Electrolyte Replacement

This document was compiled from several other individuals work and several websites. Contributors include: Chad Alligood PharmD MICU, Scott Sagraves MD, Sachin Phade MD and Nichole Allen PharmD Surgery/Trauma, Glen Meade RPH, and Brian Dawson MD. If you find errors or have suggestions for improvement e-mail bcd0522@ecu.edu Thanks.

Intracellular: Cations K and Mg. Anions: Phosphates and proteins Extracellular: Cations Na. Anions: Cl Water requirements 35ml/kg/day with insensible losses of 700-800 ml/day The 4:2:1 rule: 1-10kg = 4ml/kg/hr, 10-20kg = 2ml/kg/hr, and for every kg greater than 20 1ml/kg/hour. This give you the estimated maintenance fluid rate. Electrolyte Review Solution Na NS 154 D5W NS 77 LR 130 Cl 154 77 109 K 4 Ca 3 HCO3 28 Glucose 50 grams -

Serum osmolality = [2 x Na] + [BUN/2.8] + [glucose/18] Serum Osmolality = (2*Na) + (BUN/2.8) + (glucose/18)

Sodium: (Normal range is 134-145 mEq/L)

Daily requirement for Na = 1-2 mEq/kg/day Hyponatremia (<130-134 mEq/L) Causes: 1. Euvolemic: SIADH, psychogenic polydipsia, hypothyroidism, and inappropriate fluids. 2. Hypovolemic: Diruetics, aldosterone def, renal tubular dysfunctions, dehydration, 3rd space losses. 3. Hypervolemic: CHF, cirrhosis, and nephrosis Treatments: 1. Water restriction, treat underlying cause. 2. mEq Na needed = (140-Serum Na) * (0.6*kg) Note: For glucose >200 for every 100 increase the Na decreases by 3-4 Hypernatremia (>145 mEq/L) Causes: 1. Water losses: diarrhea, emesis, sweating, diruesis, DI 2. Decreased water input: altered thirst, impaired access

3. Excessive Na intake: salt, hypertonic fluid replacement, sodium bicarbonate. 4. Wtaer deficit (L) = 0.6 * Kg * [(Na measured/Na normal)-1] Note: For each L water deficit, serum Na will rise 3mEq above 140mEq/L Treatments: 1. Correct free water deficits 2. May need some normal saline if individual is dehydrated

Phosphorus (Normal range 2.4-4.5mg/dl)

Recommended daily amount 700 mg (31mg=1mM) Absorption = 70% Elimination: Mostly Renal Life threatening if levels <1.0 Phosphorous is required for ATP, adequate levels of phosphorous are needed for adequate vent weaning. Phos is also a requirement in 2,3-DPG an important part of helping the red blood cell release oxygen effectively (shifts dissociation curve to the rt) Ca * Phos >30 may precipate into tissues (often problem for ESRD) Hypophosphatemia (<2.4mg/dL) Signs/Symptoms: respiratory insufficiency, muscle weakness, decreased cardiac function, seizures, coma, guillan burre like manifestations, diplopia, dysarthria, dysphagia, glucose intolerance, rhabdomyolysis. Causes: ETOH withdrawal, DKA, TPN without adequate phos, Chronic ingestion of antacids, refeeding syndrome. Treatment: Replace as below Weight based replacement (based on adjusted body weight if obese): ABW = IBW +0.4(TBW-IBW) IBW is 2.3 * every inch above 60 + 45.5kg for females or 50kg for males. If Creatinine Clearance is <30 give of the calculated dose CrCl (male) = (140-age)/Serum Creatinine CrCl (female) = CrCl * 0.85 If serum phosphorous <1mg/dl give 0.64mMol/kg max rate of 10mMol/hr If serum phosphorous 1.0-1.5mg/dl give 0.64mMol/kg max rate of 7.5mMol/hr If serum phosphorous 1.6-2.2mg/dl give 0.32mMol/kg max rate of 7.5mMol/hr If serum phosphorous 2.3-3.0mg/dl give 0.16mMol/kg max rate of 7.5mMol/hr

At PCMH we have: Oral replacements: 1. Neutraphos 250mg packet (mix in 6-8 oz. water/juice) a. Each packet contains 8.0mMol of phosphorous, 7.1mEq of potassium, and 7.1mEq of sodium. 2. K-Phos neutral tablets a. Each tablet contains 8.0mMol of phosphorous, 1.0mEq potassium, and 11.1mEq of sodium. IV Replacements: 1. Sodium Phosphorous: a. Every 3mMol of phosphorous has 4.0mEq of sodium 2. Potassium Phosphorous: a. Every 3mMol of phosphorous has 4.4mEq of potassium May recheck the phos level within minutes of IV infusion or one hour after po replacement. Keep in mind calcium an phosphorous have a reciprocal relationship. Hyperphosphatemia: (>4.5mg/dL) Signs/Symptoms: muscles cramps, delirium, seizures, hypotension, heart failure, PROLONGED QT interval on ECG Causes: Renal diseases, cancer, trauma, burns, bisphosphonate, ischemic bowel, laxative use,. Treatments: Aluminum and magnesium containing antacids, Calcium acetate, Sucralfate, Saline Diuresis, Dialysis

