CRRT, TPN and Phos

Discussion in 'Pharmacy' started by VCU07, 09.27.14.

  1. SDN is made possible through member donations, sponsorships, and our volunteers. Learn about SDN's nonprofit mission.
  1. VCU07

    VCU07 Member 10+ Year Member

    Joined:
    02.21.04
    Messages:
    731
    For this of you who manage critical care pts, what's the most phos you have put in a TPN for a CRRT pt? Got a level <0.5 with 60mmole naphos in tpn and that's after an additional 45mmole bolus. Thanks
     
  2. SDN Members don't see this ad. About the ads.
  3. njac

    njac Senior Member 10+ Year Member

    Joined:
    03.20.05
    Messages:
    10,967
    Location:
    Now headed all the way west!
    Status:
    Pharmacist

    Wayyyy back in residency I had an HD or on TPN whose phos we couldn't get over 0.7.

    We ended up pouring fleets phosphosoda in the HD bath.

    CRRT though. Does the patient have any functioning enteral access?
     
  4. VCU07

    VCU07 Member 10+ Year Member

    Joined:
    02.21.04
    Messages:
    731
    Unfortunately, no enteral access. It always freaks me out to use extremely high doses of electrolytes in parenteral nutrition. May need consider phos in the crrt fluids. Thanks
     
  5. njac

    njac Senior Member 10+ Year Member

    Joined:
    03.20.05
    Messages:
    10,967
    Location:
    Now headed all the way west!
    Status:
    Pharmacist
    Any chance you can get Q12H chemistries and maybe run a separate "electrolyte bag" so you wouldn't have to waste an entire TPN when they turn around?

    Phos is a tough one, for multiple reasons.
     
    VCU07 likes this.
  6. VCU07

    VCU07 Member 10+ Year Member

    Joined:
    02.21.04
    Messages:
    731
    I thought about an electrolyte bag too. I don't see this pt. Coming off crrt any time soon. In fact, she continues to deteriorate. I'm trying not to give out too much info for privacy regulation. Got q12 chemestries and a prn phos in place.
     
  7. Eugenia

    Eugenia 7+ Year Member

    Joined:
    03.08.09
    Messages:
    7
    Status:
    Pharmacist
    I always thought HD does NOT remove phos unlike CVVH which does remove phos.
    Can somebody comment on that?
     
    Last edited: 09.27.14
  8. PharmDstudent

    PharmDstudent 7+ Year Member

    Joined:
    01.08.07
    Messages:
    4,342
    Status:
    Pre-Health (Field Undecided)
    How are the na and k levels looking? What about increasing phos by adding and then adjusting kphos in addition to having naphos? What about chloride levels? Can you ditch kcl for kphos or more naphos for nacl? Does she have calcium and an acetate in the TPN? (Remember that Phoslo is calcium acetate.)
     
  9. njac

    njac Senior Member 10+ Year Member

    Joined:
    03.20.05
    Messages:
    10,967
    Location:
    Now headed all the way west!
    Status:
    Pharmacist
    My understanding was that because the vast vast majority of phos is intracellular, you don't see a significant removal on labs with HD because you will have extra cellular movement.

    Versus with CRRT, because you're not stopping it, you don't measure this same equilibrium, and it's a more consistent removal and extra cellular flow.

    My severely hypophosphatemic lady definitely had a total body deficiency, she was another with a multitude of issues, medical and surgical.
     
  10. VCU07

    VCU07 Member 10+ Year Member

    Joined:
    02.21.04
    Messages:
    731
    I already have 60mmoles of phos in the tpn....no nacl or kcl. I also bolused her with another 45mmole. She's had a total of 105mmoles daily for the past two days (210mmoles total). I've never given a pt this much phos for the level to go down even further! I may be taking njacs advice and see if we can add fleets to dialysate.
     
  11. Eugenia

    Eugenia 7+ Year Member

    Joined:
    03.08.09
    Messages:
    7
    Status:
    Pharmacist
    NJAC, thank you for clarification.

    At our institution we never add phos to dialysate bath.
    I have never seen kphos/naphos given as a bolus either
    We are only allowed to dispense 15-30 mmol/250 NS IV run over 4-6 hrs as per hospital policy.
     
  12. njac

    njac Senior Member 10+ Year Member

    Joined:
    03.20.05
    Messages:
    10,967
    Location:
    Now headed all the way west!
    Status:
    Pharmacist
    It's incredibly rare for a patient with renal dysfunction to be hypophosphatemic, we're usually fighting the other direction.

    The phosphosoda in dialysis bath was an out of the box suggestion (can't remember whose idea it was in the end) that ended up working.

    You are correct that phos isn't "bolused" per se, the administration that you described is the usual manner that supplementation is given. Even with NaPhos, it is usually given ~30mmol/6hr. I think the "bolus" term was used to describe a one time supplemental dose, vs existing phos running continuously via TPN.
     
  13. VCU07

    VCU07 Member 10+ Year Member

    Joined:
    02.21.04
    Messages:
    731
    Yes, the word bolus in this case was meant to denote an exogenous source outside the tpn. In terms of the phos, it recovered to 2.2 the next day. New challenges now exist as the pt is being switched to HD. Thanks guys
     
  14. KidPharmD

    KidPharmD Pediatric Pharmacist 2+ Year Member

    Joined:
    01.21.14
    Messages:
    327
    Status:
    Pharmacist
    Verified
    Pharmacist
    Verified
    Faculty
    Just as a note. (Glad you found a solution) In my expierence with TPN and CRRT of any kind, if the CRRT is having a profound effect on an electrolyte, the effect is usually too great to be controlled with TPN. We always give supplement outside the TPN or adjust the Dialysate/Replacement fluid.
     
  15. Dred Pirate

    Dred Pirate 2+ Year Member

    Joined:
    01.18.14
    Messages:
    1,486
    Status:
    Pharmacist
    same here, usually the crrt fluid is best to control electrolytes.

    If you have issues with Na or K, does your institution use glycophos?
     

About the ads

Similar Threads
  1. braingel
    Replies:
    12
    Views:
    5,615
  2. dudek1984
    Replies:
    2
    Views:
    1,079
  3. DrDawg
    Replies:
    1
    Views:
    1,741
  4. PharmDstudent
    Replies:
    8
    Views:
    1,733
  5. moto_za
    Replies:
    4
    Views:
    983
Loading...

Share This Page