46 Electrolyte Replacement

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46 Electrolyte Replacement

  1. 1. Calcium, Phosphate and Magnesium Replacement I. Calcium (25 mEq = 500 mg elemental calcium). A. Parenteral Calcium Salts Calcium chloride 1 gram 13.6mEq (272mg) of elemental Calcium Calcium gluconate 1 gram 4.65mEq (90mg) of elemental Calcium B. Parenteral Calcium Therapy Indication Dose Rate of Infusion Symptomatic 4.65 to 18.6 mEq of 1 gram (Calcium gluconate Hypocalcemia elemental Calcium (1-4 or chloride) over 10 (tetany) grams of Calcium minutes, then 1-2 gluconate) gram(s)/hour. Calcium infusion should be continued until Calcium level reaches 8-9 mg/dl. For calcium replacement, the rate of infusion should be about 1-2 gram(s)/hour. Calcium chloride should be given via a central line due to a higher incidence of thrombophlebitis. Calcium chloride is compatible in most common IV infusion solutions, i.e. 0.9% NaCl, 5% dextrose. II. Phosphorus A. Parenteral Phosphate Salts Potassium Phosphate: 4.4 mEq of K+/ml and 3 mM of phosphate/ml Sodium Phosphate: 4 mEq of Na+/ml and 3 mM of phosphate/ml B. Parenteral Phosphate Therapy Serum PO Action Serum phosphorus 1-2 mg/dl Give 0.2 mmol/kg over 4-6 hours Serum phosphorus < 1 mg/dl Give 0.3 mmol/kg over 4-6 hours Parenteral phosphate should be diluted and mixed in as large a volume of fluid (i.e. 250 ml) as possible. When ordering parenteral phosphate, always order the amount of phosphate in mmol units. C. Oral: Neutra-Phos Powder (1 packet) 250 mg (8 mmol)/packet
  2. 2. III. Magnesium A. Magnesium Salts: Magnesium (elemental) 1 gram = 83.3 mEq Magnesium sulfate 1 gram = 8.1 mEq B. Oral Preparation: Mg Chloride 535 mg = 64 mg (5.33mEq) Mg/tablet Mg gluconate 500 mg = 27 mg (2.25 mEq) Mg/tablet Mg oxide 400 mg = 241.3 mg (20.1 mEq) Mg/tablet Magnesium Citrate 1.745 gram/30 ml C. Parenteral Magnesium Therapy In patients with normal renal function, up to 50 mEq (6 grams) of magnesium may be given IV over 4 to 6 hours (usually infuse 1 gram/hour), mixed in 50 to 100 ml of 0.9% NaCl or 5% dextrose. Magnesium sulfate is incompatible with soluble phosphates and with alkali carbonates and bicarbonates (except in dilute solutions).
  3. 3. DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center in conjunction with the Pharmacy Department. They are intended to serve as a general statement regarding appropriate patient care practices based upon the available medical literature at the time of development. They should not be considered to be accepted protocol or policy, nor are intended to replace clinical judgment or dictate care of individual patients. ADULT ELECTROLYTE REPLACEMENT PROTOCOLS SUMMARY Standing electrolyte replacement protocols are available for use in adult patients admitted to Orlando Regional Healthcare hospitals. These are instituted upon direct physician order entry into Sunrise XA. The protocols are listed below. SPECIFIC REQUIREMENTS: • Intravenous piggyback infusions of electrolytes must be administered with free-flow protected infusion devices (i.e. infusion pump). • Patients must meet the following criteria prior to initiation of the Potassium, Magnesium, or Phosphorus protocols: o SCr < 2 mg/dL o Weight > 40 kg • The electrolyte replacement protocols, Calcium chloride (Level I areas only) or Calcium gluconate (all levels of care), Magnesium sulfate, Potassium chloride, or Potassium Phosphate, may be ordered individually or in combination. POTASSIUM REPLACEMENT PROTOCOL – INTRAVENOUS • Recommended rate of infusion is 10 mEq/h • Maximum rate of intravenous replacement is 20 mEq/h with continuous ECG monitoring (the maximum rate may be increased to 40 mEq/h in emergency situations – see Policy #5080) • Standard Concentrations: 10 mEq/50 mL, 10 mEq/100mL, 20 mEq/50 mL and 20 mEq/100 mL o Maximum Concentration for Central IV administration = 20 mEq/50 mL o Maximum Concentration for Peripheral IV administration = 10 mEq/50 mL Current Serum Central IV Peripheral IV Administration Monitoring Potassium Level Administration 3.6 – 3.9 mEq/L 20 mEq IV over 2 HR x 1 10 mEq IV over 1 HR x 2 No additional action 20 mEq IV over 2 HR x 1 3.4 – 3.5 mEq/L AND 10 mEq IV over 1 HR x 3 No additional action 10 mEq IV over 1 HR x 1 Recheck serum potassium 3.1 – 3.3 mEq/L 20 mEq IV over 2 HR x 2 10 mEq IV over 1 HR x 4 level 2 hours after infusion complete 20 mEq IV over 2 HR x 2 Recheck serum potassium 2.6 – 3 mEq/L AND 10 mEq IV over 1 HR x 5 level 2 hours after infusion 10 mEq IV over 1 HR x 1 complete Recheck serum potassium 2.3 – 2.5 mEq/L 20 mEq IV over 2 HR x 3 10 mEq IV over 1 HR x 6 level 2 hours after infusion complete Recheck serum potassium Call Physician AND Call Physician AND < 2.3 mEq/L level 2 hours after infusion 20 mEq IV over 2 HR x 3 10 mEq IV over 1 HR x 6 complete • If both potassium and phosphorus replacement required, subtract the mEq of potassium given as potassium phosphate from + total amount of potassium required. (Conversion: 3 mmols KPO4 = 4.4 mEq K ) • Call pharmacy for assistance if needed. 1 Approved 05/29/01 Revised 01/14/08
  4. 4. POTASSIUM REPLACEMENT PROTOCOL – ORAL or ENTERAL (PT) • Standard dosage forms: KCl 20mEQ tablet or KCl 10% solution (20 mEq/15 mL) Current Serum Total Potassium Replacement Monitoring Potassium Level 3.7 – 3.9 mEq/L 20 mEq KCl PO/Per feeding tube x 1 dose No additional action 3.5 – 3.6 mEq/L 20 mEq KCl PO/Per feeding tube Q2H x 2 doses No additional action 3.3 – 3.4 mEq/L 20 mEq KCl PO/Per feeding tube Q2H x 3 doses Recheck serum potassium level 4 hours after last oral dose 3.1 – 3.2 mEq/L 20 mEq KCl PO/Per feeding tube Q2H x 4 doses Recheck serum potassium level 4 hours after last oral dose Call Physician AND Recheck serum potassium level 4 hours < 3.1 mEq/L 20 mEq KCl PO/Per feeding tube Q2H x 4 doses after last oral dose MAGNESIUM REPLACEMENT PROTOCOL • Infusions should be no faster than 1gm of magnesium sulfate every 30 minutes. • Standard Concentrations: 1 gm/100 mL and 2 gm/50 mL Current Serum Magnesium Level Total Magnesium Replacement Monitoring 1.5 – 2 mEq/L 2 grams Magnesium Sulfate IV over 1 HR No additional action 2 grams Magnesium Sulfate IV over 1 HR x 0.9 – 1.4 mEq/L Recheck serum magnesium level 2 hours 2 doses after infusion complete Call Physician AND Recheck serum magnesium level 2 hours < 0.9 mEq/L 2 grams Magnesium Sulfate IV over 1 HR x after infusion complete 2 doses 2 Approved 05/29/01 Revised 01/14/08
  5. 5. PHOSPHORUS REPLACEMENT PROTOCOL • Replacement must be ordered in mmol of phosphorus. • Recommended rate = 3mmol/hr (= 4.4 mEq/h of K) • Maximum rate = 10 mmol/hr (= 15 mEq/h of K) • Use SODIUM phosphate for patients with serum potassium > 4.5 mEq/L and serum sodium < 145 mEq/L • Standard Concentrations: o Potassium Phosphate: 15 mmol/250 mL and 21 mmol/250 mL o Sodium Phosphate: 15 mmol/250 mL, 21 mmol/250 mL, and 30 mmol/250 mL Current Serum Total Phosphorus Replacement Monitoring Phosphorus Level 2 – 2.5 mg/dL 15 mmol Potassium Phosphate IV over 4 HR No additional action Recheck serum phosphorus level 2 hours 1 – 1.9 mg/dL 21 mmol Potassium Phosphate IV over 4 HR after infusion complete Call Physician AND 30 mmol Potassium Phosphate IV over 4 HR Recheck serum phosphorus level 2 hours < 1 mg/dL (Administered as: 15 mmol Potassium after infusion complete Phosphate IV Q2H x 2 doses) • If both potassium and phosphorus replacement required, subtract the mEq of potassium given as potassium phosphate