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Background In critically ill patients, maintaining appropriate serum potassium concentrations requires careful supplementation to correct hypokalemia but avoid hyperkalemia. At the study institution, an institution-based, nurse-driven standardized electrolyte replacement protocol is used in critically ill patients with a serum creatinine concentration of 2 mg/dL or less. If the serum creatinine concentration is greater than 2 mg/dL, electrolyte replacement requires a physician order. Objective To determine if standardized potassium supplementation is safe in critically ill patients with renal insufficiency not requiring renal replacement therapy. Methods This study was an institutional review board–approved, single-center, retrospective evaluation of critically ill patients receiving intravenous potassium replacement per protocol. Patients were grouped according to serum creatinine concentration (≤ 2 mg/dL or > 2 mg/dL) at the time of replacement. The primary outcome was the incidence of hyperkalemia (potassium concentration ≥ 5 mEq/L) following potassium replacement. Secondary outcomes were the incidence of hyperkalemia, change in serum potassium concentration, and need for hyperkalemia treatment. Outcomes were analyzed using χ2 and t tests. Results Of 814 patients screened, 145 were included (99 with serum creatinine ≤ 2 mg/dL and 46 with serum creatinine > 2 mg/dL). The incidence of hyperkalemia was not different between groups (P = .57). Five patients experienced hyperkalemia; none received hyperkalemia treatment. Change in serum potassium was similar for patients in the 2 groups (P = .33). Conclusions A standardized, nurse-driven electrolyte replacement protocol can be used safely in critically ill patients with renal insufficiency not requiring renal replacement therapy.

Aims Surgical patients are prone to hypokalaemia due to gastrointestinal losses1. Hypokalaemia prolongs ileus2 and thus prompt management is essential. No current guideline on hypokalaemia focuses on surgical patients. We aimed to identify the prevalence of hypokalaemia in emergency surgical patients as well as measure timeliness and appropriateness of replacement. Methods We retrospectively reviewed adult emergency surgical admissions exceeding 48 hours between 05/05/2020 and 15/07/2020. A sub-group analysis assessed the timing of intravenous replacement and duration taken to normalise potassium (3.5 mmol/L). We used another NHS trust’s guideline3 as standard for appropriate potassium replacement. Results Of 110 surgical admissions, 26 cases were hypokalaemic. Of these, 15 had initially normal potassium level. Three cases were likely iatrogenic secondary to inappropriate fluid prescribing. Mean potassium in the hypokalaemic group was 3.2 mmol/L (80.8% mild vs. 19.2% moderate). Mean length of stay was 11.3 days for hypokalaemia versus 6.54 days in normokalaemic cases. Mean duration of hypokalaemia was 2.13±1.45 days. Potassium replacement was prescribed correctly in only 50% of cases (23% not prescribed; 25% insufficient; 2% incorrect) and of these correct prescriptions, 46% were not actually administered. When intravenous replacement was given, there was a mean 3.55-hour delay between lab result and administration. Conclusion The majority of hypokalaemic cases developed during admission. Only 27% of these patients had correct potassium replacement in terms of both prescription and administration. Consequently, we have created a local guideline for hypokalaemia in surgical patients to standardise both prevention and management.

Objectives This review aimed to explore and summarize information from available cases of pediatric acute hydroxychloroquine overdose with confirmed hydroxychloroquine exposure to give the clinicians a helpful perspective for its better recognition and management. Methods Electronic searches were conducted in PubMed/MEDLINE, Web of Science, Scopus, EBSCO and Serbian Citation Index. The abstracts from 2 toxicology conferences were manually checked for additional relevant publications, as well as reference lists of the retrieved publications. Descriptive statistics, narrative summation, and tabulation of the extracted data were made. Results Nine publications and a total of 9 patients were included in the review. Reported age of the patients varied from 2.5 to 16 years (median, 16 years). There were more female patients (77.8%). Estimated total ingested hydroxychloroquine dose was reported in 7 cases (77.8%), and it ranged from 4.0 to 20.0 g (median: 12.0 g). Four patients (44.4%) ingested hydroxychloroquine with a coingestant. Altered mental status (100.0%), cardiotoxicity (88.9%), hypotension (77.8%), and hypokalemia (55.6%) were the most commonly reported clinical manifestations. The majority of the patients were hospitalized (88.9%). More than half of the patients (55.6%) were reported to be treated in the intensive care unit. Most frequently reported therapeutic measures were the following: administration of intravenous fluids/infusions (77.8%), vasopressors (77.8%), bicarbonate therapy-sodium bicarbonate (66.7%), potassium replacement (55.6%), and intubation/ventilation (55.6%). Three patients (33.3%) died. Conclusions Management of acute hydroxychloroquine overdose in children should be symptomatic and tailored to observed clinical manifestations. There is a need for additional investigations to better understand the impact and effectiveness of various treatment options.

