Inpatient Electrolyte Repletion

*These are general recommendations and electrolyte repletion will be individualized per patient*

POTASSIUM _
 Goal is typically serum K+ of 4 mmol/L, especially in cardiac patients (AFib, HF, etc.) but lower
targets may be appropriate for other patient populations
 General rule of thumb is that 10 mEq of potassium is expected to increase the serum potassium
by 0.1 mmol/L
o Ex. Patient has serum K+ of 3.4 mmol/L, 60 mEq of KCl will raise the serum K+ to 4
mmol/L
o This rule should NOT be applied in patients with renal dysfunction/AKI
 Oral doses greater than 60 mEq should be split into a smaller BID dose – patients can rarely
tolerate the GI side effects of a potassium dose that large
 If a patient cannot take the ER KCl capsules/tablets, we are able to switch to an oral solution
 IV should only be used if there is concern for compromised oral absorption or in severe
hypokalemia (< 2.5 mmol/L)
 For patients requiring at least 40 mEq of IV repletion, we will typically do multiple doses of 20
mEq over 2 hours. This is due to the risk of extravasation (hence: why we can do more
concentrated infusions if the patient has a central line)
 Can be added to IVF in patients requiring maintenance repletion (ex. DKA)
 Potential causes of drug- induced hypokalemia: loop diuretics, thiazide diuretics, carbonic
anhydrase inhibitors, amphotericin
 If patients are requiring frequent spot dosing due to medications or their current disease state,
consider scheduled daily repletion or (if an appropriate indication exists) potassium-sparing
medications such as a mineralocorticoid receptor antagonist or ACE/ARB.
 SODIUM _
 Asymptomatic hyponatremia: hypovolemic, euvolemic, or hypervolemic
o Hypovolemic: Isotonic fluid administration and holding of any diuretics
o Euvolemic: Fluid restriction to < 1 L per day
o Hypervolemic: Diuresis + fluid restriction
 Symptomatic patients or those with Na < 120 mM/L may require hypertonic saline (3%) infusion
o Administer 50% of sodium deficit over a 12-hour period
 Na deficit (mEq) = (140 -[Na+ ]observed) x 60% total body weight (kg)
 Do not increase Na concentration by more than 2 mEq/L/hr or 12 mEq/L over 24hrs
o Rapid increase in sodium concentration can cause fluid shifts in the brain, resulting in
osmotic demyelination syndrome.
 Potential causes of drug-induced hyponatremia: thiazide diuretics, loop diuretics,
carbamazepine, NSAIDs, amitriptyline, SSRIs
 Reminder: cirrhotic patients may have hyponatremia at baseline that is NOT to be corrected to
“normal” lab values

PHOSPHOROUS _
 Goal is typically serum phosphorus of 3 (normal range 2.5-4.5 mg/dL)
 Causes of hypophosphatemia: refeeding syndrome, respiratory alkalosis, DKA treatment (insulin
and fluid repletion therapy), increased renal elimination (diuretics, glucocorticoids, sodium
bicarbonate, excessive phos binder use)
 Hypophosphatemia prevention:
o Supplement with oral options (eg. K-Phos Neutral); can be given as once doses or
scheduled Q6-8H depending on need to replete
 Phos NaK, K-Phos Neutral: 8 mmol phos, 7.1 mEq potassium, 6.9 mEq sodium
 K-Phos Original: 3.6 mmol phos, 3.7 mEq potassium
 Phosphate Neutral 250 mg: 8 mmol phos, 13 mEq sodium, 1.1 mEq potassium
 Hypophosphatemia treatment:
o Asymptomatic:
 Oral options (eg. K-Phos Neutral); poorly absorbed
 Often require several scheduled doses of 1-2 packets to achieve desired phos
o Symptomatic:
 General repletion dosing (non-weight-based approach):
 15-30 mmol IV phosphorus over 3-6 hrs at max of 7.5 mmol/hr (max
dose of 60 mmol)
 Weight-based repletion of phosphorus in general patients:
 Low dose, serum phosphate level 2.3 to 2.7 mg/dL: Initial: 0.08 to 0.16
mmol/kg over 4 to 6 hours.
 Intermediate dose, serum phosphate level 1.5 to 2.2 mg/dL: Initial: 0.16
to 0.32 mmol/kg over 4 to 6 hours.
 High dose, serum phosphate level <1.5 mg/dL: Initial: 0.32 to 0.64
mmol/kg over 4 to 6 hours.
  Weight-based repletion of phosphorus in critically ill patients:
 Low dose, serum phosphate level 2.3 to 3 mg/dL: Initial: 0.16 to 0.32
mmol/kg over 4 to 6 hours.
 Intermediate dose, serum phosphate level 1.6 to 2.2 mg/dL: Initial: 0.32
to 0.64 mmol/kg over 4 to 6 hours.
 High dose, serum phosphate <1.5 mg/dL: Initial: 0.64 to 1 mmol/kg over
8 to 12 hours.
 Available IV products:
 Sodium phosphate: 4 mEq Na+ per 3 mmol phosphate
o Order sets available for 10, 15, or 20 mmol phosphate
o Generally will infuse over 3 hrs
 Potassium phosphate: 4.4 mEq K+ per 3 mmol phosphate
o Order sets available for 10, 15, or 20 mmol phosphate
o Generally will infuse over 3 hrs

CALCIUM _
 Oral calcium is almost always preferred, with IV repletion being reserved for severe and
symptomatic hypocalcemia (Ex: Cardiac signs and symptoms)
 Ionized calcium is a more accurate measure of serum calcium - but also more expensive
o Calcium Goal = 8.8-10.5 mg/dL
o Ionized Calcium Goal = 1.1-1.28 mg/dL
o If ionized calcium is not available, calculate corrected calcium to account for albumin
since 40-60% of total serum calcium is bound to albumin
 Calcium corrected = (4- Albobserved) 0.8 + Caobserved
 Calcium Replacement:
o Ionized Ca 1-1.1 mMol/L (or corrected Ca 7.5-8.7 mg/dL) --> give calcium gluconate 2gm
o Ionized Ca < 1 mMol/L (or corrected Ca <7.5 mg/dL) --> give calcium gluconate 4 gm
o If using IV, run at 1 gm/hr
 Calcium Gluconate is preferred for routine supplementation – Calcium chloride is RESTRICTED
to emergent situations due to the risk of vascular damage
o Calcium chloride 1 gm provides 270 mg elemental calcium (13.6 mEq)
o Calcium gluconate 1 gm provides 93 mg elemental calcium (4.65 mEq)
o 1 gm calcium chloride = 3 gm calcium gluconate
 MAGNESIUM _
 Goal is typically serum magnesium of 2 – especially in certain cardiac patients (Afib, HF, etc.)
 Serum magnesium must be corrected for adequate potassium repletion to occur.
 Magnesium can take over 24 hours to equilibrate, meaning the next am labs may reflect a
falsely elevated serum magnesium.
 IV strengths available: 2 gm and 4 gm
 Oral magnesium is poorly absorbed – will typically use IV inpatient for this reason
 Recommend magnesium oxide as oral repletion --> typical dose is either 400 mg daily or BID
 Oral magnesium repletion may cause diarrhea, but this may be a desirable side effect in patients
who are experiencing constipation
 Infuse each gm of magnesium over 1 hour unless symptomatic (4 gm of magnesium = 4-hour
infusion)
 Potential causes of drug-induced hypomagnesemia: PPIs (impairment of dietary absorption),
loop diuretics, amphotericin