Role of Pharmacist In Electrolytes Management
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Role of Pharmacist In Electrolytes Management

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Role of Pharmacist In Electrolytes Management Role of Pharmacist In Electrolytes Management Presentation Transcript

  • 1 PATIENT'S ELECTROLYTES MANAGEMENT THE PHARMACIST ROLE PH. AHMED M. ALFIKY Pharmaceutical Care Department King Abdullah Medical City
  • 2 Solute Homeostasis • Electrolytes - Charged particles • Cations: Sodium (Na+) 14.61%, 3%, 0.9% 0.45%, 0.225 %, Potassium (K+) 2 mEq/mL (Potassium Chloride and Phosphate), Calcium (Ca++) 100 mg/mL , (Calcium Chloride and gluconate ), and Magnesium (Mg++) 0.8 meq/mL ,4 mEq /mL • Anions: Bicarbonate (HCO3-), Chloride (Cl-), Phosphate (PO4---). • Non-electrolytes - Uncharged particles • Proteins, urea, glucose, O2, CO2
  • • Lactated Ringer’s • 130 mEq Na 109 mEq Cl 28 mEq lactate • 4 mEq K 3 mEq Ca • 0.9% NaCl 154 mEq Na 154 mEq Cl • 0.45% NaCl 77 mEq Na 77 mEq Cl
  • Why is it important to replace the electrolytes ?
  • Potassium • Regulates resting membrane potential. • Regulates fluid, ion balance inside cell. - Hypokalemia: • Neuromuscular disorders – Weakness, flaccid paralysis, respiratory arrest, constipation • Hypotension. • Dysrhythmias • Cardiac arrest. - Hyperkalemia : • Early – hyperactive muscles , paresthesia • Late - muscle weakness, flaccid paralysis • Peaked T-waves • Dysrhythmias – Bradycardia, heart block, cardiac arrest
  • Hyponatremia Symptoms • Anorexia • Headache • Nausea • Emesis • Impaired response to verbal stimuli • Impaired response to painful stimuli • Bizarre behavior • Hallucinations • Obtundation • Incontinence • Respiratory insufficiency • Decorticate or decerebrate posturing • Bradycardia • Hypertension or hypotension • Altered temperature regulation • Dilated pupils • Seizure activity • Respiratory arrest • Coma • Hypotension • Renal failure as consequence of hypotension • Tachycardia • Weakness • Muscular crampsThirst • Lethargy • Irritability • Seizures • Fever • Oliguria
  • HYPOMAGNESEMIA • Irritability, confusion, arrhythmias, weakness, nystagmus,seizures, coma, and death • concomitant hypokalemia and hypocalcemia Hypocalcemia • Tetany, muscle spasms, lethargy, seizures Chloride • Tonicity Disturbence
  • • Working with physicians, pharmacists play an important role in the determination of underlying causes of these disorders, particularly when disorders are medication-related, and in providing knowledge of the potential implications of individual medications. • Pharmacists also often evaluate and recommend treatment of electrolyte disturbances. • What are the standards for safe and effective administration in Peripheral Vs Central line ? the Recommended maximum concentrations and maximum rates of infusion? • Available Intravenous and oral forms?
  • • How to replace and maintain the electrolytes? - REPLACEMENT DOSE, central venous catheter. - MAINTANCE DOSE. • Physician orders verification and calculations millmoles (mmol) , milliequivalnts (mEq) or grams or percentage. • Proper Labeling . • High risk Electrolytes? auxiliary labeling Concentrated electrolytes shall not be part of routine floor stock. • Administration : - Do not give IV PUSH (except for magnesium and calcium). - Mechanical infusion pump for all replacement electrolytes.
  • • Renal function • Salt form • acid/base status • Time of lab draw • Route of administration • Absorption issues • Diarrhea, nausea/vomiting
  • Potassium
  • Hypokalemia Severity Serum K concentration (mEq/L) Initial I.V. K replacement dose Mild/Moderate 2.5-3.4 20-40 mEq Severe >2.5 40-80 mEq • Every 1 mEq/L below 3.5 represents a 100-200 mEq deficit. • One time dose of 40 mEq is not adequate replacement. • Magnesium levels should be monitored and replacement given if necessary since potassium repletion is ineffective in the presence of hypomagnesemia. • Oral replacement if asymptomatic and K is < 3.8 mEq/L. • Oral = IV K at same doses. Potassium chloride slow release tablet contains 8 mmol potassium per tablet. (Tablets should not be crushed or chewed). • Liquid has unpleasant taste.
  • . • Adult doses from 40-100 mEq/day may be required for potassium repletion given in 2 - 4 divided doses per day. • In adults, start with 20-40 mEq/day and titrate to desired level. A 40 mEq dose may be given every 2 hours for a maximum dose of 120 mEq within a 6 hour period. • Oral potassium can be prescribed in conjunction with IV potassium. • When oral potassium therapy is combined with parenteral supplementation for adults, a maximum total dose (IV + PO) is 120 mEq within a 6 hour period. • Do not use sustained release potassium products, when an immediate response is desired. potassium chloride solution, should be used for a quicker response. • Avoid dextrose vehicles - may stimulate insulin release and decrease K specially in Initial replacement therapy. • Potassium salts MUST NEVER be given IM or as an IV push.