from + total amount of potassium required. (Conversion: 3 mmols KPO4 = 4.4 mEq K ) • Call pharmacy for assistance if needed. CALCIUM REPLACEMENT PROTOCOL • You must specify the salt form (gluconate or chloride) • Calcium chloride: o Reserved for Level I areas only o Must be administered via a central line o Maximum rate = 1 gm IV over 10 minutes • Calcium gluconate: o May be used in all levels of care o Administration via a central line is preferred; however, it may be given peripherally with adequate IV access. o Maximum rate = 3 gm IV over 10 minutes • Standard concentrations: o Calcium chloride: 1 gm/50 mL, 2 gm/100 mL, 3 gm/150 mL o Calcium gluconate: 1 gm/50 mL, 2 gm/100 mL Total Calcium CHLORIDE Current Ionized Total Calcium GLUCONATE Replacement Monitoring Calcium Level Replacement (Level I areas only) 1 – 1.1 mmol/L 1 gram IV over 1 HR 1 gram IV over 1 HR No additional action 0.85 – 0.99 mmol/L 2 grams IV over 1 HR 2 grams IV over 1 HR Recheck serum ionized calcium 2 hours after infusion complete < 0.85 mmol/L Call Physician AND Call Physician AND Recheck serum ionized calcium 2 grams IV over 1 HR 3 grams IV over 1 HR 2 hours after infusion complete 3 Approved 05/29/01 Revised 01/14/08
  6. 6. Advertisement Advertisement Scaleva from Arkema Calcium Propionate oral chelation therapy With The New Generation Cleaning Niacet: World's largest producer Fast, Effective Safe Chelation How Solution for the Food Industry Low dust; Granular; Crystal; Do I know? Read My Story Medmix Systems AG www.Arkema.com Powder www.ThisCureWorks.com/HeavyMetals multi-component www.Niacet.com mixing and application systems for medical use www.medmix.ch offer magnesium The Internet Journal of Internal Medicine™ ISSN: 1528-8382 sulfate manufacture magnesium sulfate | Home | Editors | Current Issue | Archives | Instructions for Authors | Disclaimer | Share aluminum sulfate, with others | monensin sodium www.jinxingchem.com Ads by Google Potassium Phosphorus Calcium MG Creatinine Calcium Buy Detoxamin the safe, gentle & proven chelation therapy alternative Electrolyte Replacement: A Review www.detoxamin.com Quality Minerals Read printer friendly Resource Bradley J. Visit the Largest Nutraceuticals Buyers' Phillips MD Subscribe in a reader Guide on the Internet! Critical Care Share with others www.NutraceuticalsWorld.com Medicine calcium chloride of china Boston Manufacturer of Ads by Google Calcium Chloride high Medical Center Calcium Magnesium quality, honest service Calcium Ascorbate www.wfxdy.com Boston Collagen Therapy Sodium Ascorbate University Potassium Selenocyanate School of Medicine Citation: B. J. Phillips : Electrolyte Replacement: A Review . The Internet Journal of Internal Medicine. 2004 Volume 5 Number 1 Table of Contents Introduction Electrolytes I. CALCIUM II. MAGNESIUM A. ORAL MAGNESIUM
  7. 7. REPLACEMENT B. INTRAVENOUS MAGNESIUM REPLACE... III. PHOSPHOROUS A. ORAL PHOSPHORUS REPLACEMENT B. INTRAVENOUS PHOSPHOROUS REPLA... IV. POTASSIUM INTRAVENOUS POTASSIUM ADMINISTRA... Clinical information Warnings / Precautions Potassium Chloride General State... ORAL POTASSIUM ADMINISTRATION GU... Abstract In accordance with a best practice model for the delivery of care to ICU Patients, a process of developing protocols for the standard replacement of fluid & electrolytes should exist in most units. This is an important step in an evolution towards a systems-based approach in the ICU. As a baseline for these changes, we must alter the way in which we monitor lab values. Introduction
