What are the detailed electrolyte derangements and their correction protocols, including exact dosages and durations?

From the Guidelines

Electrolyte derangements should be corrected promptly and carefully, with a focus on the severity and chronicity of the imbalance, as outlined in the proposed guidelines for the management of severe malaria in children 1. To manage electrolyte derangements, the following protocol can be used:

• For glucose levels less than 3 mmol/l, administer 5 ml/kg of 10% dextrose.
• For potassium levels less than 3.5 mmol/l, administer 0.25 mmol/kg over 30 minutes.
• For total calcium levels less than 2 mmol/l, administer 0.3 ml/kg of 10% Ca gluconate over 30 minutes.
• For magnesium levels less than 0.75 mmol/l, administer 0.2 ml/kg of 50% MgSO4 over 30 minutes.
• For phosphate levels less than 0.7 mmol/l, administer 0.2 mmol/kg of NaPO4 over 30 minutes. It is essential to monitor electrolyte levels closely and adjust the correction protocol as needed to prevent overcorrection or undercorrection, as recommended in the guidelines for the management of severe malaria in children 1. The correction protocol should be tailored to the individual patient's needs, taking into account the severity and chronicity of the electrolyte imbalance, as well as any underlying medical conditions, such as renal function and cardiac status. The goal of electrolyte replacement is to restore normal electrolyte balance while minimizing the risk of complications, such as cardiac arrhythmias or respiratory failure, and this can be achieved by following the proposed guidelines for the management of severe malaria in children 1.

From the FDA Drug Label

The administration of oral potassium salts to persons with normal excretory mechanisms for potassium rarely causes serious hyperkalemia. However, if excretory mechanisms are impaired or if potassium is administered too rapidly intravenously, potentially fatal hyperkalemia can result Treatment measures for hyperkalemia include the following: (1) elimination of foods and medications containing potassium and of any agents with potassium-sparing properties; (2) intravenous administration of 300 to 500 mL/hr of 10% dextrose solution containing 10 to 20 units of crystalline insulin per 1,000 mL; (3) correction of acidosis, if present, with intravenous sodium bicarbonate; (4) use of exchange resins, hemodialysis, or peritoneal dialysis. Dosage must be adjusted to the individual needs of each patients The dose for the prevention of hypokalemia is typically in the range of 20 mEq per day. Doses of 40 to 100 mEq per day or more are used for the treatment of potassium depletion.

The electrolyte derangement in question is hyperkalemia and hypokalemia. For hyperkalemia:

• Elimination of potassium sources
• Intravenous administration of 10% dextrose with insulin: 300 to 500 mL/hr with 10 to 20 units of insulin per 1,000 mL
• Correction of acidosis with intravenous sodium bicarbonate
• Use of exchange resins, hemodialysis, or peritoneal dialysis For hypokalemia:
• Prevention: 20 mEq per day
• Treatment: 40 to 100 mEq per day or more, divided into doses of no more than 20 mEq per dose 2 2

From the Research

Electrolyte Derangements

• Hyponatremia is the most common electrolyte disorder, affecting approximately 5% of adults and 35% of hospitalized patients 3
• It is defined by a serum sodium level of less than 135 mEq/L and most commonly results from water retention
• Symptoms and signs of hyponatremia range from mild and nonspecific to severe and life-threatening

Correction Protocol for Hyponatremia

• For severely symptomatic hyponatremia, US and European guidelines recommend treating with bolus hypertonic saline to reverse hyponatremic encephalopathy by increasing the serum sodium level by 4 mEq/L to 6 mEq/L within 1 to 2 hours, but by no more than 10 mEq/L within the first 24 hours 3
• Concurrently administered desmopressin (1-2 µg parenterally every 6-8 hours) and hypertonic saline with weight-based doses adjusted to increase the serum sodium concentration by 6 mEq/L, avoiding inadvertent overcorrection of severe hyponatremia 4
• The use of urea in euvolemic and hypervolemic hyponatremia is also discussed, with prospective studies needed to show the benefit in decreasing morbidity by increasing serum sodium in patients with chronic hyponatremia 5

Dosage and Duration

• Hypertonic saline should be administered as a bolus injection or continuous infusion, with the appropriate dose and administration modality depending on the patient's symptoms and serum sodium level 6
• Desmopressin should be used concomitantly with hypertonic saline to prevent rapid correction of serum sodium, with the duration of treatment depending on the patient's response and serum sodium level 4
• The rate of correction of hyponatremia should be limited to avoid iatrogenic osmotic demyelination, with a goal of increasing the serum sodium level by no more than 10-12 mEq/L in any 24-hour period and/or 18 mEq/L in any 48-hour period 4

Treatment Options

• Hypertonic saline, isotonic saline, water restriction, long loops diuretics, urea, or vaptans can be used to treat hyponatremia, with the choice of treatment depending on the patient's underlying condition and serum sodium level 5
• Urea and vaptans can be effective treatments for the syndrome of inappropriate antidiuresis and hyponatremia in patients with heart failure, but have adverse effects such as poor palatability and gastric intolerance with urea, and overly rapid correction of hyponatremia and increased thirst with vaptans 3