BackgroundRules of thumb for potassium replacement are used in intensive care units despite minimal empirical validation.ObjectiveTo evaluate the effectiveness and safety of rule-of-thumb potassium replacement in critically ill patients with mild and moderate hypokalemia.MethodsA retrospective, observational study was done of patients with mild (potassium, 3-3.9 mEq/L) and moderate (potassium, 2-2.9 mEq/L) hypokalemia admitted to a medical intensive care unit who received potassium replacement. Expected and actual frequencies of replacement that achieved target potassium concentrations (≥ 4 mEq/L) were compared by using a χ2 test. Logistic regression analysis was used to assess whether rule-of-thumb administration affected the probability of target attainment within 24 hours of replacement.ResultsSerum potassium concentrations were checked within 24 hours after potassium replacement on 354 of 577 days (61.4%) when replacement was provided. Concentrations were within target range in 82 instances (23.2%). Of 62 episodes of replacement expected to achieve the target according to the rule-of-thumb estimation, 22 did (35%). Rule-of-thumb administration was associated with greater likelihood of target attainment (odds ratio, 2.12; 95% CI, 1.18-3.85; P = .01). This difference in likelihood remained significant after adjustment for covariates (odds ratio, 2.18; 95% CI, 1.04-4.56; P = .04).ConclusionIn critically ill patients given potassium replacement without regard to a formal protocol, the target serum potassium concentration was achieved more often than expected according to the rule-of-thumb estimation but less than one-third of the time.

Introduction Diabetic ketoacidosis is a life-threatening condition that requires prompt management. Objectives We aimed to assess the impact of adherence to potassium replacement protocol according to the guidelines of Diabetes Poland on the duration of diabetic ketoacidosis (DKA) treatment. Patients and methods This retrospective analysis included 242 adults (median age, 27 years; range, 21-38 years). Nonadherence to potassium replacement protocol was assessed, along with the relationship between nonadherence and duration of DKA management. Nonadherence to the protocol was defined as too low or too high doses of potassium compared with the recommended potassium replacement protocol. Results The median duration of DKA treatment was longer in the nonadherent group than in the adherent group: 37 hours (interquartile range [IQR], 27-48) and 30 hours (IQR, 17-43), respectively (P = 0.005). Treatment duration correlated positively with nonadherence to potassium replacement protocol (r = 0.18; P = 0.005) and severity of DKA (r = 0.52; P

We report a documented outbreak of clenbuterol food poisoning involving 13 patients who consumed snake meat in Shenzhen. They developed headache, palpitation, tachycardia, hypokalaemia and other symptoms within first 3 hours after exposure. They were initially treated with gastric lavage, fluid and potassium replacement and other supportive measures. All of them completely recovered after admission for up to 48 hours. Public health investigation identified clenbuterol compound in four victims' urine and the food source of snake meat they consumed. (Hong Kong j.emerg.med. 2015;22:46-49)