Potassium (Normal range 3.5-5.0Meq/L)

Minimum daily requirement is 1600-2000 mg (40-50mEq) Absorption: rapid and complete Elimination: Renal In general every 10mEq of potassium will increase the serum potassium by 0.1mEq/L Symptoms of Hypokalemia: a. Fatigue, muscle weakness, leg cramps, ileus, weak or irregular pulse, ECG changes. Causes of Hypokalemia: a. Emesis, TPN, diarrhea, fistulas, renal, acid/base abnormalities, adrenal Note: For every decrease in pH of 0.1 a corresponding decrease in serum K by 0.4-0.5 mEq may be expected

Treatment: Replace, see below (usually every 10mEq of K will increase K by 0.1mEq/L) At PCMH we have: Oral replacements: 1. Klor powder 20mEq kcl (mix in 4oz water/oj) 2. Kdur 10 and 20mEq tablets (may be dissolved if necessary) 3. Micro K 10mEq capsules (Take with 4oz of water/oj) 4. Potassium Bicarbonate 25mEq tablets If using oral replacement be aware that generally doses >40meq at once may cause GI side effects. IV Replacements: 1. KCL a. Administer 20mEq over 1hour minimum (note: If given via central line may mix 20mEq in 50ml of NS, but if given in a peripheral IV then 20mEq must be diluted in 250ml of NS with a max dose of 80mEq/L) If Creatinine Clearance is <30 give of the calculated dose. May recheck within minutes of completing IV infusion and about one hour after administration of po medications. Hyperkalemia (>5.5) Signs/Symptoms: On ECG peaked T waves when K is >6-7, this is an emergency. Clinical signs include parasethias, paralysis, fatigue, weakness. Causes: Increased K load, decreased K excretion, DKA, acidosis, Beta blockers, NSAIDS, digoxin, succinylcholine. (Aggressive replacement of Phosphorus using neutraphos). Treatments: Calcium Gluconate 1 gram or Calcium Chloride 10% tg 0.51g NaHCO3 1 ampule IVP, Insulin 10 units + D50 IVP, B2 agonists high doses, Kayexalate.

Calcium (Normal range 8.5-10.2mg/dL)

Recommended daily requirement: 1000-1300 mg Absorption: 33% Elimination: Sweat, bile, pancreatic juice, saliva, urine, feces, milk. Note that there are not specific guidelines for the replacement of calcium but some would recommend replacement if corrected Ca is <8.5 or iCa is <4.0. Corrected Ca Measured Ca + 0.8(4-Albumin)

Hypocalcemia (<8 mg/dl) Signs and symptoms: Parasethias, confusion, intestinal cramping, diarrhea, arrhythmias, muscle spasms, chvosteks sign (face), Trousseaus sign DTR arm Causes: Transfusions, alkalosis, rhabdomyolysis, pancreatitis Treatment: Replace as below At PCMH we have: Oral replacements: 1. Calcium Acetate 667mg tablet (169 mg elemental Ca) 2. Calcium Carbonate 1250mg tablet (500 mg elemental Ca) 3. Calcium Carbonate 500mg tablet (tums) (200 mg elemental Ca) 4. Calcium Carbonate liquid 1250mg/5ml Note: these enteral products may cause GI side effects. IV Replacements (Each gram over at least 20 minutes) CalciumGluconate is preferred method: 1. *Calcium Gluconate 1gm in 50ml D5 or NS (90mg elemental Ca) a. may also administer 2gm in 50ml D5 or NS 2. Calcium Chloride 1gm in 50ml D5 or NS (272mg elemental Ca) a. Note that Calcium chloride has three times the elemental calcium of Calcium gluconate. Note: these IV products may cause phlebitis and extravasation particularly when using Calcium Chloride. Replace slowly as rapid IV infusion may lead to vasodilation, decreased blood pressure, bradycardia, arrhythmias, syncope, and in extreme cases death. Dont forget that Calcium and Phosphorous have a reciprocal relationship. Hypercalcemia (>11-12 mg/dL): Signs/Symptoms: nausea, vomiting, constipation, depression, polyuria, headache, weakness, fatigue, kidney stones, mental status changes. Causes: Primary/secondary parathyroidism, metastatic bone carcinoma (breast) Treatments: Rehdration with NaCL, Loop diruesis with lasix, calcitonin, mithramycin, diphosphates, steroids (slow onset)

Magnesium (Normal range 1.5-2.8mg/dL)

