ICU Electrolyte Replacement Protocol


Exclusion Criteria: Do Not Initiate Protocol

Potassium (K) PO

Potassium (K) PO Replacement:
(Normal Range 3.5 to 5.0 mEq/L)

Potassium (K)
Level (mEq/L)
Potassium Dose *
for Cr. <1.5
Potassium Dose *
for Cr. 1.5-1.9
Repeat K level
(Lab)
> 4 No Treatment No Treatment Next AM Lab
3.8 - 3.9 3.8 - 3.9 20 mEq KCL PO x 1 dose 10 mEq KCL PO x 1 dose Next AM Lab
3.6 - 3.7 40 mEq KCL PO x 1 dose 20 mEq KCL PO x 1 dose Next AM Lab
3.3 - 3.5** 30 mEq KCL PO q 4 hrs x 2 doses 30 mEq KCL PO x 1 dose Next AM Lab
3.0 - 3.2** 40 mEq KCL PO q 3 hrs x 2 doses 30 mEq KCL PO q 4 hrs x 2 doses BMP 2 hours after
last dose given
< 3.0**
(Notify MD)
Start TELEMETRY
40 mEq KCL PO STAT (Solution
preferred for first dose), then
40 mEq KCL PO q 2 hrs x 2 doses
Start TELEMETRY
40 mEq KCL PO STAT (Solution preferred for first dose), then 40 mEq KCL PO in 4 hrs x 1 dose
BMP 2 hours after
last dose given
* Use KlorCon M20 if patient can swallow whole tablet (DO NOT CRUSH TABLETS)
Use KCL Oral solution (20mEq/15 cc) if patient has a feeding tube or cannot swallow whole tablets.
** Add Magnesium level to same lab if K is < 3.6 and refer to Mg protocol below

Potassium (K) IV

Potassium (K) IV Replacement:
(Normal Range 3.5 to 5.0 mEq/L)

K+ Replacement Repeat K level (Lab)
3.6 - 3.9 KCL 20 meq over 2 hours IV (20 meq/100 milliliters water) or by PO) 6 hrs after infusion complete.
3.1 - 3.5 KCL 40 meq over 2 hours IV (20 meq /100 milliliters water) (or by PO) 6 hrs after infusion complete.
2.5 - 3.0 KCL 60 meq over 3 hours IV (20 meq /100 milliliters water) 6 hrs after infusion complete.
1.8 - 2.4 KCL 80 meq over 4 hours IV (20 meq /100 ml water) 6 hrs after infusion complete.
< 1.8 Start TELEMETRY
Notify physician. KCL 80 meq over 4 hrs IV (20 meq /100 ml water)
6 hrs after infusion complete.

Magnesium (Mg) PO

Magnesium (Mg) PO Replacement:
(Normal Range 1.5 to 2.5 mg/dl)

Magnesium (Mg) Level Magnesium Dose Repeat Mg Level (Lab)
> 2.0 mg/dl No Treatment Next AM Lab
1.5 to 1.9 mg/dl 400 mg Magnesium Oxide PO x 1 Next AM Lab
1.2 to 1.4 mg/dl 400 mg Magnesium Oxide PO q
4 hours x 2 doses
Next AM Lab
< 1.2 mg/dl Notify MD for order Per MD order

Magnesium (Mg) IV

Magnesium (Mg) IV Replacement:
(Normal Range 1.5 to 2.5 mg/dl)

Mg Magnesium Dose Repeat Mg Level (Lab)
1.6 - 1.8 Magnesium sulfate 2 grams IV over 2 hours.
(2grams/100 milliliters D5W).
(Infuse at 1gm/hr)
Repeat Mg+ 6 hours after infusion complete.
1.0 - 1.5 Magnesium sulfate 3 grams IV over 3 hours.
(3 grams/100 milliliters D5W).
(Infuse at 1gm/hr)
Repeat Mg+ 6 hours after infusion complete.
Less than 1 Magnesium sulfate 4 grams IV over 4 hrs.
(4 grams/50 milliliters water).
(Infuse at 1gm/hr)
Repeat Mg+ 6 hours after infusion complete.