Purpose The adherence to and effectiveness and safety of a timed, electronic, assessment-driven potassium-replacement protocol (TARP) were compared with an electronic nurse-driven replacement protocol (NRP) are reported. Methods A retrospective observational study was conducted in a community hospital evaluating protocol adherence, effectiveness, and safety for 2 potassium-replacement protocols. All adults on medical units with an order for potassium replacement per protocol during the 3-month trial periods were reviewed. All patients requiring potassium replacement per protocol were included in the analysis. Adherence to the protocol was assessed by evaluating the dose of potassium administered and performance of reassessments. Effectiveness of the protocol was assessed by evaluating the time to achieve target potassium levels. Safety was assessed by evaluating the route of administration and occurrence of hyperkalemia. Results A total of 300 patients treated using potassium-replacement protocols required potassium replacement during the study period, with 148 patients in the NRP group requiring 491 instances of potassium replacement. In the TARP group a total of 564 instances requiring potassium replacement corresponded to 152 patients. Of the 491 instances requiring replacement in the NRP group, the correct dose was administered and reassessment performed 117 times (23.8%). Overall adherence ( p p p p p Conclusion The TARP improved the effectiveness and safety of potassium-replacement therapy over the traditional NRP without negatively affecting timeliness of care.

A high incidence of hypokalaemia was noted in Trauma and Orthopaedics of Ninewells Hospital. We sought to establish the reason behind this and implemented three PDSA cycles via questionnaires to 30 ward staff, both doctors and nurses over a 1 week period in December, February and July 2016. Key baseline measures include availability of IV fluids with 40mmol potassium on the wards, confidence prescribing or administering IV fluids with 40mmol potassium, necessity for cardiac monitoring during slow IV potassium replacement and recognition of confusion and learning need in this area. Interventions made include awareness and education session, departmental guideline, improving stock of IV fluids and hypokalaemia management pathway for mild, moderate and severe hypokalaemia. Post-intervention results showed 70% from 33% who said 40mmol IV potassium was available, 87% from 67% were confident prescribing or administering IV potassium and 70% from 27% were aware that cardiac monitoring was not necessary.

This article reviews the management of diabetic ketoacidosis (DKA) in adults with a focus on the three basic principles of treatment: intravenous fluid therapy, intravenous insulin administration and potassium replacement. The recommendations are modelled on the national guidance for the management of DKA in children. We highlight the importance of being alert to signs of life-threatening complications of the condition such as cerebral oedema and adult respiratory distress syndrome (ARDS). We also discuss the use of near-patient testing of capillary beta-hydroxybutyrate (b-OHB) using a ketone meter as an aid to managing and preventing DKA.

Diabetic ketoacidosis (DKA) is a common diabetic emergency often managed by general physicians. However, in contrast to its management in children, there was no national guideline/protocol for adults until the recent national protocol was issued for use throughout Scotland. This national protocol was developed from the audit activity described in this article. A prospective audit of the management of DKA and local protocol adherence was carried out at Raigmore Hospital, Inverness (April 2000 to March 2001). This showed deficiencies in the management of DKA with delay in intravenous fluid and insulin administration, and laboratory monitoring being undertaken less frequently than recommended by local guidelines. In addition, 14 DKA management protocols from 17 Scottish trusts were reviewed. The rate and volume of fluid replacement varied slightly between the trusts. There was general agreement within protocols on laboratory monitoring, potassium replacement, insulin administration and bicarbonate usage. The audit showed that there was scope for improvement in the management of DKA and that there were sufficient similarities in protocols used throughout Scotland to allow collaboration on a national protocol. It is anticipated that this will serve to enhance the profile of guidelines and facilitate standardisation and therefore improvement in patient care. Copyright © 2007 John Wiley & Sons.

