Original Date: 01/2022 Purpose: To standardize the electrolyte monitoring and replacement of patients in the burn unit.
Exclusions
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- Renal failure (acute or chronic)
- Ongoing continuous renal replacement therapy (CRRT) or intermittent hemodialysis (iHD)
- Creatinine clearance <20 mL/minute
- Patients with cardiac arrhythmias who need more aggressive electrolyte repletion
- Patients at risk for acute kidney injury
- Rhabdomyolysis with ongoing resuscitation
Frequency of Phosphorous, Magnesium, and Ionized Calcium Labs
- Burn intensive care unit
- Active resuscitation – check all with each scheduled lab draw and replete as needed
- Stable ICU patients – check Monday, Wednesday, and Friday
- Burn intermediate unit
- Check Monday, Wednesday, and Friday
- Burn floor
- Check Monday and Friday
*If a patient has required consistent replacement of one, check daily as needed until levels are stable.*
Potassium Replacement
- Review serum phosphorus level prior to potassium replacement.
- If serum phosphorous level is greater than 2.5 mg/dL, replete potassium with potassium chloride (KCl): Potassium level Replacement Re-check level 3.4-3.5 mEq/L 40 mEq KCl PO/IV (PO preferred)
- 40 mEq KCL PO x 1
- 20 mEq KCL IV x 2 doses
With next set of morning labs 3.0-3.3 mEq/L 60 mEq KCl PO/IV (PO preferred)
- 20 mEq KCL PO x 3 doses
- 20 mEq KCL IV x 3 doses
With next set of morning labs <3.0 mEq/L 80 mEq KCL PO/IV (PO preferred)
- 40 mEq KCL PO x 2 doses
- 20 mEq KCL IV x 4 doses
Immediately and with next set of AM labs
- If serum phosphorous level is less than 2.5 mg/dL, replete serum potassium with potassium phosphate (KPhos)
- Intravenous KCl:
- Central venous access: infuse at 20 mEq/hour
- Peripheral venous access: infuse at 10 mEq/hour
- Intravenous KCl:
Phosphorous Replacement
- Review serum potassium level prior to phosphorous replacement.
- If serum potassium is <4.0 mEq/L, use potassium phosphate
- If serum potassium is ≥4.0 mEq/L, use sodium phosphate Formulations Phosphorous Potassium Sodium Potassium phosphate (Kphos) (IV) 3 mmol/mL 4.4 mEq/mL – Phos-Nak packet (PO) 8 mmol 7.1 mEq 6.9 mEq Sodium phosphate (NaPhos) (IV) 3 mmol/mL – 4 mEq/mL Serum phosphorous level Replacement Re-check level 2.0-2.5 mg/dL If potassium <4.0 mEq/L:
– Phos-Nak 2 packets PO q4 hours x 3 doses (48 mmol phosphorous, 42.6 mEq potassium), or
– 15 mmol KPhos (has 22 mEq potassium)
If potassium ≥ 4.0 mEq/L:
– 15 mmol NaPhos
With next set of morning labs 1.6-1.9 mg/dL If potassium <4.0 mEq/L:
– Phos-NaK 2 packets PO q4 hours x 4 doses (64 mmol phosphorous, 56.8 mEq potassium), or
– 30 mmol KPhos (has 44 mEq potassium)
If potassium ≥ 4.0 mEq/L:
– 30 mmol NaPhos
With next set of morning labs <1.6 mg/dL If potassium <4.0 mEq/L:
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– 45 mmol KPhos (has 66 mEq potassium)
If potassium ≥ 4.0 mEq/L:
– 45 mmol NaPhos
6 hours after replacement and with next set of morning labs
- IV phosphorous replacement are diluted in normal saline by default; they can be ordered in D5W if desired
Magnesium Replacement
- Magnesium replacement is done with magnesium sulfate Magnesium level Replacement Re-check level 1.5-1.9 mg/dL -2 grams IV q2 hours times 2 doses
-Each 2 gram dose is infused over 2 hours
No indication to re-check 1.0-1.4 mg/dL -2 grams IV q2 hours times 3 doses
-Each 2 gram dose is infused over 2 hours
No indication to re-check <1.0 mg/dL -2 grams IV q2 hours times 4 doses
-Each 2 gram dose is infused over 2 hours
With next set of morning labs
Calcium Replacement
- Replete calcium based upon an ionized calcium level using intravenous calcium gluconate. Ionized Calcium level Replacement Re-check level 0.8-0.9 mmol/L 1 gram calcium gluconate IV No indication to re-check <0.8 mmol/L 2 grams calcium gluconate IV With next set of morning labs
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