Electrolytes: Enteral and Intravenous – Adult – Inpatient Clinical Practice Guideline Note: Active Table of Contents – Click each header below to jump to the section of interest Table of Contents INTRODUCTION .................................................................................................................................. 6 DEFINITIONS ....................................................................................................................................... 6 RECOMMENDATIONS ........................................................................................................................ 7 1. POTASSIUM (K+) ............................................................................................................................. 7 3- 2. PHOSPHATE (PO4 ) ........................................................................................................................ 9 3. MAGNESIUM (MG2+) ...................................................................................................................... 10 4. CALCIUM (CA2+) ............................................................................................................................ 12 5. SLIDING SCALE ELECTROLYTES ............................................................................................... 14 METHODOLOGY ............................................................................................................................... 15 COLLATERAL TOOLS & RESOURCES ........................................................................................... 17 1 Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: [email protected] Vermeulen, [email protected] Last Revised: 12/2017 Content Expert: Name: Philip Trapskin, PharmD, BCPS – Department of Pharmacy Phone Number: (608) 263-1328 Email Address: [email protected] Contact for Changes: Name: Philip Trapskin, PharmD, BCPS – Department of Pharmacy Phone Number: (608) 263-1328 Email Address: [email protected] Guideline Authors: Emily Jackson, PharmD Sara Shull, PharmD, BCPS Joshua Vanderloo, PharmD, BCPS Original authors: Lindsey Goldsmith, PharmD; Gordon Sacks, PharmD Reviewers: Pierre Kory, MD – Critical Care Kenneth Kudsk, MD – General Surgery Edward Lalik, MD – Hospitalist Joshua Medow, MD – Neurological Surgery Anne O’Connor, MD – Cardiovascular Medicine David Yang, MD – Medical Director of UW Health Clinical Laboratories Theodore Berei, PharmD, BCPS – Cardiovascular Medicine Caitlin Curtis, PharmD, BCNSP – Nutrition Support Jeff Fish, PharmD, BCPS – Critical Care Marie Pietruszka, PharmD, BCPS – General Medicine Committee Approvals: Pharmacy and Therapeutics Committee – December 2017 2 Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: [email protected] Vermeulen, [email protected] Last Revised: 12/2017 Table 1. UW Health Guidelines for the Use of Oral, Enteral, and Intravenous Electrolytes in Adults1-34 Gastric (NG/OG/PEG) For patients with A Standard Adult IV High-risk Adult IV Electrolyte Concentration Oral enteral access in small Notes dose dose bowel, IV preferred due to adverse GI effects 20 mEq potassium 20 mEq potassium chloride powder packets Use oral/enteral 3.6-3.9 mmol/L chloride 20 mEq (see note 4) (dilute in ~100 mL per supplementation caps/tabs/powder packet, see note 3) 40 mEq potassium 40 mEq potassium Consider oral/enteral 1. If CrCl < 30 mL/min, reduce dose by 50% chloride chloride powder packets 3.1-3.5 mmol/L repletion; 40 mEq 40 mEq (see note 4) 2. For oral doses >20 mEq, divide into Potassium caps/tabs/powder (dilute in ~100 mL per (see note 4) increments of 20 mEq given every 2 hours (see note 2) packet, see note 3) Normal 3. If patient is fluid restricted, dilute oral powder If asymptomatic: may consider combination of enteral reference: in 50 mL and IV repletion with 20 mEq oral potassium chloride 3.5-5.1 4. Intravenous infusion rate: caps/tabs/powder and 40 mEq IV (see note 4) mmol/L 2.5-3.0 mmol/L 60 mEq (see note 4) 60 mEq (see note 4) Peripheral line: max 10 mEq/hour If symptomatic: IV repletion recommended (see IV Central line: max 20 mEq/hour dose columns) < 2.5 mmol/L IV repletion recommended (see IV dose columns) 80 mEq (see note 4) 80 mEq (see note 4) Consider no replacement, except in patients admitted on cardiac units, who have had recent cardiac surgery, or who have cardiac disorders, including arrhythmias, prolonged QTc, and digitalis toxicity, or in 5. If CrCl < 30 mL/min, reduce dose by 50% patients with eclampsia or pre-eclampsia 6. If CrCl < 30 mL/min and using magnesium 1.5-1.8 mg/dL sulfate solution: In these patient populations, consider 0.05 g/kg IV Magnesium 1.5-1.8 mg/dL: Magnesium (see note 8, 9, 10) sulfate solution 2000 mg (dilute