Oral potassium replacement is still inevitable. To reduce the irritation of the gastric and intestinal mucosa, pellet and matrix based formulations ensuring extended release of potassium chloride are used. The dissolution tests may help to understand the in vivo steps of the release of potassium chloride and the absorption of potassium.Using dissolution tests extended to 12 hours the authors evaluated potassium chloride release characteristics of pellet and matrix tablet based formulations used for potassium replacement.The tests were performed in line with the CPMP/EWP/QWP/1401/98 guideline at nine time points (0, 1, 2, 3, 4, 5, 7, 9 and 12 hours) in three dissolution media (0.1 M hydrochloric acid, pH 1.2; acetate buffer, pH 4.5; phosphate buffer, pH 6.8).Similar results were found in all three dissolution media.It is conceivable, that the release of potassium chloride begins already in the stomach (pH = 1.2) and at an average speed of gastrointestinal transit - in about 6-7 hours - 80% of the potassium chloride content of both formulations is dissolved by the time of the entrance to the large bowel. It seems likely, that in vivo in the proximal section of the gastrointestinal tract more potassium chloride is dissolved out of the matrix based formulation, than from the pellet based one. Both formulations meet the clinical requirements of the effective potassium chloride release.Bevezetés: Az orális káliumpótlás számos betegség esetében ma is elkerülhetetlen. A gyomor-, bélnyálkahártya irritációjának csökkentése végett általában elnyújtott kálium-klorid-leadású pelletizált vagy mátrixszerkezetű gyógyszerformákat használnak. A kioldódási vizsgálatok segítséget nyújthatnak a kálium-klorid-leadás és a káliumfelszívódás in vivo történéseinek megértéséhez. Célkitűzés: A szerzők egy pellet- és egy mátrixtabletta-szerkezetű, káliumpótlásra használatos gyógyszerforma kálium-klorid-leadását vizsgálták 12 óra időtartamra kiterjesztett kioldódási vizsgálattal. Módszer: A vizsgálatot a CPMP/EWP/QWP/1401/98 irányelvnek megfelelően végezték el. A mérések kilenc időpontban (0, 1, 2, 3, 4, 5, 7, 9, 12 óra) és három kioldóközegben (0,1 M sósav, pH 1,2; acetátpuffer, pH 4,5; foszfátpuffer, pH 6,8) történtek. Eredmények: Mindhárom kioldóközegben hasonló eredményeket kaptak. Következtetések: Feltételezhető, hogy a kálium-klorid felszabadulása mindkét gyógyszerforma esetében már a gyomorban (pH = 1,2) megkezdődik, és átlagos sebességű passzázs során – 6–7 óra alatt – a vastagbélbe való belépés idejére mindkét gyógyszerformából kioldódik a kálium-klorid-tartalom 80%-a. Valószínűnek látszik, hogy in vivo a mátrixtablettából a gastrointestinalis traktus proximalis szakaszán nagyobb arányban oldódik ki a kálium-klorid, mint a pellettechnológiával készült készítményből. Mindkét gyógyszerforma teljesíti a hatékony kálium-klorid-leadás klinikai feltételeit. Orv. Hetil., 2015, 156(12), 479–482.

PURPOSE The purpose of this triangulated study was to evaluate potassium protocols used in clinical practice. RATIONALE Hypokalemia occurs frequently in the clinical setting and can have serious consequences. It is further complicated by the fact that it has multiple causes and patient symptoms can range from asymptomatic to death. considering the complexity and potential seriousness of hypokalemia, it is important that treatment be appropriate. DESCRIPTION OF THE PROCESS The triangulated approach included an examination of the empirical evidence, a comparison of potassium protocols currently in use, and an evaluation of the potential benefits and risks of using a potassium protocol in a sample of patients. OUTCOME There is wide variation in potassium protocols and no empirical evidence in support of or opposition to these protocols. An evaluation of the use of a potassium protocol in a sample of patients indicates that patients not on protocols are not being routinely treated according to general protocol potassium replacement recommendations. CONCLUSIONS The use of narrowly defined potassium protocols may lead to overtreatment or incorrect treatment in the complex setting of hypokalemia. IMPLICATIONS FOR NURSING PRACTICE Findings suggest the need for validation of clinically significant hypokalemia, the addition of other electrolyte measures when evaluating and treating hypokalemia, and the use of routine serum potassium levels and maintenance of serum potassium levels equal to or more than 4.0 mmol/L in certain patient populations. Most important, the etiology of hypokalemia, not used in qualifying criteria on any of the potassium protocols examined, should form the basis for treatment.

Thyrotoxic Periodic Paralysis is an uncommon disorder seen primarily in Asian males and caused by excessive thyroid hormones. This is an endocrine emergency that can lead to respiratory failure, dysrhythmia, and death. The mainstay of therapy has been potassium replacement, however, recent evidence suggests propranolol is a more effective therapy. We present a severe case of TPP in a 22-year-old Latino male with rapidly progressive ascending paralysis and hypokalemia severe enough to lead to cardiac arrest.

