Abnormality | Management recommendation |
Hyperphosphatemia | |
Moderate, ≥2.1 mmol/L (6.5 mg/dL) | Restrict phosphate intake (avoid IV and oral phosphate; limit dietary sources) |
Phosphate binders: | |
Calcium acetate* Adult: 2 to 3 tabs (1334 to 2668 mg) with each meal; or | |
Calcium carbonate* Adult: 1 to 2 grams with each meal; Pediatric: 30 to 40 mg/kg with each meal; or | |
Sevelamer¶ Adult: 800 to 1600 mg with each meal; Pediatric: 40 to 54 mg/kg with each meal; or | |
Lanthanum carbonate Adult: 500 to 1000 mg with each mealΔ; or | |
Aluminum hydroxide Adult: 300 to 600 mg with each meal; Pediatric: 12.5 to 37.5 mg/kg four times daily with meals; (avoid use in patients with renal insufficiency) | |
Severe | Dialysis, CAVH, CVVH, CAVHD, or CVVHD |
Hypocalcemia, total serum calcium ≤1.75 mmol/L (7 mg/dL) or ionized calcium ≤0.8 mmol/L (3.2 mg/dL) | |
Asymptomatic | No therapy |
Symptomatic | Calcium gluconate administered slowly with ECG monitoring; patients with acute hypocalcemia and hyperphosphatemia should not be treated with calcium until the hyperphosphatemia is corrected (unless they have tetany or a cardiac arrhythmia from hypocalcemia) |
Calcium gluconate◊ Adult: 1 gram (10 mL of 10 percent solution); Pediatric: 50 to 100 mg/kg. Slow IV infusion (maximum 50 to 100 mg per minute) in large vein. May be repeated after 5 to 10 minutes if symptoms or ECG changes persist. | |
Hyperkalemia§ | |
Moderate and asymptomatic, ≥6.0 mmol/L | Avoid IV and oral potassium |
ECG and cardiac rhythm monitoring | |
Sodium polystyrene sulfonate¥ Adult: 15 to 30 grams orally; Pediatric: 1 gram/kg orally. Onset 1 to 2 hours. Repeat every 4 to 6 hours up to four times daily as needed based on repeat serum K+ level. | |
Severe (>7.0 mmol/L) and/or symptomatic | Same as above, plus: |
To stabilize cardiac membranes: | |
For patients with ECG changes (widening of the QRS complex or loss of p-waves but not peaked t-waves alone), give calcium gluconate by slow IV infusion to prevent life-threatening arrhythmias: | |
Calcium gluconate Adult: 1 gram (10 mL of 10 percent solution); Pediatric: 50 to 100 mg/kg. Slow IV infusion (maximum 50 to 100 mg per minute) in large vein. May be repeated after 5 to 10 minutes if ECG changes persist. | |
To temporarily shift potassium into cells: | |
Give IV insulin and dextrose: | |
IV insulin and dextrose Adult: regular insulin (10 units) IV plus 100 mL of a 50 percent dextrose solution (D50) IV; Pediatric: regular insulin (0.1 unit/kg) IV, plus 25 percent dextrose solution (D25) 0.5 gram/kg (2 mL/kg of D25) IV over thirty minutes. May be repeated after thirty to sixty minutes. Monitor fingerstick glucose closely. | |
Sodium bicarbonate can be given to induce influx of potassium into cells if patient is acidemic. Sodium bicarbonate and calcium solutions should not be administered through the same line due to incompatibility. | |
Sodium bicarbonate Adult: 45 to 50 mEq; Pediatric: 1 to 2 mEq/kg. Slow IV infusion over five to ten minutes. | |
Beta 2 agonist inhalation: Albuterol per nebulisation or metered dose inhaler | |
Albuterol Adult: 10 to 20 mg in 4 mL saline nebuilzed over 20 minutes or 10 to 20 puffs per metered dose inhaler over 10 to 20 minutes; Pediatric: 0.1 to 0.3 mg/kg per nebulisation. | |
Dialysis | |
Uremia (renal dysfunction) | |
Fluid and electrolyte management | |
Uric acid and phosphate management | |
Adjust renally excreted drug doses | |
Dialysis (hemo- or peritoneal) | |
Hemofiltration (CAVH, CVVH, CAVHD, or CVVHD) |
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