Potassium, Phosphate, and Acid-Base Management

• Replacement is required (A).
• Replacement therapy should be based on serum potassium measurements (E).
• Start potassium replacement immediately if the patient is hypokalemic; otherwise, start potassium concurrent with starting insulin therapy. If the patient is hyperkalemic, defer potassium until urine output is documented (E).
• Starting potassium concentration in the infusate should be 40 mmol/L (E), and potassium replacement should continue throughout IV fluid therapy (E).
• There is no evidence that replacement has clinical benefit (A). Severe hypophosphatemia should be treated (C).
• Potassium phosphate salts may be used as an alternative to or combined with potassium chloride/acetate (C).
• Administration of phosphate may induce hypocalcemia (C).
Acid base
• Other acute resuscitation protocols no longer recommend bicarbonate administration unless the acidosis is “profound” and “likely to affect the action of adrenaline/epinephrine during resuscitation” (A).
• Fluid and insulin replacement without bicarbonate administration corrects ketoacidosis (A).
• Data show that treatment with bicarbonate confers no clinical benefit (B).
• Repair fluids containing various buffering agents (bicarbonate, acetate, and lactate) have been used (C). The efficacy and safety of these agents have not been established.