This review describes the current guidelines of German diabetes association for the management of diabetic coma, both of diabetic ketoacidosis and hyperosmolal coma. The outline focuses on emergency treatment and the management on the intensive care unit, in particular, volume and insulin therapy, and potassium replacement. The delineation of the concept of low insulin therapy is emphasized to avoid the incidence of disequilibrium syndrome. Also, the indications for bicarbonate therapy in diabetic ketoacidosis are critically discussed, as well as phosphate and magnesium replacement. With today's therapeutic possibilities the therapeutic goal, i.e. a low mortality, may be achieved, dependent on the underlying illness.

Pseudohyperkalemia, also known as factitious or spurious hyperkalemia, is predominantly due to hemolysis during the collection process of the specimen. Pseudohyperkalemia is a condition in which the falsely elevated potassium can cause significant clinical dilemma as patients may be given unnecessary and harmful treatment for hyperkalemia. In addition, pseudohyperkalemia can also mask hypokalemia resulting in patients potentially not receiving adequate potassium replacement. Thus, it is pivotal for clinicians and laboratory personnel to have a high index of suspicion for this condition in order for the patient to receive appropriate treatment. We present a case of pseudohyperkalemia without obvious hemolysis due to the use of a 23-gauge needle blood draw in a patient with stage IV chronic kidney disease from focal segmental glomerulosclerosis.

Objectives The primary objective was to compare the efficacy of enteral potassium replacement (EPR) and intravenous potassium replacement (IVPR) as first-line therapy. Secondary objectives included comparison of adverse effects and number of doses required to resolve the episode of hypokalaemia. Trial design The EIPS trial is designed as a randomised, equivalence trial between two treatment arms. Study setting The study was conducted at the paediatric cardiac intensive care unit (PCICU) at Aga Khan University Hospital, Karachi. Participants 41 patients (aged 1 month to 15 years) who were admitted to PCICU post cardiac surgery were recruited (23 IVPR arm and 18 EPR arm). Intervention Intervention arms were block randomised on alternate weeks for IVPR and EPR. Outcome measure Change in serum potassium levels in (mmol/L) and percentage change after each event of potassium replacement by the intravenous or enteral route. Results Both groups (41 patients) had similar baseline characteristics. Mean age was 4.7 (SD±4) years while the most common surgical procedure was ventricular septal defect repair (12 patients, 29.3%). No mortality was observed in either arm. Four episodes of vomiting and one arrhythmia were seen in the EPR group. After adjusting for age, potassium level at the beginning of the episode, average urine output, inotropic score and diuretic dose, it was found that there was no statistically significant difference in change in potassium levels after EPR and IVPR: 0.86 mmol/L (±0.8) and 0.82 mmol/L (±0.7) respectively (p=0.86, 95% CI −0.08 to 1.10), or percentage change in potassium level after enteral and intravenous replacement: 26% (±30) and 24% (±20) (95% CI −3.42 to 4.03, p=0.87). Conclusion EPR may be an equally efficacious alternative first-line therapy in treating hypokalaemia after surgery in selective patients with congenital heart disease. Ethics and dissemination This study has been approved by Ethics Review Committee at AKU. Trial registration number NCT02015962.

Background Many therapies used in critical care cause potassium depletion. Current practice relies on potassium replacement protocols after a patient becomes hypokalemic. Potassium bolus therapy creates risk for patients, is costly, and increases nurses’ workload. Objectives To determine if administering potassium preemptively in maintenance intravenous fluid would prevent episodes of hypokalemia and reduce the need for potassium boluses. Methods Medical records of 267 patients with normal potassium and creatinine levels at admission who did not receive total parenteral nutrition were reviewed. The 156 patients who met the study criteria were categorized by group: those who received potassium via maintenance intravenous fluid (treatment; n = 76) and those who did not (control; n = 80). The treatment group had potassium chloride or acetate added to intravenous fluid delivered at 36 to 72 mmol/d. Results The 2 groups did not differ significantly in age, race, sex, or admitting diagnosis. Type of diagnosis, length of stay, and potassium and creatinine levels at admission did not affect the number of potassium boluses for either group. The patients given maintenance potassium preemptively received significantly fewer (P < .001) potassium boluses (0.8) than did the control group (2.73), for a mean savings of $231 per patient for the treatment group. Conclusions Patients with normal potassium and creatinine levels at admission benefitted from a maintenance intravenous dose of potassium of 72 to 144 mmol/L per day. Compared with control patients, patients receiving this dose avoided detrimental hypokalemic events, had fewer invasive procedures and lower costs, and required less nursing care.

