Acidosis...K+lvl of 5.2 and a bag of potassuim 20meq

**canoehead, BSN, RN** · Apr 16, 2010

What was her glucose?

aCRNAhopeful · Apr 16, 2010

You really didn't provide much specifics for anyone to try to guess what happened here. Was the fluid started pretty much as soon as they got to the ER? It takes awhile for the BMP or CMP or lytes panel to come back and they may not have known. Potassium is usually high in acidosis by my understanding so I can't think of a benefit of giving more. Are you sure the bag was just purely 20 mEq of K? Was it D51/2 with 20 of K? Too many question marks for anyone to really answer a question about the specific case youre talking about.

donnasRN · Apr 16, 2010

Hey, I'm only a student, but maybe I can be of some help since this is still fresh in my mind lol. From my understanding, serum K+ level increases in metabolic acidosis (and decreases in metabolic alkalosis) but is not so much affected in respiratory acidosis (so I don't think it would have anything to do with CO2 since that is resp not metabolic). That being said, I don't think hanging K+ would benefit in a state of metabolic acidosis, it would just increase the serum K+ level even more. Was it pure K+ they were infusing? Any other fluids that may have lead to the fluid overload? What was her acidosis caused from, DKA? What was her BS? ABG levels? Once they got the level, did they give her insulin to lower the K+ or any other Tx and then gave the K+ to prevent hypokalemia? Sorry, lots of questions but it helps with learning LOL

5263rn · Apr 16, 2010

I don't know the specifics of the diagnosis or underlying disease, but will give an example of giving a K+ rider with a normal K+ level. When a diabetic is being treated with an Insulin drip for hyperglycemia or DKA, the insulin can cause a K+ shift into the cells and drops the serum K+ level. For that reason if the K+ is normal or even slightly elevated, K+ riders will be given. Again I don't know all the specifics of the medical history, but I hope that helps. Good luck to you.

GilaRRT · Apr 16, 2010

As stated, not enough information. However, in the setting of metabolic acidosis, it is not uncommon to see a shift of potassium to the extracellular environment. As the acidosis corrects, potassium will shift back in. However, in some cases such as DKA, you can loose potassium by the way of hydronium ion/potassium ion exchange in the kidney. If this is the case, you will actually have a total body deficit in spite of an elevated serum potassium.

When considering ventilation and potassium changes a good rule of thumb is, for every 10 mmHg you decrease CO2, you can expect a 0.5 mEq decrease in serum potassium. Therefore, even people in respiratory acidosis may in fact have a very low potassium following correction of their ventilation status. In addition, you can roughly expect the potassium to decrease 0.6 for every 0.1 increase in PH.

So, assuming your patient has a potassium of 5.2 and say a PH of 7.1, and you intend to have a PH of 7.4, you can expect the potassium to fall to approximately 3.4 based on PH change alone. You in fact have a potassium depleted patient on your hands.

If any of this is the case, I would expect the physician to order potassium replacement. In fact, I may even suggest the possibility of potassium replacement in a patient with a K+ of 5.2 with an acidosis that we intend to correct.

kieraloo · Apr 16, 2010

As stated, not enough information. However, in the setting of metabolic acidosis, it is not uncommon to see a shift of potassium to the extracellular environment. As the acidosis corrects, potassium will shift back in. However, in some cases such as DKA, you can loose potassium by the way of hydronium ion/potassium ion exchange in the kidney. If this is the case, you will actually have a total body deficit in spite of an elevated serum potassium.
When considering ventilation and potassium changes a good rule of thumb is, for every 10 mmHg you decrease CO2, you can expect a 0.5 mEq decrease in serum potassium. Therefore, even people in respiratory acidosis may in fact have a very low potassium following correction of their ventilation status. In addition, you can roughly expect the potassium to decrease 0.6 for every 0.1 increase in PH.
So, assuming your patient has a potassium of 5.2 and say a PH of 7.1, and you intend to have a PH of 7.4, you can expect the potassium to fall to approximately 3.4 based on PH change alone. You in fact have a potassium depleted patient on your hands.
If any of this is the case, I would expect the physician to order potassium replacement. In fact, I may even suggest the possibility of potassium replacement in a patient with a K+ of 5.2 with an acidosis that we intend to correct.