  8. 8. We recommend checking “routine labs” on a 4am-4pm cycle (every 12 hours) on ALL stable ICU patients. Other phlebotomy draws should only be performed when clinically indicated; we must become more efficient with our use and interpretation of laboratory values. Depending on the underlying abnormality, aggressive replacement will be expected. During the pre-rounds at 6am, house-staff begin addressing any underlying fluid or electrolyte deficiencies. We then review the “morning labs” as a team during the 7am rounds and decide further treatment. Urine electrolytes should also be followed as deemed necessary by clinical judgment. Our goals should be: K > 4.0 Mg > 2.0 Phos > 3.5 Ion. Ca > 4.0 Alb > 2.5 Hct > 30. Also, it is important to ensure that ALL of our patients are receiving their daily requirements of the electrolytes. Oral Potassium (at least 2 mEq/kg/day) should be the routine and can either be given in divided oral doses or added to the tube feedings (continuous replacement via tube feedings is an efficacious method of electrolyte replacement. and we are reviewing our current policies in this regard). If a patient is on diuretics, then we will need to increase the oral replacement. Oral daily Mg replacement should also become standard (either with Mg- sulfate or Mg-oxide and should range from 400mg – 1 g/day, based on the weight of the patient). If the oral form is not well tolerated, then we will need to shift towards IV replacement. Our medical and surgical approaches have proven to significantly lower
  9. 9. both morbidity and mortality over the past thirty years; they are aggressive and have set new standards for our field. Similarly, our routine approaches should strive for the same level of care. By successfully implementing such a system in your ICU, you can establish a far more efficient approach in regards to fluid and electrolyte management. We certainly do not wish to remove clinical judgment from the system nor create a “robotic-like” atmosphere, however we must recognize the fact that wide variations in care do exist and at times, lead to unacceptable clinical states. By establishing these guidelines, we hope to create a consistent baseline in order to improve patient safety and the overall efficiency of intensive care units. Electrolytes I. CALCIUM TREATMENT OF HYPOCALCEMIA SYMPTOMS: Tetany, muscle spasms, lethargy, seizures NORMAL LEVELS: Total Calcium: 8.4-10.2 mg/dl (2.1-2.6 mmol/L) Ionized Calcium: 3.8-5.3 mg/dl (0.95-1.35 mmol/L) CORRECTION FOR LOW ALBUMIN For every 1mg/dl of albumin below 4 mg/dl, add 0.8 mg/dl to total calcium = [(4 - alb) x 0.8] + calcium 1. 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
  10. 10. calcium phosphate precipitation in the cornea, lung, kidney, cardiac conduction system, and blood vessels. 2. Determine potassium, phosphorus and magnesium levels. If the magnesium concentration is low, it should be corrected, otherwise it will be difficult to normalize potassium and calcium. 3. Hyperkalemia and hypomagnesemia potentiate the cardiac neuromuscular irritability produced by hypocalcemia. Hypokalemia and hypermagnesemia protect against the effects of hypocalcemia. 4. For each 5 units of packed RBCs transfused, administer 1-2 gms (1- 2 amps) of calcium gluconate. 5. As a guideline, the total calcium will increase by 0.5 mg/dl for every gram of calcium gluconate given intravenously. 6. Patients who develop acute hypocalcemia after parathyroidectomy, may require up to 10 gms of calcium gluconate intravenously in 1000 ml fluid at a rate of 1 gm/hr (100 ml/hr) A. ORAL CALCIUM REPLACEMENT *Absorption is variable and depends on PTH, Vitamin D, and gastric pH. TRADE ELEMENTAL FORMULARY AGENTS NAME CALCIUM Calcium Carbonate 500 mg chewable tabs Tums® 200 mg Calcium Carbonate 650 mg tablets 260 mg Calcium Carbonate 1250 mg tablets OsCal 500® 500 mg Calcium Carb 250 mg + Vit D 125 IU/tablet OsCal 250 +D® 100 mg Calcium Glubionate syrup 1.8 gm/5ml NeoCalglucon® 115 mg/5ml
