NHCP Electrolyte Repletion Protocol

ICU Sharepoint: Effective 01JAN2015, Revised 01APR2018.

Scope: Adults 18+ y/o in the ICU.

EXCLUSION CRITERIA:

• Cr >1.7 mg/dL or GFR <50 mL/min

• On CVVHD or intermittent hemodialysis

• Urine output <0.5 cc/kg/hr

• Peds patients <18 y/o, or pt <40 kg

• Pt receiving PTN

• Assess for causes of potassium loss: GI drainage, surgical drains, burns, diarrhea, and medications.

• When hypokalemia and hypomagnesemia coexist, magnesium deficiency should be corrected to facilitate the correction of hypokalemia.

• Consider IV replacement for serum potassium level <3.2 mmol/L

• Each 10 mEq K+ should increase potassium levels by 0.1 mmol/L

• Patients with renal insufficiency (CrCl <30) should receive <50% of the initial empirical dose.

• Notify Medical Officer

  • Potassium Level >5 or <2.9 mmol/L

  • Increased Cr level >1.7 mg / dL or GFR <50 mL/min

  • Urine output <0.5 cc/kg/hr

• After replacement, repeat serum potassium level per protocol and re-dose if necessary

• Monitoring

  • Signs/Symptoms of Hypokalemia - nausea, vomiting, leg cramps, weakness, ECG changes (prominent U waves and/or flat or inverted T waves), ventricular arrhythmia, absence of bowel sounds.

  • Signs/symptoms of hyperkalemia: bradycardia, abdominal cramps, irritability, tingling, twitching or numbness of extremities, ECG changes from baseline (Widened QRS, peaked T-waves)

• Assess for causes of magnesium loss: GI losses, renal losses, sepsis, alcoholism, malnutrition, medications

• In emergency situations - maximum infusion rate of magnesium sulfate = 1 g in 10 mL NS or D5W IV over 7-10 minutes

• Patients with renal insufficiency (CrCl <30) should receive <50% of the initial empiric dose

• Equivalencies:

  • Magnesium oxide 400 mg tablet (242 mg/tab elemental mag) is about magnesium sulfate 2.5 g (98.6 mg/g elemental mag)

  • 1g magnesium sulfate = 8.12 mEq

  • 1 tablet MgO = 20 mEq

• After replacement, recheck serum Mg level per protocol and re-dose if necessary

• Monitoring

  • Signs/Symptoms of hypomagnesemia - neuromuscular hyperexcitability, weakness, apathy, delirium, ECG changes from baseline (widening of QRS and peaking T waves with moderate depletion; widening of PR interval, diminution of T waves, and atrial and ventricular arrhythmias with severe depletion).

  • Signs/Symptoms of hypermagenesemia - varied based on severity

    • Mild hypermagnesemia - usually asymptomatic

    • Moderate hypermagnesemia - nausea, vomiting, loss of deep tendon reflexes, hypotension, bradycardia, ECG changes (increased PR interval, increased QRS interval duration).

    • Severe hypermagnesemia - respiratory paralysis, refractory hypotension, atrioventricular block, cardiac arrest

• Assess for causes of hypophosphatemia: malnutrition, alkalosis, DKA, alcoholism, GI losses, medications

• Nursing: If sodium >145 mg/dL and potassium <5.0 mg/dL, use potassium phosphate IV. Consider sodium phosphate for patients with serum K >4. If both sodium and potassium are elevated, do not use protocol, call physician.

• Patients with renal insufficiency (CrCl <30) should receive <50% of the initial empirical dose.

• Each 15 mmol KPhos contains 22 mEq of potassium

• Each 15 mmol NaPhos contains 20 mEq of sodium

• Each K-Phos Neutral tablet = 250 mg (8 mmol) phos, 13 mEq Na, 1.1 mEq K.

• After replacement, recheck serum phosphorous level per protocol and re-dose if necessary

• Monitoring:

  • Signs/Symptoms of hypophosphatemia: weakness, bone pain, rhabdomyolysis, paralysis, altered mental status

  • SIgns/symptoms of hyperphosphatemia: hypotension, hyperreflexia, seizure, altered mental status, paresthesias