Minimal daily requirement: 310-420mg Absorption: 30-40% Elimination: Renal

Again note that there are not formal guidelines for replacement of magnesium but many recommend replacing if <1.7mg/dL and especially if the patient has a low potassium as magnesium is a necessary cofactor for adequate potassium replacement as it helps pump potassium into the cells. If extremely low Mag then may replace with 0.1mg/kg of actual body weight. On trauma service if we replace Mag we generally will give 1gram per every 0.1mg/dL that we are below 2.0mg/dL) Magnesium is involved in myoneuronal conduction by activating cholinesterase, controlling acetylcholine and thus controlling striated muscle and CNS activity. Hypomagnesemia (<1.6) Signs/Symptoms: Tremors, hyperreflexia, arrhythmias, bradycardia, tetany, seizures. Causes: malabsorption, malnutrition, kidney disease, hypoparathyroidism, hyperthyroidism, fluoride poisoning Treatments: Replace as below. At PCMH we have: Oral replacements: 1. Magnesium Oxide 400mg tablets (240mg elemental Mg) 2. Magnesium Hydroxide 30ml (MOM = Milk of Magnesia) (1000mg of elemental Mg) 3. Magnesium Gluconate 500mg tablets (64mg elemental Mg) Note: Enteral magnesium has GI side effects such as diarrhea, notice the MOM above. IV Replacements: 1. Magnesium Sulfate 1gm in 100ml D5 given over 60minutes 2. Magnesium Sulfate 2gm in 50ml D5 and given over 120minutes 3. Magnesium Sulfate >2gm in 100 ml D5 and given over longer periods (1gram over each hour) If Creatinine Clearance is <30 then give of the calculated dose. May recheck within minutes of IV infusion or about one hour after PO replacement. Hypermagnesemia (>2.8) Signs/Symptoms: Stupor, Coma, arrhythmias, heart block, a-fib, platelet clumping.

Causes: Iatrogenic is leading cause, renal failure, tumor lysis syndrome, lithium intoxication, DKA, hypothyroidism, hypoparathyroidism. Treatments: Dialysis, Calcium gluconate

General Caloric Needs: * In males, IBW = 106lbs for 5 feet + 6lbs for every inch above 60 inches In females, IBW = 100lbs for 5 feet + 5lbs for every inch thereafter Adults (18-65) with IBW: 25-30 kcal/kg Elderly (65+) with IBW: 25 kcal/kg Overweight/Obese with adjusted weight: 25-30 kcal/kg Adjusted Body Weight = [(Actual weight IBW) X 0.35] + IBW Calculation of basal metabolic rate using Harris-Benedict formulas: Males: BMR (kcal/day) = 66 + [13.7 X weight (kg)] + [5 X height (cm)] [6.8 X age (yrs)] Females: BMR = 665 + [9.6 X weight] + [1.7 X height] [4.7 X age] Increase 25% for mild peritonitis, long bone fx, or mild to moderate injury Increase 50% for multilorgan failure, severe injury, or infection in ICU patients Increase 100% for burns involving 40-100% TBSA General Protein Needs (4kcal/g) RDA 0.8g/kg Renal failure without dialysis 0.5-0.6g/kg; ARF with hemodialysis >1g/kg CRF with HD 1.2g/kg; with PD 1.2-1.5g/kg; with CRRT 1.2-2g/kg Hepatic encephalopathy 0.5-0.7g/kg Cirrhosis without encephalopathy 0.8g/kg; increase to goal of 1.5g/kg Trauma/Sepsis 1.5-2g/kg Extensive would healing 1.5-2.5g/kg Minor elective surgery 1.2g/kg Nitrogen balance = (Protein intake/6.25) (UUN + 4) Dextrose Needs (3.4 kcal/g) At least 100g/day to prevent ketosis Max infusion rate, <5mg/kg/min (<7g/kg/day) Lipid Needs (10kcal/g) Minimal requirement: 50g two times each week to prevent essential acid deficiency <1g/kg/day and should not exceed 30% of total calories in full TPN or 60% of calories in PPN Vitamins and Minerals Fat soluble vitamins (A, D, E, K) Stored in fat deposits and are slowly depleted

Water soluble vitamins (B-complex, C) Not stored in appreciable amounts and are depleted rapidly Ascorbic acid Essential for wound repair Replaced 1g daily Larger doses can cause diarrhea and renal stones and may interfere with laboratory studies Zinc Cofactor in enzymatic function and wound repair Known deficiency in burn patients Possibly necessary for nitrogen retention Replace zinc sulfate 220mg/day Glutamine Supports intestinal cell replication and growth Deficiency results in atrophy of intestinal mucosa Aids the synthesis of intracellular antioxidant glutathione Absent from all standard parenteral formulas Attenuates pancreatic atrophy and hepatic steatosis associated with standard intravenous formulas Insufficient quantities in most enteral formulas May supplement 0.5g/kg/day in divided doses Acid/Base Anion gap = [Na+ (Cl- + HCO3-)] = 8 12 HCl + NaHCO3 NaCl + H2CO3 H2O + CO2 10 mm Hg of PaCO2 pH 0.08 [HCO3-] 0.15 pH Metabolic acidosis: last 2 digits of the pH = PaCO2

Respiratory Acidosis BE = 0 HCO3 = 24 Metabolic Acidosis

Metabolic Alkalosis

Respiratory Alkalosis

pH = 7.4