Potassium Electrolyte Repletion If patient also has hypomagnesemia, replete magnesium before repleting potassium Oral:

Magnesium Electrolyte Repletion Oral - Only do if patient does not tolerate IV • Magnesium oxide (can cause diarrhea and cause some more Mg loss) - 400 to 800mg PO daily • Magnesium protein complex (does not cause diarrhea, not available everywhere) - 133 or 266mg PO TID Intravenous (does not cause burning sensation) - Dr. Satya Patel @SatyaPatelMD #Magnesium #Electrolyte #Repletion #management #hypomagnesemia

Intern Pocket Cards - Electrolyte Repletion Guide Electrolyte Repletion: - Potassium (ref range 3.5-4.5) - Magnesium (ref range 1.3-1.7) - Calcium (ref range 8-10) - Phosphate (ref range 2.5-4.5) Dr. Satya Patel @SatyaPatelMD Full Inpatient Pocket Cards Collection: https://bit.ly/pocketcardset #Electrolyte #Repletion #Guide #management #inpatient #internship #potassium #phosphate #phosphorus #magnesium

Potassium Repletion - Oral vs IV Oral KCl - 40mEq at a time, q2-4 hrs - Side Effect: GI upset IV KCl - 10 mEq/hr via peripheral vein - 20 mEq/hr via central line - Side Effect: Burning pain proximal to IV site Dr. Eric Strong https://twitter.com/DrEricStrong #Potassium #Repletion #Hypokalemia #Oral #Intern #Management

Electrolyte Repletion Potassium - ref range 3.5-4.5 - if acute MI, cardiac conditions >4.5 if VT Magnesium • ref range 1.3-1.7 • >2 if CAD or active cardiac conditions >2.5 for VT Calcium • ref range 8-10 • No need to replete unless corrected Ca <7 Phosphate • ref range 2.5-4.5 • Pay attention to K load with different formulations #Electrolyte #Repletion #management #intern

Checklist Approach to Hypokalemia Consider risk factors for arrhythmia: - EKG changes (especially QT prolongation) - Digoxin - Myocardial ischemia - Concomitant severe hy pomagnesemia Evaluation - Check magnesium lev el - Repeat electrolytes if doubt exists about their validity (e.g. incongruous with clinical context & EKG) Consider magnesium repletion - May be the fastest way to reduce the risk of arrhythrnia (aggressive magnesium can be given safely, whereas potassium needs to be given at a controlled rate). - Repletion Of Mg is often necessary to successfully replete the potassium. Consider target potassium level - Most patients (including cardiac patients): > 3.5 - Severe renal failure: > 3 mM ? - DKA: >5.3mM ? Enteral potassium is preferred if possible - Contraindications to enteral route = severe hypokalemia (<2.5 mM), NPO, or profound shock with questionable enteral absorption. - Dose & monitoring depend on renal function & estimated potassiurn deficit. Intravenous potassium - Use only if cmtraindication to enteral. - Rate of 10 mEq/hr for routine repletion. - Rate of 20 mEq/hr for severe hypokalemia or DKA (either via central line or split into two simultaneous infusions of 10 mEq/hr in two peripheral lines). - Dose & frequency Of monitoring depend on renal function & estimated deficit. Dr. Josh Farkas @pulmcrit - Internet Book of Critical Care #Checklist #Hypokalemia #Management #CriticalCare

Electrolyte Repletion Significant electrolyte depletion can result in serious complications. These guidelines are meant to assist with empiric dosing of electrolytes for inpatients. Doses may need to be adjusted based on patient-specific factors, including creatine & cardiac status; & responses to initial doses. Goal serum potassium concentration 4.0 – 5.0 mEq/L Goal serum ionized calcium concentration 1.12 – 1.3 mmol/L Goal serum magnesium concentration 2.0 – 2.4 mg/dL Goal serum phosphorus concentration 2.7 – 4.6 mg/dL IV electrolyte replacement can produce life-threatening complications, serious arrhythmias & phlebitis; therefore, supplementation must be carefully monitored. There are multiple underlying factors for electrolyte disorders in adult inpatients, including alterations in absorption, distribution, hormonal, and/or homeostatic mechanisms can all cause disturbances. Treating the underlying cause and prescribing adequate therapy is essential for repletion. In addition, the intracellular vs. extracellular electrolyte concentrations must be considered. Due to distribution variances, labs may not directly correlate with true electrolyte level. Therefore, continuous monitoring is essential to properly replete patients. Satyendra Dhar MD, @DharSaty #hypokalemia #hyponatremia #hypocalcemia #hypomagnesemia #hypophosphatemia #electrolytes

SIADH Treatment Options 1. Treat underlying cause of SIADH: Pain, Primary lung pathology, Post-operative phenomenon, Medications, Basically anything 2. Free water restriction • All food has water • Electrolyte Free Water Clearance (EFWC) Equation • For practical purposes, restrict to 1 to 1.5L per day (if you plan on using this as a long-term solution, you should prove feasibility during hospitalization) 3. Salt tabs • Start with lg NaCl PO TID • With lower Na, you should increase the number and frequency of salt tablets administered • This can cause volume overload 4. Urea powder • Induces osmotic water elimination by promoting passive sodium reabsorption in the ascending limb of the loop of Henle • Contraindicated in cirrhosis given the potential for it to be metabolized into ammonium by urease-producing bacteria in the colon 5. 0.9% NS • If Urine osmolality < 538 AND UNa + UK < 154, can try giving 0.9% NS • Give 250 cc NS boluses at a time • Re-check the serum Na+ in 2-4 hours and decide before giving more 6. Vasopressor receptor antagonists (-vaptans) • Blocks ADH receptor • Major side effects: Thirst, Nausea, Hypotension, Increased urine output Satya Patel, MD @SatyaPatelMD #SIADH #Management #hyponatremia #nephrology #treatment