The objective of this study was to present a case series of patients with hypokalemic periodic paralysis. We described all patients with diagnosis of hypokalemic periodic paralysis admitted to the Al Ain Hospital (UAE) during the year 2006. Seventeen patients, all males and mostly Asians, were presented to the Al Ain Hospital over a 12-month period. The majority were admitted during the summer months. Four were thyrotoxic. All of the 17 patients received oral potassium supplements and recovered well without any major complications. In conclusion, clinicians should have a high index of suspicion, especially among Asians presenting with flaccid paralysis and hypokalemia. The main steps in the management include exclusion of other causes of hypokalemia, potassium replacement, hydration and close monitoring of the cardiac rhythm and serum potassium levels. When possible, the underlying cause must be adequately addressed to prevent the persistence or recurrence of paralysis.

Adrenal surgery today is safe and if performed laparoscopically or retroperitoneoscopically comparably easy for the patient with short hospital stays. Larger lesions suspected for being malignant should preferably be operated with an open technique. The outcome is usually excellent, with no needs for potassium replacement and reduction in the number of hypertensive drugs, as well as usual normalization of blood pressure. Also cases with nodular hyperplasia may be operated if lateralization of aldosterone excess is found.

A 38 year old man was admitted to an emergency department with complains of fever for 2 days and bilateral upper and lower weakness. Dengue NSI came to be positive. Platelets were also found to be on the lower side. Serum potassium found to be on the lower side .power on the lower limb 3/5 and upper limb 4/5.power improved after potassium replacement.

Hyperemesis gravidarum (HG), defined as severe nausea and vomiting resulting in dehydration, is a common reason for emergency admission in gynaecology (1). The management of HG is supportive, including the correction of dehydration and electrolyte disturbances and use of antiemetics. An audit in our unit identified that women with HG were not receiving appropriate fluid resuscitation and in particular inadequate potassium replacement. A proforma was developed by a multidiscplinary team to prompt appropriate investigations, medications, and fluid resuscitation. The proforma was introduced in paper format and electronically, accompanied by an education programme for junior doctors. This intervention has improved prescribing practice and fluid resuscitation for these patients. Length of admission has reduced. Efforts have been made to ensure this change is sustainable in the long term, through involvement of the junior doctors using the proforma at all stages of the project.

Thyrotoxic periodic paralysis (TPP) is a variant of periodic paralysis (PP) that occurs in patients with underlying mutations in genes for cation channels, if they develop thyrotoxicosis. It is disabling, and fatalities sometimes occur. Here, we present a patient with TPP who developed hypokalemic paralysis that was probably aggravated by the administration of a carbohydrate, probably contributing to, if not causing, a fatal outcome.A 30-year-old Chinese patient received (131)I treatment for Graves' disease (GD) in our hospital. Three days later in the middle of the night, he developed aggravating paralytic symptoms after a heavy evening meal. The next morning, he was seen in a small clinic and was treated with 1250 mL 5% glucose containing 25 mL 10% potassium chloride (KCl). By early afternoon, he had not improved and was transferred to a city hospital, arriving with grade I muscle strength and severed facial and bulbar paralysis that was shortly followed by cardiac arrest with failure of resuscitation. Shortly before he died, his serum K(+) was 1.15 mEq/L (normal=3.5-5).We postulate that severe hypokalemia developed in our patient in part in response to the high intravenous glucose load that he received. We advocate caution against using intravenous glucose solutions for potassium administration in patients with TPP and recommend a review of guidelines suggesting this form of treatment. In rural settings with limited resources, we favor oral potassium, not to exceed 100 mEq per day, and transfer to a modern medical facility in settings where muscle weakness is developing in patients with TPP.

