Hypomagnesaemia

Oral route is preferred first line for patients with serum magnesium between 0.4mmol/L and
0.7mmol/L as up to 50% of an IV dose may be excreted renally due to rapid rises in serum magnesium
partially removing the stimulus for magnesium uptake in the body.

Renal Impairment: Magnesium is renally excreted, reduce doses by 50% in patients with CrCl
<30ml/min

Grade 1: Mild (0.5- Grade 2: Moderate (0.4- Grade 3 and 4: Severe

0.7mmol/L 0.5mmol/L (<0.4mmol/L
NB: Only replace if patient
is symptomatic

1st Line Oral: Oral: Day 1 - IV:

Magnesium Magnesium Magnesium Sulphate

Glycerophosphate 8mmol Glycerophosphate 8mmol 40mmol in 500mL
(2 x 4mmol tabs) three (2 x 4mmol tabs) three Glucose 5% (preferred)
times a day. times a day. Treatment or Sodium Chloride 0.9%
normally required for at over 12 hours.
least 5 days as plasma (Maximum 40mmol daily)
magnesium levels may be
artificially high while Day 2-5 - IV:
magnesium equilibrates
Magnesium Sulphate
with intracellular
20mmol in 500ml
compartment.
Glucose 5% (preferred)
or Sodium Chloride 0.9%
over 6 hours. (Maximum
20mmol daily)

2nd Line IV: IV:

(e.g
where Magnesium Sulphate Magnesium Sulphate
oral 10mmol in 250mL Glucose 20mmol in 500mL Glucose
treatment 5% (preferred) or Sodium 5% (preferred) or Sodium
is not Chloride 0.9% over 3 hours Chloride 0.9% over 6 hours.
possible Treatment normally
or not required over 5 days
tolerated) (maximum 20mmol daily)

Fluid restricted patients –

IV:

Magnesium Sulphate
20mmol in 50mL Glucose
5% over at least 5 hours
(max rate 4mmol/hr)
Notes: Magnesium Sulphate has a high osmolarity and can cause tissue damage if it extravasates.
Maximum concentration for peripheral IV infusion is 0.8mmol/mL (20%) using a large peripheral vein.

In fluid restricted patients, Magnesium Sulphate 20mmol can be given in 50mL Glucose 5% over at
least 5 hours (max rate 4mmol/hr). Ideally this should be given via a central line, but if not available
give via the largest peripheral vein possible due to the risk of phlebitis and extravasation.

The absolute maximum infusion rate of Magnesium Sulphate is 36mmol/hr, but ideally do not exceed
4mmol per hour as more rapid infusion rates are associated with increased risks of phlebitis,
hypocalcaemia and hypotension.

10mmol Magnesium = 5ml Magnesium Sulphate 50% Injection

Monitoring:

Magnesium levels should be monitored daily during replacement. Calcium and Potassium levels
should also be measured daily due to impact magnesium supplementation can have on their levels.

Patients receiving IV infusion of Magnesium should have heart rate, blood pressure, respiratory rate
and urinary output monitored during infusion.

References:
UKMi 2017 How is acute hypomagnesaemia treated
Nottingham University Hospitals Hypomagnesaemia Guideline
Oxford University Hospitals Management of Hypomagnesaemia in Haematology Patients
 Hyponatraemia
Treatment only required for symptomatic patients with a serum sodium <130mmol/L or
asymptomatic patients with significant hyponatraemia <125mmol/L

The rate of correction of hyponatraemia should generally be a rise of 6-9mmol/L/24 hours, never
exceeding 12mmol/L/24 hours due to the risk of sudden osmotic shift and demyelination

Hypovolaemic Euvolaemic Hypervolaemic

Look for: Check: Look for:

History of diarrhoea TSH Oedema

Diuretic use 9am Cortisol Raised JVP
Tachycardia Paired serum and urine osmolality Ascites
Postural hypotension Renal function Coarse crackles on lung
Reduced skin turgor base
Dry membranes

Treatment: SIADH (Urine Other causes (e.g Treatment:

osmolality >100 osm/kg, severe
Stop relevant drugs serum osmolality <275 hypothyroidism, Treat underlying cause
osm/kg: adrenal insufficiency,
Restore fluid volume Fluid and salt restriction
CKD)
with 0.9% Sodium Treatment:
Chloride infusion Treatment:
Stop offending drugs
Treat underlying cause
Fluid restriction to
1L/day - may need to Fluid restriction to
reduce to 750mL/day 1L/day - may need to
reduce to 750mL/day

2nd Line:

If no response in 48
hours (Na <125mmol/L)
refer to endocrine team
for consideration of
Demeclocycline 150mg
QDS and titrate every 3-
4 days

Or

Tolvaptan - only on
consultant
endocrinologist advice,
requires non-formulary
application
Acute onset (<48 hours), life threatening hyponatraemia with fitting or other neurological deficits:

This is a medical emergency and consideration should be given to admission of patient to HDU/ITU.

