PHARMACY GUIDELINES

Adult Intravenous Phosphorus Replacement Therapy

General Information:
• Reference Phosphorus Levels:
Serum phosphorus: 0.87-1.45 mmol/L or 2.7-4.5 mg/dL
• Formulary IV Phosphorus Preparations:
1 mEq of Phosphorus = 0.33 mmol
Phosphorus (mg/dL) x 0.32 = Phosphorus (mmol/L)
1 mmol Phosphate = 31 mg elemental phosphorus

Phosphate Salt Phosphate Content Sodium Content Potassium Content

Sodium Phosphate 3 mmol/mL 4 mmol/mL 0
Potassium Phosphate 3 mmol/mL 4.4 mmol/mL
Hypophosphatemia: Can be divided into mild-moderate hypophosphatemia (Serum level ≥
0.32 mmol/L and < 0.87 [≥ 1 mg/dL and < 2.5 mg/dL]) or severe hypophosphatemia (Serum
level < 0.32 mmol/L [1 mg/dL]). If physician order did not state the salt of phosphate to be
used, sodium phosphate would be used as default and 0.9% sodium chloride solution would
be used as the default diluent.
Intravenous Phosphorus Replacement (Intermittent Infusion):
Serum Phosphorus Replacement Guidelines
0.32-0.87 mmol/L (Mild-Moderate) Phosphorus 0.16-0.32 mmol/kg over 3 hours (round off
to the nearest 1.5 mmol of PO4), diluted in 100 mL of
0.9% sodium chloride.
< 0.32 mmol/L (Severe) Phosphorus 0.32-0.64 mmol/kg over 3 hours (round off
to the nearest 3 mmol of PO4), diluted in 100 mL of
0.9% sodium chloride. Maximum daily dose 45 mmol
(doses above 30 mmol requires cardiac monitoring).
Dilution & Infusion Rate:
• Bolus doses should be administered via IV pump
• Bolus doses should not be infused in the same lumen as calcium or TPN.
• For potassium phosphate orders, central or peripheral administration must be
specified. If not specified, the peripheral concentration will be dispensed.
• For sodium phosphate, identification of access is not required.
• Maximum rate of administration for both potassium and sodium phosphate is 7.5
mmol phosphorus/hr
• Maximum concentration of potassium phosphate for central administration is 0.3
mmol phosphorus/mL (i.e. 30 mmol of phosphorus [44 mmol of potassium] /100 mL)
• Maximum concentration of potassium phosphate for peripheral administration is 0.06
mmol phosphorus/mL (i.e. 15 mmol of phosphorus [22 mmol of potassium] /250 mL)
• Maximum concentration of sodium phosphate is 0.3 mmol phosphorus/mL (i.e. 30
mmol of phosphorus/100 mL)
• ICU standard Concentrations:
1. 15 mmol sodium phosphate in 100 mL 0.9% sodium chloride over 4 hours
2. 20 mmol sodium phosphate in 100 mL 0.9% sodium chloride over 4 hours
3. 30 mmol sodium phosphate in 100 mL 0.9% sodium chloride over 6 hours
Precautions:
• Patients with renal failure: dose phosphate judiciously (or even do not give)
• Obese patients: calculate the dose based on ideal body weight.
 • Potassium or sodium overload may occur, depending on the used salt.
• To avoid soft tissue (metastatic) calcification with symptomatic hypocalcaemia,
serum calcium multiplied by serum phosphorus (in SI units) should not exceed 5.
• Administer dextrose conservatively until phosphorus levels normalize. (Glucose
stimulates insulin secretion, increasing phosphorus consumption for ATP-dependent
processes.
Monitoring:
• Serum phosphorus levels should be checked after bolus dose is given. Peak levels (1-
2 hours after bolus) will provide closer monitoring in cases of severe
hypophosphatemia.
• If after bolus serum level is < 0.7 mmol/L, the dose should be repeated.
• Monitor serum calcium, potassium, phosphorus, and magnesium daily during
phosphate replacement.
• Among complications associated with IV phosphorus blousing; hyperphosphatemia,
metastatic calcification, hypocalcaemia, hypocalcemic tetany, hypotension, and
hyperkalemia.
References:

1. Guidelines for Phosphorus Replacement, King Faisal Specialist Hospital & Research
Center
2. Hypophosphatemia in Adults: Potassium and Sodium Phosphate Treatment
Guidelines, Kingston General Hospital, Ontario-Canada;
http://www.kgh.on.ca/pharmacy/Guidelines.pdf
3. Guidelines for Phosphorus Replacement in Adults, Medical University of South
Carolina Pharmacy Services:
www.musc.edu/pharmacyservices/medusepol/Adult_Phosphorus_Guidelines.pdf
4. Phosphorus Administration Guidelines, Massachusetts General Hospital, Department
of Pharmacy & Department of Nursing Critical Care:
http://www.massgeneral.org/pharmacy/icu%20Guidelines/PHOSPHORUS_new.htm
5. Potassium and Sodium Phosphate-IV Dilution, GlobalRPh Inc.
http://www.globalrph.com/calcium_dilution.htm
6. Electrolyte Replacement Protocol, Oregon Health & Science University
www.ohsu.edu/medicine/residency/handouts/pharmpearls/Nephrology/ElectrolyteRe
placementProtocol.pdf
7. Adult Electrolyte Replacement Protocols;
www.surgicalcriticalcare.net/Guidelines/electrolyte_replacement.pdf
8. Monitored Unit Electrolyte Replacement Protocols;
www.emcrit.org/misc/electrolyte_replacement.pdf
9. Electrolyte Infusion Guidelines at University of Kentucky Hospital;
http://www.hosp.uky.edu/Pharmacy/formulary/criteria/electrolyte.htm