  11. 11. Calcium acetate (Phos Lo®) is available for phosphate binding and not calcium replacement in patients with renal insufficiency since its calcium absorption is poor. USUAL DOSE: 500- 2000 mg elemental calcium a day, in divided doses (bid-qid) ADVERSE EFFECT: Constipation B. INTRAVENOUS CALCIUM REPLACEMENT Intravenous replacement should be used if severe symptomatic hypocalcemia exists (corrected calcium is <7.7 mg/dl) or if there is a high risk for complications secondary to hypocalcemia. FORMULARY AGENTS Elemental Calcium__ Calcium chloride 10 % 1 gm/10 ml syringe 272 mg (13.6 mEq) Calcium gluconate 10% 1 gm/10 ml ampule 90 mg (4.5 mEq)___ Repeat calcium levels can be drawn the next day or sooner, if necessary. MAXIMUM CONCENTRATIONS: Calcium gluconate: 1 gm in 50 ml D5W or NS Calcium chloride*: 1 gm in 100 ml D5W or NS *Calcium chloride should not be given IM or SC because severe tissue necrosis may occur INFUSION RATE: Infuse over 30-60 minutes. Rapid administration may cause bradycardia, hypotension and vasodilation. Infiltration of IV calcium may cause severe tissue necrosis and sloughing.
  12. 12. II. MAGNESIUM TREATMENT OF HYPOMAGNESEMIA SYMPTOMS: Irritability, confusion, arrhythmias, weakness, fasciculation's, nystagmus, seizures NORMAL LEVELS: 1.7-2.7 mg/dl A. ORAL MAGNESIUM REPLACEMENT 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. Elemental Magnesium Usual FORMULARY AGENTS mg mEq_____ Dose_________ MgOxide 400 mg tablets 240 20 1-2 tablets daily MgHydroxide (MOM®) 10 ml 360 30 1-2 times a day MgHydroxide (Maalox®) 10 ml 180 15 1-2 times a day ADVERSE EFFECTS: Diarrhea (may be reduced by dividing daily doses) B. INTRAVENOUS MAGNESIUM REPLACEMENT For Mg levels < 1.2 mg/L or symptomatic or patient unable to take oral Magnesium sulfate equivalencies: 1 gm MgSO4 =100 mg Mg= 8 mEq Mg SYMPTOMATIC/ASYMPTOMATIC
  13. 13. WEIGHT OR Mg < 1.2 mg/dl AND Mg > 1.2 mg/dl < 50 kg 2-3 gm Mg Sulfate 1-2 gm Mg Sulfate >50 kg 3-4 gm Mg Sulfate 2-3 gm Mg Sulfate Additional doses of 1-2 gms/day of Mg sulfate may be required for several days if the patient has not previously been receiving magnesium. Renal insufficiency (CLcr < 20ml/min) may require lower doses of magnesium. Caution should be used when replacing magnesium in any patient with renal insufficiency. MAXIMUM CONCENTRATION: 1 gm in 5 ml D5W or NS MAXIMUM INFUSION RATE: 1 gm over 7 minutes 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 Repeat magnesium levels can be drawn the next day or sooner, if necessary. III. PHOSPHOROUS TREATMENT OF HYPOPHOSPHATEMIA SYMPTOMS: Anorexia, bone pain, muscle weakness, respiratory failure, CHF, hemolysis, rhabdomyolysis NORMAL LEVELS: 2.4 - 4.5 mg/dl (0.8 - 1.5 mmol/L)
  14. 14. 1. Determine Ca x PO4 product before administering phosphorus; If the product is greater than 60 mg/dl, there is a risk of calcium phosphate precipitation in the cornea, lung, kidney, cardiac conduction system, and blood vessels. A. ORAL PHOSPHORUS REPLACEMENT For Phosphorus > 1 mg/dl (>0.3 mmol/L), oral therapy may be used: FORMULARY Phosphorus Sodium Potassium AGENTS mmol /mEq Neutra-Phos® 8 7 7 per capsule/powder packet* Neutra-Phos K® 8 0 14 per capsule/powder packet* Skim milk per 8 oz 4 3 5 USUAL DOSE: 1-2 powder packets* or capsules* (8-16 mmol) of Neutra-Phos or Neutra-Phos K po/ng tid. *Each Neutra-phos capsule/packet must be opened and diluted with 75 ml of water before administration. 8 oz skim milk (4 mmol of Phos) tid ADVERSE EFFECT: Diarrhea (will decrease Mg absorption) NOTE: Magnesium, calcium and aluminum containing antacids may bind phosphorus and prevent its absorption, so should be avoided in patients with low phosphate levels.