If patient has seizures or a decrease in consciousness level:

IV bolus of 100mL 1.8% Sodium Chloride given through and infusion pump over 30 minutes - ONLY
IN AN HDU SETTING WITH FREQUENT SODIUM MONITORING

The aim of this would be to stop patient fitting and raise serum sodium by 1-2mmol/L in first 2 hours.
Within the first 24 hours, the aim is still to increase sodium by 6-9mmol/L and never exceeding
12mmol/L in 24 hours.

References:
Inpatient Management of Hyponatraemia
Norfolk and Norwich University Hospitals Hyponatraemia in Adults Guideline
Nottingham University Hospitals Hyponatraemia in Adults Guideline
 Hypernatraemia
Sodium excess is usually caused by renal failure or drug therapy. Other causes of hypernatraemia
include diarrhoea, vomiting, burns, sweating, diabetes insipidus, osmotic diuresis, primary
hyperaldosteronism. Treatment depends on the underlying cause and whether there is overall fluid
depletion or sodium excess. Efforts should be made to identify and rectify the underlying cause.

NOTE: If a patient’s sodium level is above 160mmol/L, the patient MUST be reviewed by a
consultant

Calculation of total body water (TBW) deficit:

Water deficit (L) = Current TBW x ( (Serum Sodium - 140) / 140)

Current TBW:
Young men: 60% actual body weight (kg)
Young women: 50% actual body weight (kg)
Elderly men: 50% actual body weight (kg)
Elderly women: 45% actual body weight (kg)

This formula gives an estimate of the volume of additional fluid required to correct the serum sodium
concentration to 140mmol/L.

1st Line: Replace water enterally where possible.

2nd Line: In severe cases, or if the patient is nil by mouth, IV glucose 5% may be used. 0.9% Sodium
Chloride should only be used in cases where patients are severely haemodynamically compromised.

Total water deficit may exceed 5L, this should be corrected over 2 to 3 days (monitor sodium regularly
and make sure sodium levels are not corrected too quickly). In diabetes insipidus, treatment with
desmopressin may be needed. This should be initiated by a consultant only. Over rapid correction of
hypernatraemia may rarely lead to central pontine myelinolysis. Serum sodium should be checked
every 4 hours when correcting sodium levels. Central nervous system observations should also be
carried out.

NOTE: The maximum recommended reduction in serum sodium concentration is 12mmol/L in 24

hours.

References:

Wirral University Teaching Hospital/CCG: Blood and Electrolyte, and vitamin deficiencies guideline
 Hypokalaemia
These guidelines are not suitable for treating hypokalaemia in diabetic ketoacidosis – see diabetic
ketoacidosis guidelines on the intranet

Oral replacement should be used first line for asymptomatic patients with serum potassium between
2.5mmol/L and 3.5mmol/L unless the patient is unable to take replacement orally. Intravenous
replacement should be reserved for patients with severe hypokalaemia <2.5mmol/L or symptomatic
patients.

Oral Replacement

Serum potassium concentrations Suggested oral replacement Suggested monitoring

3.0 - 3.5 mmol/L Sando-K® 2 tablets twice a Monitor serum potassium at least
day twice weekly until stable or >4.5
(mild hypokalaemia) mmol/L, then re-assess

2.5 - 2.9 mmol/L
(moderate hypokalaemia)
Sando-K® 2 tablets three
times a day
Monitor serum potassium daily until
>2.9 mmol/L then manage as for mild
hypokalaemia (above).
Check serum magnesium and replace
as per hypomagnesaemia guideline if
deficient.

Intravenous replacement

Serum potassium concentrations Suggested IV replacement Suggested monitoring

2.5-3.4 mmol/L 20 - 40 mmol potassium Monitor serum potassium after 24

chloride in 1 litre sodium hours and review accordingly. Repeat
(e.g. if patient unable to take chloride 0.9% over at least 8 infusion if appropriate. Switch to oral
potassium orally) hours. management as soon as practical.

< 2.5 mmol/L and/or patient
symptomatic
40 mmol potassium chloride
in 1 litre sodium chloride 0.9%
over 6 hours.
Monitor serum potassium
concentration after 6 hours and
repeat infusion if appropriate.
Check serum magnesium and replace
as per hypomagnesaemia guideline if
deficient.
Maximum infusion rate:
Occasionally Potassium may need be infused at a faster than the rates outlined above. The following
rates should not be exceeded:

General Wards: The rate of Potassium infusion must not exceed 10mmol/hour

ACU, HDU and ITU: The rate of infusion must not exceed 20mmol/hour. ECG monitoring is required
for rates of infusion above 10mmol/hour.

Fluid restricted patients:

Peripheral infusion - The maximum concentration of Potassium Chloride that can be infused is
80mmol/L. This preparation is not routinely available in the Trust and must either be
extemporaneously produced by the Pharmacy Aseptic unit or by addition of Potassium Chloride to the
standard preparations - THIS MAY ONLY BE DONE ON THE INTENSIVE CARE UNIT. Infusions above a
concentration of 40mmol/L are painful and can cause significant phlebitis - use the largest peripheral
vein possible and carefully monitor the infusion site.