  • • Potassium levels must be checked after each replacement dose. If using immediate release preparations, a level should be checked no sooner than 60 minutes. If using a sustained release product, a level should be checked no sooner than 3 hours. Patients receiving maintenance doses of oral potassium do not require levels after each dose.
  • • All IV maintenance infusions with KCl at a concentration greater than 40 mEq/L must be administered via an infusion pump. • Peripheral administration. • Central administration. • Cardiac Monitoring: greater than 10 mmol/hour SERUM less than or equal to 2.5 mmol/L. DOSE exceeds 80 mmols - Rapid infusion of KCl may cause cardiac arrest.
  • - Risk Factors for developing hypokalemia: • Severe vomiting/diarrhea • amphotericin B • Chronic diuretics • metabolic alkalosis • insulin • beta2 agonists (e.g., terbutaline) • Decreased intake of K+ • Acid/base imbalance • Trauma and stress • Increased aldosterone • Beware if diabetic – Insulin pushes K+ into cells – Ketoacidosis – H+ replaces K+ , which is lost in urine • β – adrenergic drugs or epinephrine
  • • A single salbutamol nebulizer treatment may lower serum K by 0.2-0.4 mmol/L. • A single dose of succinylcholine will increase serum K by 0.5- 1.0 mmol/L. • Hyperkalaemia may occur with TMP/SMX (trimethoprim- sulfamethoxazole) therapy and with the use of hypertonic agents (e.g. D50, mannitol). • A serum K of 3-4 mmol/L correlates with a 100-200 mmol K deficit. At a serum K of 2-3 mmol/L, the deficit is 200-400 mmol. • Serum potassium may be expected to increase by ˜ 0.25 mmol/L for each 20 mmol IV KCL infused. • Hypokalemia : • intracellular shift, including albuterol, insulin, theophylline, and caffeine.
  • Hyperkalaemia: - Risk Factors for developing hyperkalemia: • Serum K+ > 5.5 mEq / L • Check for renal disease • Massive cellular trauma • Insulin deficiency • Addison’s disease • Potassium sparing diuretics (spironolactone, amiloride, etc.) • Decreased blood pH • Exercise pushes K+ out of cells • use of high dose TMP/SMX for PCP in HIV infected patients - Hemodialysis
  • Management : • 10% Calcium Gluconate or Calcium Chlorideas calcium will antagonize the effects of potassium to rapidly stabilize cardiac muscle function • Insulin (0.1U/kg/hr) and IV Glucose • albuterol • Metabolic alkalosis (if the patient is acidemic) – 1 L H20 with 150meq of NaHCO3 • Lasix 1mg/kg (if renal function is normal) • Sodium polystyrene sulfonate acts as a cation exchange resin, binding to potassium in the gastrointestinal tract to facilitate elimination. • Renal replacement therapy
  • Magnesium
  • HYPOMAGNESEMIA • thiazide and loop diuretics, amphotericin, cisplatin, cyclosporine, and digoxin. • 1 g IV Mg = 8 mEq= 4 mmol • Normal serum levels needed for potassium and calcium replacement (If the magnesium concentration is low, it should be corrected, otherwise it will be difficult to normalize potassium and calcium). • Approximately 50% of the dose given is renally eliminated. • Replace P.O. if patient can tolerate (diarrhea -rate limiting side effect ,may be reduced by dividing daily doses). Serum Mg concentration (mEq/L) Oral Intravenous 1.0-1.5 (mild/moderate) Magnesium oxide 400 mg 1-2 tablets TID 8-32 mEq <1.0 (severe) N/A 32-64 mEq
  • • An additional consideration is that magnesium levels drawn after infusion may be falsely elevated due to magnesium’s slow distribution into body tissues • Takes 3 to 5 days for total repletion. • Max IV rate = 1 g per hour. • < 20% (200 mg/ml) concentration before administration. • MAX. CONC. : 1 gm in 5 ml D5W or NS • MAX. INFUSION RATE: 1 gm over 7 minutes
  • • For Mg levels > 1.2 mg/dl AND asymptomatic, oral* therapy may be used: • *Oral absorption is variable with 15-50 % of a dose being absorbed. 1-2 tablets daily • Magnesium sulfate may be given IM, however it can be very painful. Doses greater than 1 gm must be given in different injection sites. • For symptomatic patients, bolus doses of IV magnesium are required. • For asymptomatic patients, adding magnesium to the patient's maintenance IV fluids will allow for better retention of magnesium • HYPERMAGNESEMIA • ntravenous calcium (chloride or gluconate) to stabilize cardiac and neuromuscular function. • loop diuretics or renal replacement therapy
  • PHOSPHOROUS