  15. 15. B. INTRAVENOUS PHOSPHOROUS REPLACEMENT For Phosphorus < 1 mg/dl (< 0.3mmol/L), IV phosphorus should be given. FORMULARY AGENTS Phosphorus Sodium Potassium Potassium phosphate 3 mmol/ml 0 4.4 mEq/ml Sodium phosphate 3 mmol/ml 4 mEq/ml 0 USUAL DOSE: For acute decreases in PO4: 0.25 mmol/kg IBW* For chronic depletion of PO4: 0.5 mmol/kg IBW* Renal insufficiency (CLcr <20ml/min): reduce dose by 50% As a guideline, the phosphorus level will increase by an average of 1.2 mg/dl with a dose of 0.25mmol/kg *IBW: Men = 50 + 2.3 (inches over 5 feet) Women = 46 + 2.3 (inches over 5 feet) Recommended concentrations and rate of administration: KPhos 6 mmol / 100 ml NS or D5W over 4 hours peripherally or centrally not to exceed 15 mmol per minibag* NaPhos 10 mmol / 100 ml NS or D5W over 4 hours peripherally or centrally. Maximum concentrations and rate of administration: Use of these concentrations and rates requires continuous monitoring and is restricted to those areas which can provide that level of care except in emergent situations.
  16. 16. This method of administration is NOT recommended if: total calcium is < 7.5 mg/dL or > 11 mg/dL (corrected for albumin**) phosphorus is > 2 mg/dL OR significant renal dysfunction (Clcr < 10 ml/min) KPhos 15 mmol / 100 ml NS or D5W over 2 hours centrally.* NaPhos 15 mmol / 100 ml NS or D5W over 2 hours centrally. *Although 15mmol of KPhos provides 22 meq of potassium which exceeds the recommended dose of potassium per minibag (20 meq), the maximum infusion rate of 2 hours complies with current potassium administration guidelines (i.e., 20meq/100ml NS or D5W over minimum 1 hour centrally). **Correction for low albumin: For every 1mg/dL of albumin below 4 mg/dL, add 0.8 mg/dL to total calcium: Ca corrected = [(4- albumin) x 0.8] + Ca measured Phosphorus levels should be drawn at the end of the infusion and should always be drawn prior to any additional doses administered. Note: Phosphorus has historically been administered over 4 to 6 hours due to the potential risk associated with high doses and rapid administration (i.e., hypocalcemia, hypotension, metastatic calcification, renal failure). However, most of this data comes from cases of hypercalcemia treated with large doses of intravenous phosphates in which phosphorus levels were typically normal. More aggressive electrolyte replacement is not considered as risky. IV. POTASSIUM
  17. 17. INTRAVENOUS POTASSIUM ADMINISTRATION Clinical information A. Normal serum potassium value is 4.0 - 5.0 mmol/L B. Magnesium levels should be monitored and replacement given if necessary since potassium repletion is ineffective in the presence of hypomagnesemia. Warnings / Precautions A. Rapid infusion of KCl may cause cardiac arrest. B. Avoid extravasation. Thrombophlebitis may result and is related to the rate, concentration and size of vein. C. Signs and symptoms of hypokalemia (K+ < 3.5 mmol/L) muscle weakness 5. hypotension anorexia 6. weak pulse vomiting 7. ECG changes: flattened ST segment, T wave heart block, dysrhythmias inversion and U wave elevation hypotension weak pulseECG changes: flattened ST segment, T wave D. Risk Factors for developing hypokalemia diarrhea, vomiting amphotericin B diuretics metabolic alkalosis insulin beta2 agonists (e.g., terbutaline) E. Signs and symptoms of hyperkalemia (K+ > 5.0 mmol/L) confusion 4. flaccid paralysis listlessness, irritability 5. bradycardia paresthesias of extremities 6. peaked T-waves on ECG, dysrhythmias flaccid paralysis bradycardia ECG changes peaked T-waves on ECG,
