K+/Mag replacement protocol

[Sugarcoma, RN]

A question that I have been unable to find an answer to at my current job about mag/k+ protocol. This protocol is ordered on everyone admitted to our ICU. Usually by the nurses as the docs themselves RARELY put in admission orders of any kind.

When you have Hemodialysis or TPN pt.s do you still follow the mag/K+ replacement protocol at your facility?

Our nutrition department writes the orders for TPN based on that morning labs and often-times when they have been replaced people do not redraw the labs and the a.m values available in the computer do not accurately reflect the pt.s current levels.

Same with hemodialysis pts. the docs often write their orders based on the morning lab values prior to redraw after replacement.

We have no policy I can find covering TPN and dialysis pts. I have asked multiple people including my manager only to be told.....yes always/no, never, and it depends. On what no one can really tell me. The docs and nutrition people are not available to me (work nights).

I ask because a few times I have had pts like this for a couple nights in a row and find their levels become elevated because no one is taking into account it was replaced (by me) that a.m. even though it is charted and I have passed it onto dayshift. I am fearful my pts. will end up with hyperkalemia/magnesmia because people often forget to redraw and the docs/nutrition people are not taking that into consideration. What I started to do is leave messages for the nutrition/hemo docs in the a.m. telling them current levels and amount of replacement and when that didn't work I started not replacing unless of course the level was very low. I would be interested to know how other facilities handle this. At my previous facility only the hemo docs or nutrition team addressed K and mag levels for these pts. but it was not an ICU.

[tri-rn]

We don't have a protocol that covers every patient in our unit, it has to be put in separately. It's not used on HD patients so no, we don't generally supplement them unless they're REALLY low, having increased ectopy, or there's some other reason.

[Sun0408, ASN, RN]

We have a k, mag and phos protocol that all of our ICU pts are on when admitted. There levels are checked every am. If any one of the levels are replaced, we are required, per protocol to redraw 6 hours post infusion. A hemo pt is not normally added to the protocols because their levels tend to be higher, but we still check. When they go to hemo, they can adjust those levels with the HD solutions. We also watch for creatinine levels, if it goes above 2, we do not replace unless ordered to do so by the MD. If a pt is on TPN, yes we still replace and rarely have I seen their numbers high.

[morte, LPN, LVN]

I think your concern is legit. Have you tried a memo to your nurse manager, with CC to the medical director of your unit?

[BelgianRN]

In our institution TPN is delivered without any potassium or magnesium in it as long as they are in the ICU. And these patients rely completely on our suppletion over 24 hours to keep them balanced. Magnesium levels are not drawn frequently unless they are on a continuous magnesium drip for (pre-)eclampsia or something or when they are on CVVH.

We don't have any formal protocol to replace either potassium or magnesium in our ICU patients. We are told to use our best judgment and contact the MD's when in doubt. So over the years we've come up with our own schematic that works for us nurses and our MD's.

Generally all our patients receive 2g MgSO4 in their maintenance fluids (1g if on HD). And when they do tachy-problems they'll receive 2g extra (or 1g if HD). Any additional dosages are done on MD order and usually will be accompanied by checking magnesium levels during morning labs.

Potassium gets suppleted by 20 mEq/hour until either >3 mmol/l (no cardiac issues) or > 4 mmol/l (arrhythmia) or 5.5 mmol/l (on specific MD order).

For HD patients this gets downgraded to 10 mEq/hour and these patients are limited to a maximum level of 3.5 mmol/l (unless higher as per MD order). And we draw labs hourly if we are suppleting and we base them of the potassium levels in our ABGs. For patients with therapeutic hypothermia we keep the level > 2.5 mmol/l and supplete to 3.0 mmol/l if they are having unstable rhythms (any higher and they need an MD order).

Sometimes when my patients receive a lot of potassium suppletion I'll add MgSO4 to their suppletion (2g MgSO4 once) since it sometimes stop the potassium depletion in patients (a trick I picked up from an MD at work).