Central line infusion - There is no maximum concentration for central line infusion and neat Potassium
Chloride can be used if clinically indicated. The maximum rate of infusion is still 10-20mmol/hour.

Notes:
Hypokalaemic patients, particularly those with severe hypokalaemia, should have their magnesium
levels checked and replenished if deficient. Magnesium is involved in the transport of Potassium in
and out of cells within the body and hypokalaemia can be refractory to treatment with Potassium
supplementation until the magnesium deficiency is corrected.

References:

How is hypokalaemia treated in adults? UKMi 2017

Blood and electrolyte disorders, and vitamin deficiencies. Wirral University Hospital/CCG.
Hyperkalaemia

These treatment guidelines are suitable for the treatment of acute hypocalcaemia only, not
Adjusted serum calcium
>1.9 - <2.12 - asymptomatic
>1.9 - <2.12 - symptomatic and
<1.9
References:
How is acute hypocalcaemia treated in adults? UKMi 2017
BNF Online accessed 08/04/2019
Acute Treatment of hypocalcaemia (adults) Gloucstershire Hospitals NHS Trust
Hypocalcaemia
chronic hypocalcaemia
Treatment
Oral:
Calci-D 1 tablet BD.
10ml Calcium Gluconate 10% in
100mL Sodium Chloride 0.9%
or Glucose 5% over 10-20
minutes.
Can be given as slow IV
injection over 3 minutes in
emergencies but ECG
monitoring required
Monitoring
Weekly initially, then re-check
every 3-6 months once stable.
Titrate Calci-D dose to 1 OD
once serum adjusted calcium is
in normal range and titrate
further/stop depending on the
results of further results.
Monitor serum adjusted
calcium after 1-2 hours. Repeat
treatment dose may be given
but if patient symptomatic then
often infusion is required to
prevent recurrence. This should
be given as:
100ml Calcium Gluconate 10%
in 1 litre Sodium Chloride 0.9%
or Glucose 5%. Initial rate
should be 50ml/hr, adjusted
according to response. Serum
adjusted calcium levels should
be monitored every 4-6 hours.
 Hypercalcaemia
Primary hyperparathyroidism and malignancy are responsible for 90% of cases of hypercalcaemia.
Primary hyperparathyroidism normally presents with mild chronic elevations of calcium whereas
malignant causes often have acute, severe raises in calcium with serum adjusted calcium levels >3.0.

All patients presenting with hypercalcaemia should have their parathyroid hormone (PTH) levels
checked to aid in diagnosis of the underlying cause, unless the patient has a known malignancy with
accompanying severe increases in serum adjusted calcium.

Serum Adjusted Calcium Treatment Monitoring

<3.0 Does not normally require Re-check U+E’s and serum

treatment. Encourage fluid adjusted calcium after 24 hours.
intake. If patient is vomiting and If stable or decreasing, re-check
oral intake not possible, IV weekly until normalised. If
rehydration may be considered. rapidly increasing, treat and
monitor as per new serum
Discontinue medications which adjusted calcium result.
may worsen hypercalcaemia
(e.g Thiazide diuretics,
Tamoxifen, Lithium,
Calcium/Vitamin D
preparations)

3.0-3.5 Discontinue medications which U+E’s and serum adjusted

may contribute or worsen calcium after 24 hours of IV
hypercalcaemia. rehydration.

Rehydration with 4-6 litres 0.9% Normalisation of calcium

Sodium Chloride over 24 hours
If serum adjusted calcium
still >3.0 after 24 hours, give
Zoledronic Acid 4mg IV in 100ml
0.9% Sodium Chloride over 15
minutes
usually occurs 4-7 days after
administration of
bisphosphonate. Re-checking
serum adjusted calcium before
this is not indicated.

>3.5 Discontinue medications which Daily U+E’s and serum adjusted

may contribute or worsen calcium.
hypercalcaemia.
Normalisation of calcium
Rehydration with 4-6 litres 0.9% usually occurs 4-7 days after
Sodium Chloride over 24 hours administration of
followed by Zoledronic Acid bisphosphonate.
4mg IV in 100ml 0.9% Sodium
Chloride over 15 minutes.
Second Line Treatments:

Prednisolone 40mg OD - may be considered in patients with overdoses of

Colecalciferol/hypervitaminosis D and granulomatous disease (such as sarcoidosis). Usually effective
within 2-4 days.

Calcitonin - may be considered if poor response to bisphosphonate or in cases of severe

hypercalcaemia where an immediate response is required. Calcitonin normally causes a rapid reponse
in serum adjusted calcium but this is short live (~2 days). Consultant initiation only

Renal Impairment:
No dosage adjustment of Zoledronic Acid is required in patients with a serum creatinine
<400micromol/L, although the relative risks should be balanced against the benefits of giving
Zoledronic Acid in patients with renal impairment. Zoledronic Acid is contraindicated in patients with
a serum creatinine >400micromol/L and these patients should be discussed with the renal unit.

Reference:

Zoledronic Acid (Zometa) SPC

Society for Endocrinology Emergency Endocrine Guidance: Acute Hypercalcaemia
West Cheshire CCG - Hypercalcaemia - Guidelines for Management