Electrolyte Replacement Protocol
ALL patients with renal or adrenal insufficiency are excluded from any electrolyte replacement
protocol
CALCIUM
Exclusions:
-digoxin therapy
-for every 1 g/dL decrease of serum albumin less than 4.0 g/dL, add 0.8 mg/dL to total serum calcium
level to correct value (normal serum calcium level at VUMC 8.5-10.5 mg/dL )
-IV replacement should be with calcium chloride (272 mg elemental calcium/1 gm CaCl 2) if a central
access is present; if not, use calcium gluconate (94 mg elemental calcium/1 gm calcium gluconate)
-mix one amp (1 g) CaCl2 or two amps (2 g) calcium gluconate in 100 cc NS and infuse over one hour
Ionized calcium
4.0-4.5 mg/dL
3.5-3.9 mg/dL
3.0-3.4 mg/dL
2.5-2.9 mg/dL
<2.5 mg/dL
Replace with
1 g CaCl2
2 g CaCl2
3 g CaCl2
4 g CaCl2
5 g CaCl2 and NHO
Recheck level
with next AM labs
with next AM labs
4 hours after replacement
4 hours after replacement
4 hours after replacement
MAGNESIUM
-corrected serum Mg=measured serum Mg x 0.42 + 0.05 (4 albumin in g/ dL)
-PO replacement is preferred in asymptomatic patients able to tolerate PO or PT meds
-expect magnesium depletion in patients with extensive GI losses (e. g. diarrhea, high NG output),
alcoholism, and those taking aminoglycosides, loop diuretics, and amphotericin
-IV replacement is with 2 g MgSO4 in 50 cc D5W given over 30 minutes
Serum magnesium
1.5-1.9 mg/dL
1.2-1.4 mg/dL
Replace with
2 g MgSO4 IV, or
400 mg magnesium oxide PO
4 g MgSO4 IV
0.8-1.1 mg/dL
6 g MgSO4 IV
<0.8 mg/dL
8 g MgSO4 IV and NHO
Recheck level
with next AM labs (only if
symptomatic)
4 hours after replacement, if
symptomatic; otherwise with next
AM labs
4 hours after replacement; also
check serum potassium level
4 hours after replacement; also
check serum potassium level
Electrolyte Replacement Protocol, ctd.
ALL patients with renal or adrenal insufficiency are excluded from any electrolyte replacement
protocol
POTASSIUM
Exclusions:
-crush injuries
-electrical burns
-rhabdomyolysis
-DKA
-expect to waste K with gentamicin, penicillin, and amphotericin administration, as well as with loop
and thiazide diuretics
+
-a single albuterol nebulizer treatment may lower serum K by 0.2-0.4 mEq/L
+
-a single dose of succinylcholine will increase serum K by 0.5-1.0 mEq/L
-hyperkalemia may occur with TMP/SMX therapy and with the use of hypertonic agents (e. g. D50,
mannitol)
-serum potassium may be expected to increase by 0.25 mEq/L for each 20 mEq IV KCl infused
-when using PO or PT replacement, avoid slow-release tablets
-when a central access is present, mix 20-40 mEq KCl in 100 cc NS or _ NS and infuse at a rate of
+
20 mEq/hr; however, if serum K is <2.5, 40 mEq/hr may be given with continuous cardiac monitoring
-when only peripheral access is available, mix 10 mEq KCl in 100 cc NS or _ NS and infuse at a rate
of 10 mEq/hr; 1-2 cc of plain 1% lidocaine may be added to each 100 cc bag for patient comfort
+
Serum K
Replace with
3.3-3.5 mEq/L
40 mEq KCl IV/PO/PT
Magnesium
supplementation (if
serum Mg unknown, or
is < 2.0 mg/dL)
none
3.0-3.2 mEq/L
50 mEq KCl IV
2 gm MgSO4 IV
2.6-2.9 mEq/L
60 mEq KCl IV and
NHO
2 gm MgSO4 IV
<2.6 mEq/L
80 mEq KCl IV; infuse
as 40 mEq/hr x 2 if
central line is present
and with continuous
cardiac monitoring;
NHO
2 gm MgSO4 IV
Recheck level
immediately after
replacement
immediately after
replacement and with
next AM labs
immediately after
replacement and with
next AM labs
immediately after
replacement and with
next AM labs
Electrolyte Replacement Protocol, ctd.
ALL patients with renal or adrenal insufficiency are excluded from any electrolyte replacement
protocol
PHOSPHORUS
Exclusions:
-rhabdomyolysis-DKA
-mix Na or KPO4 in 100 cc NS and infuse over 4 hours
-
Serum P
2.0-2.5 mg/dL
1.6-1.9 mg/dL
<1.6 mg/dL
Replace with
15 mmol Na or KPO4
30 mmol Na or KPO4
30 mmol Na or KPO4
Recheck level
with next AM labs
with next AM labs
6 hours after replacement