in ~50 mL) x 1 dose Magnesium sulfate Magnesium oxide Magnesium 1.1-1.4 mg/dL: Magnesium Magnesium solution 2000 mg (dilute 0.05 g/kg 0.1 g/kg 1.0-1.4 mg/dL elemental tablets 500 mg sulfate solution 2000 mg (dilute in ~50 in ~50 mL) every 4 hours (see note 8, 9, 10) (see note 8, 9, 10) BID x 2 doses mL) every 4 hours x 3 doses Normal x 5 doses 7. See Table 2 for alternative product contents reference: 8. For IV dosing, use actual body weight 1.6-2.6 unless actual is >130% ideal body weight; in mg/dL these cases, use ideal body weight 9. Maximum IV dose is 8g/day 0.1 g/kg 0.15 g/kg 10. Intravenous infusion rate < 1.0 mg/dL IV repletion recommended (see IV dose columns) (see note 8, 9, 10) (see note 8, 9, 10) Infuse doses of ≤ 0.05 g/kg over 12 hours or over 24 hours for supplements >0.05 g/kg Maximum infusion rate is 0.5 to 1 g/hr 3 Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority Contact: [email protected] Vermeulen, [email protected] Last Revised: 12/2017 Gastric (NG/OG/PEG) For patients with A Standard Adult IV High-risk Adult IV Electrolyte Concentration Oral enteral access in small Notes dose dose bowel, IV preferred due to adverse GI effects Phosphate-potassium 11. Consider oral/enteral supplementation in Phosphate-potassium packet (PHOS-NAK Consider no 0.16 mmol/kg (see any asymptomatic patient, or combination of packet (PHOS-NAK C powder) 1 packet every replacement or use notes 15 to 18), oral/enteral and IV. 2.4-3.0 mg/dL powder) 1 packet every 4 hours while awake x 3 oral/enteral consider oral/enteral 12. If CrCl <30 mL/min, reduce IV dose by 50% 4 hours while awake x 3 B,C doses (dilute in ~75 supplementation supplementation 13. If CrCl <30 mL/min, use of phosphorus doses B,C mL) tablet (K-PHOS Neutral) preferred due to Phosphate-potassium lower potassium content: Phosphate-potassium packet (PHOS-NAK 0.16 mmol/kg (see 0.32 mmol/kg (see Phosphate 2.4-3.0 mg/dL: 1 tablet packet (PHOS-NAK powder) 2 (two) packets notes 15 to 18), notes 15 to 18), every 4 hours while awake x 2 doses 1.6-2.3 mg/dL powder) 2 (two) packets every 4 hours while consider oral/enteral consider oral/enteral every 4 hours while Phosphate 1.6-2.3 mg/dL: 1 tablet Phosphate B awake x 3 doses (dilute supplementation supplementation every 4 hours while awake x 3 doses awake x 3 doses B in ~75 mL) Phosphate 1.0-1.5 mg/dL: 1 tablet Normal Phosphorus TABLET (K- every 4 hours while awake x 4 doses reference: Phosphorus TABLET (K- 0.32 mmol/kg (see 15 mmol IV once over 14. See Table 2 for alternative product content PHOS Neutral) 2 (two) 2.3-4.7 PHOS Neutral) 2 (two) notes 15 to 18), 2 hours, then 0.32 15. For IV dosing, use actual body weight 1.0-1.5 mg/dL tablets every 4 hours mg/dL tablets every 4 hours consider oral/enteral mmol/kg (see notes unless actual is >130% ideal body weight; in B (crush & dilute in ~75 while awake x 4 doses B supplementation 15 to 18) mL) these cases, use ideal body weight 16. Maximum IV dose is 45 mmol; recheck phosphate level 6 to 12 hours after dose to determine if further supplementation is 15 mmol IV once over necessary 0.64 mmol/kg (see 2 hours, then 0.64 17. Administer IV dose over 2 to 3 hours for mild < 1.0 mg/dL IV repletion recommended (see IV dose columns) notes 15 to 18) mmol/kg (see notes or moderate hypophosphatemia and over 6 15 to 18) to 8 hours for severe hypophosphatemia 18. Round IV supplementation to the nearest 7.5 or 15 mmol increment 19. Ionized (unbound) calcium concentrations Ionized are preferred over total serum calcium Calcium concentrations for hypocalcemia monitoring 20. Use oral/enteral calcium for asymptomatic Normal Serum:≤4.59 Consider oral/enteral replacement if hypocalcemia ONLY reference: mg/dL Calcium carbonate chew Calcium carbonate D asymptomatic 21. Maximal oral calcium absorption occurs at Serum: 4.6- tabs 1000 mg every 4 suspension 1250 mg 2 g calcium gluconate or 1 g calcium elemental doses ≤500 mg and when given 5.2 mg/dL Whole blood: hours x 4 doses every 4 hours x 4 doses chloride (optimally infused over 2 hours) with a meal Whole ≤4.89 mg/dL 22. For IV administration, calcium gluconate blood: 4.9- preferred due to extravasation risk with 5.6 mg/dL calcium chloride 23. See Table 2 for alternative product contents A High-risk: clinically malnourished, active alcoholism, recent surgery, admitted for cardiac disease, graft-versus-host disease, diabetic ketoacidosis, or undergoing diuresis B Patients with hyperkalemia, impaired renal function, or that require larger doses of phosphate replacement should receive replacement using the phosphorus tablet (K-PHOS Neutral) as it contains less potassium than the phosphate-potassium packet (PHOS-NAK powder) C Replete if: active alcoholism, malnourished, liver cirrhosis,