  • HYPOPHOSPHATEMIA • Role in several important body functions • Potassium Phosphate. • Sodium Phosphate. • Sodium Phosphate and Normal Saline. • Recommended Total dose infused over 4-6 hrs to reduce risk of (hypocalcemia and soft tissue calcification, hypotension, renal failure) • Oral Phosphateshould be used if asymptomatic/mild hypophosphatemia (can cause diarrhea) (will decrease Mg absorption) • Magnesium, calcium and aluminum containing antacids may bind phosphorus and prevent its absorption. PO4 Concentration (mg/dL) IV replacement dose 2.3-3.7 0.08-0.16 mmol/kg 1.5-2.2 0.16-0.32 mmol/kg <1.5 0.32-0.64 mmol/kg
  • • Millimoles • Maximum rate= 10 mmol/hr - KPhos 15 mmol / 100 ml NS or D5W over 3 hours centrally.* - NaPhos 15 mmol / 100 ml NS or D5W over 3 hours centrally. Unless total calcium is < 7.5 mg/dL or > 11 mg/dL (corrected) phosphorus is > 2 mg/dL OR significant renal dysfunction (Clcr < 10 ml/min) • IDEAL body weight (IBW) or adjusted weighs for obese patient. • 4 hours after replacement completed. • Renal insufficiency (CLcr <20ml/min): reduce dose by 50% • Maximum is 15 mM of sodium phosphate in 100 ml dextrose 5% in water • As a guideline, the phosphorus level will increase by an average of 1.2 mg/dl with a dose of 0.25mmol/kg
  • • Hyperphosphatemia • phosphate binders such as calcium carbonate, calcium acetate, and sevelamer orally with meals to reduce phosphorus absorption from the gastrointestinal tract. • renal replacement therapy
  • CALCIUM
  • HYPOCALCEMIA • NORMAL LEVELS: Total Calcium: 8.4-10.2 mg/dl (2.1-2.6 mmol/L) • Highly protein bound so always calculate corrected calcium. Corrected calcium = [(4-albumin) x 0.8] + serum calcium. • Ionized calcium remains normal in low albumin states. • Calcium chloride and Calcium gluconate • Calcium chloride only used in severe situations typically codes • Gram , mmol Total Ca (mg/dL) Dosing Continuous IV dose Mild/moderate And asymptomatic 0.08-0.16 mmol/kg 4.56-9.12 mEq Ca over 30-60 minutes <7.5 (Severe) Or symptomatic 3 g calcium gluconate over 10 minutes repeat PRN 13.6 mEq Ca over 10 min. repeat PRN
  • – If the magnesium concentration is low, it should be corrected, otherwise it will be difficult to normalize potassium and calcium – MAXIMUM RECOMMENDED CONCENTRATIONS: • Calcium gluconate: 1 gm in 50 ml D5W or NS. • Calcium chloride*: 1 gm in 100 ml D5W or NS – INFUSION RATE: Infuse over 30-60 minutes. Rapid administration may cause bradycardia, hypotension and vasodilation. – Administration via a central or deep vein is preferred. IM or SC? – Phosphate and Calcium replacements, Determine Ca x PO4 product in mg/dl before administering calcium. If product is greater than 60 mg/dl, there is an increased risk of calcium phosphate precipitation in the cornea, lung, kidney, cardiac conduction system, and blood vessels.
  • • Usual maximum total daily dose is 15 g calcium gluconate. • As a guideline, the total calcium will increase by 0.5 mg/dl for every gram of calcium gluconate given intravenously. • ORAL CALCIUM Absorption is variable and depends on PTH, Vitamin D, and gastric pH. • USUAL DOSE: 500- 2000 mg elemental calcium a day, in divided doses (BID-QID) – ADVERSE EFFECT: Constipation • For each 5 units of packed RBCs transfused, administer 1-2 grams (1-2 amps) of calcium gluconate.
  • Sodium • May reflect increased, decreased or normal total body sodium • Sodium is the major cation that determines serum osmolality, • Must assess osmolality to treat Various causes (SIADH, CHF, Ascites) • Normal serum sodium levels are 136 -145 mEq / L. • Max rate of increase in serum sodium is 8-12 mEq/L in 24 hrs • Assess underlying cause and treat first. • acute onset hyponatremia is more likely to be symptomatic and • can be more rapidly corrected compared to chronic hyponatremia, which is usually not associated with as severe of symptoms and should be corrected slowly. ** All replacement doses reflect dosing for patients with Normal renal function**
  • 34 Treatment of Hyponatremia • Correct serum Na by 1mEq/L/hr • Check serum Na q4hr • Use 3% saline in severe hyponatremia • Central venous catheter, venous irritation and pain at the injection site. • Administer osmotic diuretic (Mannitol) to excrete the water rather than the sodium • Goal is serum Na 130 • Avoid too rapid correction
  • • Hypernatremia: Plasma Na+ > 145 mEq / L – Excess Na intake (hypertonic IV solution) – Excess Na retention (oversecretion of aldosterone) – Loss of pure water • Long term sweating with chronic fever • Respiratory infection → water vapor loss • Diabetes (mellitus or insipidus) – polyuria – Insufficient intake of water (hypodipsia) Management: • 45% NSS. If caused by both Na and fluid loss, will administer NaCL. If inadequate renal excretion of sodium, will administer diuretics.