Phosphate (PO4) PO

Phosphate (PO4) Replacement:
(Normal Range 2.7 to 4.7 mg/dl)
Serum Phosphate (PO4) Level Phosphate Dose Repeat PO4 Level (Lab)
2.0 to 2.7 mg/dl 15 mmol Phos-NaK (Neutra-phos) PO q 6 hrs X 2 doses OR equivalent mg dose Next AM Lab
1.6 to 1.9 mg/dl 30 mmol Phos-NaK (Neutra-phos) PO q 6 hrs X 4 doses OR equivalent mg dose Next AM Lab
< 1.6 mg/dl (Notify MD)
REQUIRES IV REPLACEMENT
IF K <4.0: 30 mmol KPO4 (K-Phos Neutral) IV in 250 ml NS infuse over 4 hrs x 1 6 hours after replacement
IF K Level is <4.0 give KPO4 IV
As above
IF K Level is >4.0 give NaPO4 IV
IF K >4.0: 30 mmol NaPO4 (K-Phos Neutral) IV in 250 ml NS infuse over 4 hrs x 1 6 hours after replacement

Phosphate (PO4) IV

Phosphate (PO4) Replacement IV:
(Normal Range 2.7 to 4.7 mg/dl)
PO4 K+ Replacement Lab
1.8 - 2.7 > 3.6 Na phosphate 15 mmol over 4 hrs IV.
(15 mmol/250 ml D5W).
Repeat PO4 6 hours after infusion complete.
1.8 - 2.7 < 3.6 K phosphate 15 mmol over 4 hours IV.
(15 mmol/250 ml D5W).
Replace K+ as outlined above. (2 IV sites).
Repeat PO4 and K+ 6 hours after infusion
complete.
1.0 - 1.7 > 3.6 Na phosphate 21 mmol over 4 hours IV.
(21 mmol/500 ml D5W).
Repeat PO4 6 hours after infusion complete.
1.0 - 1.7 < 3.6 K phosphate 21 mmol over 4 hours IV.
(21 mmol/500 ml D5W).
Replace K+ as outlined above. (2 IV sites).
Repeat PO4 and K+ 6 hours after infusion
> 1 > 3.6 Na phosphate 30 mmol over 4 hours IV.
(30 mmol/500 ml D5W).
Repeat PO4 6 hours after infusion complete.
> 1 < 3.6 K phosphate 30 mmol over 4 hours IV.
(30 mmol/500 ml D5W).
Replace K+ as outlined above. (2 IV sites).
Repeat PO4 and K+ 6 hours after infusion complete.

Calcium (Ca) PO

Calcium (Ca) Replacement: (Normal Range 1.12 - 1.32 mmol/L)
Use Ionized Calcium Lab Level ONLY (Do Not Use Serum Calcium Level)
1.12 - 1.32 mmol/L No Treatment Next AM Lab
<1.12 mmol/L Calcium Carbonate 1250 mg PO or 1250 mg in 5 cc NG/OG/PEG
BID x 3 days
Next AM Lab

Calcium (Ca) IV

Calcium (Ca) Replacement IV:
(Normal Range 1.12 - 1.32 mmol/L)

Continue calcium replacement as below until calcium (Ionized Ca++) > 1.12 mmol/L.
NOTE: Place patient on cardiac monitor. Slow rate of infusion if patient experiences burning or pain at the infusion site.
- DO NOT REPLACE CALCIUM IF PATIENT ON DIGOXIN WITHOUT CLEARANCE FROM PHYSICIAN.
PHYSICIAN MUST SPECIFY THE SALT FORM OF CALCIUM:
  • Ca CHLORIDE: ICU only MUST be administered via Central Line
    • Maximum rate = 1 gm/100cc NS IV over 10 minutes
  • Ca GLUCONATE: Administration via a central line is preferred; however, may be given peripherally with adequate IV access.
    • Maximum rate = 3 gm/250cc NS IV over 10 minutes
Ionized Ca Level Ca Gluconate Replacement Ca Chloride Replacement Lab
1 - 1.1 mmol/L 1 gm IV in 100 cc NS over 1 hr 1 gm IV in 100cc NS over 1 hr Next scheduled lab
0.85 - 0.99 mmol/L 2 gms IV in 100 cc NS over 1 hr 2 gms IV in 100cc NS over 1 hr Recheck serum ionized calcium 2 hrs after infusion complete
< 0.85 mmol/L CALL MD And
2 gms IV in 100 cc NS over 1 hr
CALL MD And
3 gms in 250cc NS IV over 1 hr
Recheck serum ionized calcium 2 hrs after infusion complete