A wide variety of neurological manifestations are known in patients with diabetes mellitus. We describe a 40-year-old man who presented with hypokalemic paralysis. On evaluation, we found that the cause of the hypokalemia was osmotic diuresis induced by marked hyperglycemia due to undiagnosed diabetes mellitus. The patient had an uneventful recovery with potassium replacement, followed by glycemic control with insulin. Barring a few instances of symptomatic hypokalemia in the setting of diabetic emergencies, to our knowledge uncomplicated hyperglycemia has not been reported to result in hypokalemic paralysis.

Hypokalemic periodic paralysis is a condition, characterized by episodic weakness of the skeletal muscle. It may be presented as familial or sporadic (secondary). In sporadic cases, the patient may present with paralysis without any previous self or familial history. It is known that these patients are more susceptible to hypokalemia than normal individuals. In low serum K+ concentrations that the normal population can tolerate, these patients may easily suffer from paralysis. A sporadic case of hypokalemic quadriparesis associated with acute gastroenteritis without any self or family history is reported. The patient had experienced two episodes of quadriparesis within a short interval and responded dramatically to potassium replacement therapy.

We report a case of life-threatening hypokalemia in a 28-year-old bodybuilder who presented with sudden onset bilateral lower limbs paralysis few days after his bodybuilding competition. His electrocardiogram (ECG) showed typical u-waves due to severe hypokalemia (serum potassium 1.6 mmol/L, reference range (RR) 3.5–5.0 mmol/L). He was admitted to the intensive care unit (ICU) and was treated with potassium replacement. The patient later admitted that he had exposed himself to weight loss agents of unknown nature, purchased online, and large carbohydrate loads in preparation for the competition. He made a full recovery after a few days and discharged himself from the hospital against medical advice. The severe hypokalemia was thought to be caused by several mechanisms to be discussed in this report. With the ever rising number of new fitness centers recently, the ease of online purchasing of almost any drug, and the increasing numbers of youngsters getting into the bodybuilding arena, clinicians should be able to recognize the possible causes of sudden severe hypokalemia in these patients in order to revert the pathophysiology.

We report a case of hypokalaemic quadriplegia with acute respiratory failure and life-threatening cardiac arrhythmias in a 26-year-old woman who was diagnosed to have distal renal tubular acidosis. She had persistent metabolic acidosis with severe hypokalaemia and required mechanical ventilation and potassium replacement. The anaesthetic implications of renal tubular acidosis are also discussed.

Objective: To describe six cases of thyrotoxic hypokalemic periodic paralysis (THPP) in non-Asian men. Methods: We present six cases of THPP, including clinical and laboratory findings, treatment, and outcome, and review the related literature. Results: Hypokalemic periodic paralysis is a relatively common occurrence in Asian men with thyrotoxicosis; however, it is unusual in non-Asian patients with thyrotoxicosis. Among our six patients--four Caucasians, one African-American, and one Hispanic--the precipitating factors, initial manifestations, and clinical course varied. In general, treatment with 131I or potassium eliminated the paralytic episodes. Conclusion: THPP needs to be distinguished from nonthyrotoxic hypokalemic periodic paralysis. Although THPP is unusual in non-Asian men, it must be recognized because of the severe and potentially fatal complications, which are reversible with potassium replacement and antithyroid therapy.

This article is the result of a meeting of the National Council on Potassium in Clinical Practice. The Council, a multidisciplinary group comprising specialists in cardiology, hypertension, epidemiology, pharmacy, and compliance, was formed to examine the critical role of potassium in clinical practice. The goal of the Council was to assess the role of potassium in terms of current medical practice and future clinical applications. The primary outcome of the meeting was the development of guidelines for potassium replacement therapy. These guidelines represent a consensus of the Council members and are intended to provide a general approach to the prevention and treatment of hypokalemia.