So as you can see we are free to choose how to replace potassium and magnesium in our patients and our MD's sign off on it. But to make it easier for our new nurses to work with we came up with the above schedule.

[umcRN, BSN, RN]

I work in a pediatric CICU. All our post op pts have mag, Ca & K replacement orders. We keep K >3.5, ionized calcium >2 and Mag >2. Typically mag only gets checked/replaced once per shift, it gets checked with morning labs. If an adjustment is made in the TPN that new TPN won't arrive until 6 or 7 that night so it's not usually an issue. K/Ca on the other hand we can check on our iStats. We have a policy to recheck K and Ca one hour after a bolus, we also have PRN orders to check all lytes so we are covered if we want to check them for any reason. Typically, especially if a kiddo is on a lasix drip, most nurses will check the K at least twice per shift and more often if we are replacing it.

[umcRN, BSN, RN]

I work in a pediatric CICU. All our post op pts have mag, Ca & K replacement orders. We keep K >3.5, ionized calcium >2 and Mag >2. Typically mag only gets checked/replaced once per shift, it gets checked with morning labs. If an adjustment is made in the TPN that new TPN won't arrive until 6 or 7 that night so it's not usually an issue. K/Ca on the other hand we can check on our iStats. We have a policy to recheck K and Ca one hour after a bolus, we also have PRN orders to check all lytes so we are covered if we want to check them for any reason. Typically, especially if a kiddo is on a lasix drip, most nurses will check the K at least twice per shift and more often if we are replacing it.

**edit: iCal >1

[turnforthenurse, MSN, NP]

Our hospitalists are usually pretty good with putting in the standing orders for K (IV & PO), Mg (IV) and Phos (IV) replacement protocols. Other docs (such as one cardiologist in particular) doesn't like them so we have to call him every time the K is low. It would be easier to just put the patient on a K replacement protocol or at least add some daily KCl supplements to their medication regimen, especially when the patient is on Lasix. -_-

But anyway, the protocols allow us to order the appropriate replacement depending on the patient's K, Mg or Phos level. For K & Mg, we can replacement is the Cr is 3 or less (actually for Mg I think it's 2 or less, but I can't remember off the top of my head at the moment). Typically our dialysis patients aren't on protocols and the nephrologists really only care if the K is high or REALLY low.

[Sugarcoma, RN]

I really like the idea of having the protocol address the patient's CR level. Our protocol does not address specific types of patient's. We keep K+ above 4 and Mag above 2. I also really like the idea of having K and mag free TPN if the patient is on the protocol.

I did send another email to my manager for clarification and she told me that as a rule she felt we should hold off replacement for dialysis and TPN pt.s unless the levels were very low so this is what I will continue to do. Unfortunately it is very hard to get a hold of a doc on nights, they usually do not return the calls. Our fellows will not handle orders for certain doctor's pt.s so day-shift gets stuck sorting it all out.

[sonja77]

We have K replacement protocol, but we can only use it if the pt's BUN and Creat are normal. So that would disqualify any HD patient right away.

[RNpatterson]

We have standing replacement protocol orders on nearly every one of our patients. Like most posts, we do not replace HD patients but do check levels every AM. However, we also do CRRT on my unit and we DO replace and have a special order set for them. I'm not too sure about the TPN. As far as I can remember, we still replace 'lytes on TPN patients but that would be a good question for your manager or someone seasoned on the unit.

[tracylen]

Our K protocol is adjusted in the orders based on creatinine levels. I think you need to take in account all facts per individual patients before given electrolyte replacement. Magnesium does not have a protocol on our unit for our s/p CABG. The patients under the care of our critical docs have replacement criteria for everything. I feel that if you are ever questioning giving a dose, call the MD and ask for parameters related to creatinine level. As far as TPN goes call the pharmacist who mixes and ask about replacement. There is no wrong answer. If the patient is on diuretics than K may need to be replaced. We check one hour after infusion is complete. For HD patients, the electrolytes are usually replaced by HD Rn and MD. Hope this helps... Ask your coworkers, it is always good to get a consensus.