Critical Care Credentials Required Electrolyte Abnormalities Interventions Medications • Maintain continuous cardiac monitoring • Potassium • Obtain lab values, ensure treatment decisions are based on • Calcium recent values • Magnesium • Hypertonic saline

Hypokalemia • Monitor for cardiac rhythm changes, treat per appropriate guideline • Assess for low magnesium levels and treat accordingly, as potassium levels cannot be restored if magnesium levels are also low. • The following orders should be verified by transferring provider: ◦ Potassium Chloride - concentrations no greater than 20mEq/50ml D5W (or NS) for central lines and 10mEq/100ml D5W (or NS) for peripheral lines ➢ Central Lines: Serum K+ Dose Total Dose < 2.5 20mEq KCL q1hr x 5 100mEq 2.6 – 3.0 20mEq KCL q1hr x 4 80mEq 3.1 – 3.5 20mEq KCL q1hr x 3 60mEq ➢ Peripheral Lines: Serum K+ Dose Total Dose < 2.5 10mEq KCL q1hr x 10 100mEq 2.6- 3.0 10mEq KCL q1hr x 8 80mEq 3.1 – 3.5 10mEq KCL q1hr x 6 60mEq ➢ If patient’s creatinine is > 1.4, discuss with transferring provider or contact MRCC before administering potassium chloride.

Hyperkalemia • Confirm any potassium level > 5.5 prior to treatment unless patient is hemodynamically unstable. • If iStat is available, recheck serum potassium every 30 minutes after treatment. • Monitor for cardiac rhythm changes, treat per appropriate guideline • The following orders should be verified by transferring provider: ◦ Moderate (6.0-7.0) without EKG changes: Critical Care Credentials Required Credentials Care Critical ➢ Sodium bicarbonate: 1 mEq/kg IV (max 100 mEq) Required Credentials Care Critical ➢ Insulin: 10 U IV (Peds: 0.1 U/kg, max 10 U) ➢ Dextrose: 25 g IV (Peds: 0.5 - 1 g/kg, max 25 g) ◦ Severe (>7.0) or Moderate (6.0-7.0) with EKG changes - same as above plus: ➢ Calcium gluconate: 1 g IV over 10 minutes (Peds: 100 mg/kg, max 1,000 mg) Calcium chloride may be given if diluted. ➢ Albuterol: 10 mg nebulized over 15 minutes (Peds: 2.5 mg if < 25 kg; 5.0 mg if > 25 kg) ◦ Severe (>7.0) with EKG changes & instability or cardiac arrest - same as above plus: ➢ Immediately give calcium chloride

Pearls • Electrolyte imbalances can cause life-threatening arrhythmias • Never administer potassium as IV push! It can cause life-threatening arrhythmias. • Hyperkalemia in the setting of acute renal failure often requires emergent dialysis

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Critical Care Credentials Required Critical Care Credentials Required Electrolyte Abnormalities Interventions Medications • Maintain continuous cardiac monitoring • Potassium • Obtain lab values, ensure treatment decisions are based on • Calcium recent values • Magnesium • Hypertonic saline

Hyponatremia • Rapidly raising the serum sodium levels can be dangerous. Treatment should be gradual (over days), or more aggressive only if significant symptoms are present. • Brain tissue can swell with severely low or acutely low sodium levels, with the risk of stroke-like symptoms, altered mental status, brain herniation, or seizures. • In most cases, the only treatment needed is to restrict the patient’s water intake. • Verify pediatric orders with transferring physician. • Confirm with the transferring provider if treatment is indicated and obtain orders for medications. The following adult treatments are commonly used: ◦ 3% Saline – 50-100 mL over 10 minutes. Central line preferred, may give through a reliable peripheral IV ◦ 3% Saline continuous infusion – Confirm infusion rate and pump settings with transferring provider

Hypomagnesemia • If patient’s creatinine is > 1.4, discuss with transferring provider or contact MRCC before administering magnesium. • Verify pediatric orders with transferring physician. • The following adult orders should be verified by transferring provider: ◦ Magnesium Sulfate – dilute to 2g in 50mL of 5% dextrose (D5), sterile water, or normal saline

Serum Mg2+ Dose Total Dose < 1.0 mEq/L 2g over 1 hour x 2 4g 1.0 – 1.5 mEq/L 2g over 1 hour x 1 2g

Hypocalcemia • Verify with the provider that treatment is indicated. Total serum calcium levels (reported as part of a standard basic metabolic panel) should not be used as indications for replacement. The actual active ion is in the form of ionized calcium which is a separate lab test, and should be used as the basis for calcium replacement. Critical Care Credentials Required Credentials Care Critical Critical Care Credentials Required Credentials Care Critical • Patients receiving transfusions of multiple units of blood products may also need calcium replacement, as preservatives in the blood products may bind to free calcium ions. • Verify pediatric orders with transferring physician. • The following adult orders should be verified by transferring provider: ◦ Calcium Chloride – administer via central line only, or dilute and slow push via peripheral line ◦ Calcium Gluconate – central line preferred, may administer through a reliable peripheral line

Ionized Ca2+ Dose < 1 mmol/L 2g over 1 hour 1 – 1.1 mmol/L 1g over 1 hour

Pearls • Avoid calcium if digoxin toxicity is suspected. Magnesium Sulfate (2gm over 5 min) may be used instead.

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Critical Care Credentials Required