Acute onset quadriparesis can be a manifestation of a variety of neurological and metabolic conditions. We report the case of a 47-year-old alcoholic gentleman who presented with acute onset weakness of all four limbs associated with hypokalemia and very high blood glucose (hyperosmolar nonketotic diabetes—HNKD) detected for the first time. He was confirmed as having type 2 diabetes (detectable insulin and C-peptide levels) and his quadriparesis completely resolved on potassium replacement and treatment with insulin. HNKD is discussed along with the possible mechanisms of hypokalemia in this patient presenting with reversible limb weakness as an initial manifestation of type 2 diabetes. Copyright © 2002 John Wiley & Sons, Ltd.

EDITOR—Reynolds et al dealt with the important, everyday clinical problem of disorders of sodium balance and clearly stated that most cases of hyponatraemia are iatrogenic.1 However, they did not clarify the reasons for iatrogenic hyponatraemia: usually a combination of water overload and inadequate potassium replacement. Too many doctors believe that a …

I read with interest the case report by Dixon and Jones on thyrotoxic periodic paralysis (TPP) in a white woman.1 TPP is, indeed, extremely rare in women and also in the white population. However, TPP is an extremely common presentation with hypokalaemia in Orientals.2 It is imperative that any person of Oriental origin presenting with hypokalaemic weakness has their thyroid status checked2; doctors are quite likely to face this situation in the west because of increased immigration. Attacks of TPP are very common in the early hours of the night,3 but unfortunately there was no mention of the time of occurrence in the case reported.1 The authors confirmed that their patient did not require β-blockers, yet this is standard practice in this condition as potassium replacement in this sort of hypokalaemia can cause rebound …

EDITOR—Welfare et al advocate aggressive potassium replacement in gastroenteritis associated with profound hypokalaemia.1 In such …

Sue Murray, RN, MS, is clinical nurse manager-general surgery, Michele Preuss, RN, is a staff nurse-general surgery, and Frances Schultz is a staff nurse-surgical department float pool, Center for Health Sciences, University of Wisconsin-Madison. hours before the prep. We have discovered, however, that the bowel prep is quicker if the patient is on a clear-liquid diet (gelatin, clear soup, apple juice, etc.) for 24 hours. I a small qualityassurance study, we discovered that patients who had been on a clear-liquid diet 24 hours before the prep required 0.4 L less lavage solution and finished the prep in 0.9 hours less than those who were on clear liquids for a shorter time. They did, however, require an average of 18.6 mEq more potassium replacement before surgery, presumably because a clear-liquid diet supplies little potassium.

Hypokalemic periodic paralysis is characterized by episodic weakness, the presence of precipitating factors, and the tendency to resolve spontaneously. Physical examination of the patient between attacks often shows no abnormalities. Potassium replacement therapy may be needed for severe episodes.

The purpose of this investigation was to gather and summarize currently available product information on salt substitutes, low-sodium products, and medicinal potassium supplements. A review of the literature identified both risks (e.g., hyperkalemia) and benefits (e.g., changing sodiurm:potassium ratios, and low-cost substitutes for medicinal potassium replacement) resulting from the use of salt substitutes. Risks and benefits are related to individual patient conditions and treatment plans. Nutritionists and physicians must be aware of the medicinal and dietary potassium sources and be able to educate patients in the proper use of the products. Lists of medicinal and dietary sources of potassium are provided to aid health professionals in determining appropriate potassium equivalents. Case reports from the literature of patients developing hyperkalemia secondary to the use of salt substitutes are summarized. Regular monitoring of serum potassium levels is necessary to achieve and maintain normal values.

A case of hypokalemic myopathy with systolic hypertension due to chronic liquorice ingestion is described. The clinical features quickly receded on potassium replacement therapy and discontinuation of liquorice ingestion. The relationship between the clinical features and the blood values and instrumental data is shown. The aldosterone-like action of the active principle of liquorice is underlined.

Electrocardiograms were recorded in 24 patients with serum potassium of 2.5 mEq./L. or less. Only 5 (20.8%) had severe-classic changes of hypokalemia. Sixteen (66.7%) had mildmoderate changes and 3 (12.5%) had no changes. It is concluded that, although most (21 of 24, or 87.5%) of these patients had at least some definite electrocardiographic changes, in individual patients there is poor correlation between the severity of the hypokalemia and the electrocardiographic abnormalities. When changes were present, however, they were clinically helpful and evolved as expected during potassium replacement.