9.6 1.3 3.4
60. Case #3 (continued)
Here’s what the intern did…
Gave thiamine and folate in addition to IVF as
adjunctive therapy for chronic ETOHism
Appropriate
Did NOT supplement with any magnesium
preparations
Ooops!
Repeated BMP, Mg2+ level, Phos level in 8
hours
Appropriate
61. Case #3 (continued)
Patient continues to have dysphagia and
nausea/vomiting problems. His repeat labs are
listed below (bottom row)—these were drawn 36
hours after admission (patient kept refusing labs).
Service is planning on Dobhoff until full
ENT/speech pathology workup complete. What
would you do now?
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
140 4.7 99 29 11 1.1 89 9.6 1.3 3.4
136 3.9 100 23 5 0.9 46 1.3 2.4
62. Case #3 (continued)
Here’s what the intern did…
Gave 4gm magnesium sulfate IVPB
Appropriate
DID NOT further address the hypoglycemia
Ooops!
DID NOT supplement with any potassium or
phosphorus
Ooops!
Repeated labs in 24 hours
Probably should have repeated in 8-12 hours
DID NOT ANTICIPATE this patient’s potential for
continued electrolyte problems, given his alcoholism
and high risk for refeeding syndrome
Can happen even with IV dextrose infusion!!!
63. Case #3 (continued)
Patient is getting more lethargic, starts to have
fevers, service suspects aspiration pneumonia,
eventually goes to MICU. He gets nutritional
support off/on with Dobhoff, but keeps pulling it
out. Here’s the next several days’ labs, with
notes on replacement in-between
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
140 4.7 99 29 11 1.1 89 9.6 1.3 3.4
136 3.9 100 23 5 0.9 46 1.3 2.4
137 3.8 100 24 6 0.8 65 Oops! Oops!
66. Case #3 (continued)
Finally making some progress!!! At this point
tube feeds get started with some regularity. New
labs drawn 24 hours later, listed below at bottom
(line above is yesterday’s “perfect” labs). Serum
albumin around this time is 2.1 g/dL.
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
137 3.8 103 24 9 1.0 80 2.4 3.6
138 3.4 106 26 8 0.9 129 7.9 1.3 2.7
67. Case #3 (continued)
Nothing gets addressed/replaced by
intern (Ouch, that hurts!)
New labs 24 hours later, listed at bottom:
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
137 3.8 103 24 9 1.0 80 2.4 3.6
138 3.4 106 26 8 0.9 129 7.9 1.3 2.7
141 2.9 105 28 4 0.8 124 7.7 0.9 2.9
68. Case #3 (continued)
Finally, something starting to happen!!!
Gets 20mEq KCL IVPB x 2 doses 4 hours apart
Probably not enough, if you ask me…
Gets 4gm magnesium sulfate IVPB
Gets new labs in 12 hours this time (below, at
bottom):
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
137 3.8 103 24 9 1.0 80 2.4 3.6
138 3.4 106 26 8 0.9 129 7.9 1.3 2.7
141 2.9 105 28 4 0.8 124 7.7 0.9 2.9
138 3.6 106 27 3 0.8 89 1.6 Oops!
70. Case #3 (continued)
Nothing supplemented (oh boy, here we
go again…)
New labs 12 hours later, at bottom:
Na+ K+ Cl- CO2 BUN Creat Gluc Ca2+ Mg2+ Phos
137 3.8 103 24 9 1.0 80 2.4 3.6
138 3.4 106 26 8 0.9 129 7.9 1.3 2.7
141 2.9 105 28 4 0.8 124 7.7 0.9 2.9
138 3.6 106 27 3 0.8 89 1.6 Oops!
141 3.3 104 27 2 0.7 107 1.8 2.2
140 3.1 105 28 2 0.9 100 1.2 2.3
71. Some Take Home Points
Try to avoid “chasing your tail” on
patients at high risk for continued
electrolyte deficiencies
Be aggressive in these patients, do not be
afraid to replace lytes when at low-normal
end of reference range
Never underestimate the importance of
maintainting electrolyte homeostasis, for
the patient’s benefit and for YOUR benefit
Your seniors and attendings will LOVE you!!!
72. References
Cody RJ, Pickworth KK: Approaches to diuretic therapy and
electrolyte imbalance in congestive heart failure. Card Clin
1994; 12: 37-50.
Kim G, Han J: Therapeutic approach to hypokalemia.
Nephron 2002; 92(suppl 1): 28-32.
Kim H, Han S: Therapeutic approach to Hyperkalemia.
Nephron 2002; 92(suppl 1); 33-40.
Whitmire SF: Fluid and electrolytes; in Gottschlich MM (ed):
The Science and Practice of Nutrition Support; A Case-
Based Core Curriculum. Dubuque, Kendall/Hunt, 2001, pp
53-84.
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