This was a great answer, exactly what I was asking. I didn't need to provide a medical history in order to get this answer and i appreciate it. All I asked was why would you give K+ bag in a state of acidosis with a K+ of 5.2. Thank you for answering exactly what I was asking. :up:

talaxandra · Apr 16, 2010

I'm glad Gila was so helpul.

The reason other members were asking about clinical history is that all of those elements can also contribute to K+ requirements in patients with high normal serum K+. In DKA, for example, the combination of rehydration dilution, hyperglycaemia, acidosis and intravenous insulin mean that we replace at a rate of 5-20mmol/hr unless it's over 6.

I say this because your first post sounded very much as though you were poised to make a complaint to the hospital, and your response made it sound as though you were rebuking members who asked for more information. I acknowledge that you're probably stressed by your family member's illness and admission, and that internet communication is prone to misinterpretation, but I wanted to point this out anyway.

I hope she makes a full and rapid recovery.

Zookeeper3 · Apr 16, 2010

The reasons for the question is that we need to know if the patient was in DKA, diabetic kedoacidosis. WHAT WAS THE GLUCOSE LEVEL, we can't answer until we know that!!!!!!!

If the glucose is high the potassium has left the cell and is in the extracellular fluid..... so it is a false high! not a real level of what is going on with your family member/friend, so when the high glucose level is fixed with the support of the insulin carrier, the K, will move back into the cell and the intravascular level of the K will drop and be low due to excess urination from the initial high glucose level.

High blood sugar results in increased urination, with that large amounts of potassium is depleted. Once all that mess is fixed the actual blood level of potassium is low and needs to be replaced. Usually around the time that the blood glucose drops to 150 depending upon the doctor.

This is a very simple answer, that other members seem frustrated that you aren't getting and trying to find blame, where your loved one was very possibly treated as they should have, and wanted more information to help you.

Your response, stopped others from responding, as I didn't want to help you either at first. But you are forgetting that you have a vast resource of help here, that is trying to get enough information to provide you with the answer you initially asked, even if it isn't what you hoped for.

Turtle in scrubs · Apr 16, 2010

Do we even know if her glucose was an issue?

Zookeeper3 · Apr 16, 2010

with a high K and potassium replacement, it's a given as far as a legit question.

MeganS · Apr 16, 2010

"I need an answer....

I am a new nurse on a MSP unit. But I am noooooo dummy. [...] A family member of mine was admitted to the ICC today where I work with acidosis. I left my shift early and sat in the ER with her till she could go to her room. As I sat there I noticed a 250ml bag of 20meq Potassium running into her. So I asked the nurse what that was for....no real answer...I asked what her Potassium was....was later told 5.2[...]I kept asking.....why this bag was hung? [...]The question I pose is this....."

Here is my experience when I took my 90 yo mom to the ED. After a routine phone call to check on my mom, something alerted me to a problem. I went over to her home and found food containers scattered around her lazyboy. Apparently she got her meals on wheels but was unable to take the leftovers/dishes to the kitchen. A very odd situation for my hyerclean mom. Assessment revealed irregular pulse, weakness --> off to ED. After an hr with supplemental O2 with 100% sat, she started having cardiac irregularities to the point of 3rd degree heart block --> off to floor to be admitted for a pacemaker insertion.

When she was comfortable in her bed, she was hooked up to an IV for supplemental hydration which also contained K+. This was odd considering she has great difficulty clearing K+ and normally runs 5.0-5.3. Apparently the doc never looked looked at her chart before orders (her HMO has chart info on line at the facility; no excuse). Explanation I received was it was normal for elderly pts to receive K+ with the IV. But no one asked us about her K+ situation nor did they look at her labs. Go figure. After discharge, her K+ was still 5.1, and we were given Kayexlate to be administered at home.

If I had not been present or noted the K+ in her IV, her K+ would have increased beyond her highest level. Goes to show that pts need an advocate; errors can happen. :twocents: