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Electrolyte repletion

Last updated: November 7, 2023

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Hypokalemia, hypocalcemia, hypomagnesemia, and hypophosphatemia are common electrolyte disturbances in hospitalized and critically ill patients. Repletion regimens vary widely and standardized recommendations do not exist. For this reason, institutional guidelines and individual patient factors should always be taken into consideration when planning electrolyte repletion. Always consider renal and hepatic clearance and the potential for adverse effects when repleting electrolytes and attempt to identify and treat the underlying cause. It is also important to correct any concurrent electrolyte abnormalities (e.g., repletion of concurrent hypomagnesemia in a patient with hypokalemia) and consider the level of monitoring required during the correction (e.g., continuous telemetry during high-dose IV potassium repletion).

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Always check the serum magnesium level and replete magnesium prior to repleting potassium. Low magnesium can exacerbate renal potassium losses.

Repletion regimens

Various concentrations of potassium chloride are available; consult your local hospital protocol. IV solutions with high concentrations (e.g., 300–400 mEq/L) should be exclusively administered via a central line.

Repletion regimens for hypokalemia [1][2]
Serum potassium level Recommended regimen Monitoring

< 2.5 mEq/L

and/or symptomatic

  • Intravenous potassium chloride [3]
  • Maximum rate of 40 mEq/hour is recommended for administration via a central line.
  • In select circumstances, both IV and oral potassium repletion may be necessary, but this should only be done in a closely monitored setting. [3]

2.5 mEq/L–2.9 mEq/L

and/or unable to tolerate PO

3.0–3.4 mEq/L
≥ 3.5 mEq/L
  • Repletion generally not necessary.
  • Consider oral potassium chloride for patients with DKA, CHF, and/or undergoing active diuresis.

The maximum infusion rate of potassium chloride should not exceed 10–20 mEq/L per hour in a peripheral IV or 40 mEq/L per hour in a central line.

General considerations

  • Therapeutic goals
    • Target serum potassium level: ∼ 4.0 mEq/L
    • Expected increase in serum potassium levels: ∼ 0.1 mEq/L after an IV dose of 10 mEq
  • Route of replacement: depends on hypokalemia severity, symptoms, and ability to tolerate/absorb oral medication
    • Oral supplementation is typically preferred, due to a lower risk of cardiac arrhythmia and venous sclerosis.
    • IV and oral supplementation can be combined in severe cases where GI absorption is intact.
    • Oral uptake can be improved by administration with or after a meal. [2]
  • Cautions

Adverse effects of potassium repletion

Acute management checklist for hypokalemia

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Repletion regimens

Repletion regimens for hypocalcemia [10][11]

Corrected serum calcium

Recommended regimen Monitoring

≤ 7.5 mg/dL (≤ 1.9 mmol/L)

(ionized Ca ≤ 3.0 mg/dL (≤ 0.8 mmol/L))

and/or symptomatic

7.6 mg/dL–8.4 mg/dL (2.0–2.1 mmol/L)

(ionized Ca 3.1–4.3 mg/dL)
  • Monitor serum calcium level daily or as needed.

≥ 8.5 mg/dL (≥ 2.2 mmol/L)

(ionized Ca ≥ 4.4 mg/dL)
  • No repletion indicated

Use extreme caution when administering IV calcium in patients receiving cardiac glycosides or avoid it altogether, as the combination increases the risk of ventricular fibrillation.

If hypomagnesemia is present, replete magnesium concurrently with calcium as low magnesium can disrupt PTH-mediated calcium hemostasis. [12]

General considerations

Adverse effects of calcium repletion

Acute management checklist for hypocalcemia

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Repletion regimens

Repletion regimens for hypomagnesemia [13][14][15]

Serum magnesium

 Recommended regimen Monitoring

< 1 mEq/dL

and/or symptomatic

1.0–1.5 mEq/dL
  • Monitor serum magnesium 6–12 hours after every dose of IV magnesium or at least daily.

≥ 1.6 mEq/dL


Because the risk of hypermagnesemia is elevated in patients with impaired renal function (especially if the creatinine clearance is < 30 mL/min/1.73 m2), consider reducing the dose in this group by 50%.

General considerations

  • Goal serum magnesium level
    • Most patients: 1.5–2.4 mg/dL
    • In patients with an underlying cardiac disorder and/or at risk of arrhythmias: consider higher goal > 1.7 mg/dL
  • 1 g of IV magnesium sulfate has about 8 mEq of elemental magnesium.
  • Oral repletion is generally preferred when possible
  • Magnesium repletion should be continued 1–2 days after normalization of serum levels.

Adverse effects

Acute management checklist for hypomagnesemia

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Repletion regimens for hypophosphatemia

Approach

  1. Determine whether IV or PO repletion is indicated.
  2. Calculate how many millimoles of elemental phosphorus are indicated.
  3. Decide which phosphate salt should be administered.
  4. Round the total dose calculated to the closest preparation dose available (e.g., typically 7.5 mmol for IV, 8 mmol for PO).

There are no standard guidelines for phosphate repletion and individual recommendations vary. Consult your pharmacy with any questions, as individual formulations may vary!

Do not confuse phosphorous (P) with phosphate (PO43−). The concentration of the substances measured in mmol/L is identical but the mass measured in mg/dL differs by a ratio of around 3:1 (phosphate:phosphorus). [16]

For patients who are critically ill and/or receiving parenteral nutrition [17][18]

Phosphate repletion for critically ill patients and/or receiving TPN
Serum phosphorus Recommended regimen Monitoring

< 1.6 mg/dL

(< 0.51 mmol/L)

1.6–2.2 mg/dL

(0.51–0.71 mmol/L)
  • Monitor serum phosphorus level 6 hours after infusion.

2.2–3.0 mg/dL

(0.71–0.96 mmol/L)
  • Monitor serum phosphorus level 6 hours after infusion.

All other patients [14][18]

Phosphate repletion for patients who are not critically ill and not receiving TPN
Serum phosphorus Recommended regimen Monitoring

< 1.0 mg/dL (< 0.32 mmol/L),

symptomatic, and/or unable to take PO

  • Monitor serum phosphorus level 6 hours after infusion.

1.0–1.9 mg/dL

(0.32–0.64 mmol/L)
  • Monitor serum phosphorus level 6 hours after infusion (if IV) or at least daily.

≥ 2.0 mg/dL

(> 0.64 mmol/L)
  • Repletion generally not indicated

If the serum potassium is < 4.0 mg/dL, administer phosphate as potassium phosphate. If the serum potassium is ≥ 4.0 mg/dL, administer phosphate as sodium phosphate.

General considerations

  • Goal serum phosphorus level: > 2–3 mg/dL
  • Expected increase in serum phosphorus levels: ∼ 0.5 mg/dL with a dose of 0.10 mmol/kg body weight (but this is somewhat unpredictable)
  • Serum phosphorus levels may not reflect total body stores, as most of the body's phosphorus is stored in the bones and soft tissues.
  • Critically ill patients often have higher phosphorus requirements due to hypermetabolism and high urinary phosphorus excretion.
  • Dosing
    • A standard IV dose is around 15–30 mmol and should not be administered faster than 4.5–7.0 mmol/hour.
    • Reduce the dose by 50% in patients with impaired renal function who are not on hemodialysis.
  • Phosphorus preparations [16]

For IV administration, round the total phosphate dose to the nearest 7.5 mmol for ease of preparation

Adverse effects of phosphate repletion [18]

Acute management checklist for hypophosphatemia

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