  18. 18. dysrhythmias F. Risk Factors for developing hyperkalemia renal impairmentuse of ACE Inhibitors (captopril, enalapril, lisinopril, etc.)use of potassium sparing diuretics (spironolactone, amiloride, etc.)use of high dose TMP/SMX for PCP in HIV infected patients G. Patients on digoxin are more likely to develop digoxin toxicity if K+ is low. H. If burning or stinging sensation occurs while KCl is being given via peripheral line, the discomfort may be reduced by the following methods: decrease rate of infusionreduce the concentration of KCl Potassium Chloride General Statements I. Potassium chloride must never be administered by IV push or IM injection. II. All potassium chloride infusions will be supplied by the Pharmacy Department. These infusions will be commercially prepared in minibags, or compounded by the Pharmacy. Potassium Chloride vials will not be stocked in any patient care areas. Any exceptions will need to be petitioned to the P & T Committee. In pediatric or neonatal patients, all infusions will be administered via an infusion pump and burette, or by a syringe pump. III. All IV maintenance infusions with KCl at a concentration greater than 40 mEq/L must be administered via an infusion pump. IV. Peripheral administration
  19. 19. A. In adults, the maximum concentration via peripheral line is 10 mEq/100 ml. B. In adults, the maximum amount of KCl available in each IV minibag is 20 mEq. In nenoates or pediatrics only two hours worth of fluid volume will be added to the burette at anytime. Only one hour worth of fluid should be in a syringe pump. C. The maximum infusion rate via peripheral line is 10 mEq per hour. In neonates and pediatrics, the maximum infusion rate via peripheral line is 0.5 - 1 meq/kg/hour. V. Central administration A. In adults, the preferred concentration via central line is 20 mEq/100 ml. The maximum concentration for fluid restricted patients is 20 mEq/50 ml. B. In adults, the maximum amount of KCl available in each IV minibag is 20 mEq. In neonates or pediatrics only two hours worth of fluid volume will be added to the burette at anytime. Only one hour worth of fluid should be in a syringe pump. C. The maximum infusion rate via central line is 20 mEq/hr. In neonates and pediatrics, the maximum infusion rate via central line is 1 meq/kg/hour. VI. In adults, potassium levels must be checked after a total of 60 mEq has been administered. Potassium levels must be checked no sooner than 60 minutes after a given IV dose. In neonates and pediatrics, potassium levels must be checked after a total of 1 meq/kg has been administered. ORAL POTASSIUM ADMINISTRATION GUIDELINES
  20. 20. A. Oral potassium chloride replacement should be considered in asymptomatic patients with serum potassium levels < 3.8 mEq/L. B. Adult doses from 40-100 mEq/day may be required for potassium repletion given in 2 - 4 divided doses per day. In the neonate and pediatric patient, 1-3 meq/kg/day may be required for potassium repletion given in 2 - 4 divided doses per day. C. 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. In the neonate, start with 0.5 - 1 meq/kg/day and titrate to desired level with the maximum dose of 3 meq/kg within a 6 hour period. D. 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. For the neonate, a maximum total dose (IV + PO) is 3 meq/kg within a 6 hour period. E. Do not use sustained release potassium products, (e.g., KDur™) when an immediate response is desired. The potassium chloride powder, dissolved in water, or potassium chloride solution, should be used for a quicker response. F. Potassium levels must be checked after each replacement dose. If using immediate release preparations (KCl powder), 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. This article was last modified on Fri, 13 Feb 09 13:39:52 -0600
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