kg
yr
TBW: --
Renal: --
Albumin: --
1. Electrolytes & Renal Chem-8
2. Minerals & Blood Gas ABG / VBG
3. Osmolality & Urine Excretion
🔵 PART A: HYPONATREMIA MANAGEMENT (Na⁺ < 135 mEq/L) 2026 ESE / ERBP Guidelines
1. Hyperglycemia-Corrected Sodium (Pseudohyponatremia from Glucose Shift) Hillier & Katz Models
Presets:
Presets:
Corrected Na⁺ (Hillier 2.4/2.0 factor): -- mEq/L
Katz (1.6 factor): -- mEq/L
🚨 Severe Symptomatic Hyponatremia (Herniation / Seizures / Coma)
2026 Consensus Protocol: For active seizures, coma, GCS < 8, or signs of herniation: DO NOT use slow infusion formulas. Give fixed 3% NaCl bolus to raise Na⁺ acutely by +4 to +6 mEq/L, then stop immediately.
Initial 3% NaCl Bolus
Infuse over 10-20 minutes
100 - 150 mL
  • Recheck serum Na⁺ 20 minutes post-infusion.
  • Repeat up to 2 times (total 3 boluses) if severe neurological symptoms persist.
  • Target acute increase: +4 to +6 mEq/L.
  • 24-Hour Safety Ceiling: Maximum 8 mEq/L in 24 hours (4-6 mEq/L if high ODS risk: cirrhosis, malnutrition, alcoholism, Na < 105).
Adrogué-Madias Formula (Slow Infusion Planning)
Expected ΔNa⁺ per 1L Fluid
(Infusate Na - Serum Na) / (TBW + 1)
-- mEq/L
Calculated Infusion Rate: -- mL/hr
🔴 PART B: HYPERNATREMIA MANAGEMENT (Na⁺ > 145 mEq/L)
Hypernatremia & Free Water Deficit (FWD) Target Na⁺: 140 mEq/L
Presets:
Total Free Water Deficit
TBW × [(Na / 140) - 1]
-- L
Safe Correction Ceiling: Decrease serum Na⁺ by ≤ 10 mEq/L in 24 hours (approx. 0.5 mEq/L/hr) to prevent cerebral edema. Initial D5W infusion: -- mL/hr (+ replace ongoing water losses). Enteral water via NG tube is preferred if gut is functional.
🔴 PART A: HYPERKALEMIA MANAGEMENT (K⁺ > 5.0 mEq/L)
1. Emergency Hyperkalemia Protocol ("C-BIG-K-Drop") — K⁺ ≥ 6.5 or ECG Changes
2026 Toxicology Recheck ("Stone Heart" Debunked): IV Calcium Gluconate is SAFE and must NOT be withheld in hyperkalemic cardiac instability even if the patient is on Digoxin.
1. Membrane Stabilization (Immediate)

• 10% Calcium Gluconate 10-20 mL IV over 2-5 min (or 10% Calcium Chloride 5-10 mL central/arrest). Onset: 1-3 min, duration: 30-60 min.

2. Intracellular Shifting (Rapid)

• Regular Insulin 10 units IV + D50W 50 mL (25g) over 5 min.
• Salbutamol 10-20 mg nebulized.
• 7.5% NaHCO₃ 50-100 mL (44.6-89.2 mEq) [TH] or 8.4% NaHCO₃ 50-100 mEq (if pH < 7.20).

3. Elimination (Definitive)

• Furosemide 40-80 mg IV.
• Lokelma (SZC) 10g PO TID (Avoid Kayexalate/SPS due to colonic necrosis).
• Emergent Hemodialysis if refractory.

2. General / Non-Emergent Hyperkalemia Management (K⁺ 5.5 - 6.4 mEq/L without ECG changes)
1. Stop Offending Agents:
Discontinue ACEi, ARB, MRA (Spironolactone), NSAIDs, Trimethoprim, Calcineurin inhibitors, and K⁺ supplements.
2. Dietary & Glycemic Control:
Strict low-K⁺ diet (< 2-3 g/day). Administer subcutaneous insulin if patient is hyperglycemic.
3. Kaliuretic Diuretics:
Furosemide 40 - 80 mg PO/IV to enhance renal potassium excretion (ensure adequate volume status).
4. Novel K⁺ Binders:
Sodium Zirconium Cyclosilicate (Lokelma / SZC) 10g PO TID for 24-48h, then 5-10g daily. Avoid SPS.
🔵 PART B: HYPOKALEMIA MANAGEMENT & IV DRIP CALCULATOR (K⁺ < 3.5 mEq/L)
Hypokalemia Deficit & The ROMK Magnesium Gate
Presets:
Estimated Total Body Deficit
--
-- mEq
The ROMK Lock: Hypomagnesemia disables the ATP-dependent block on ROMK channels, causing uncontrolled renal K⁺ wasting. Always check and correct Mg²⁺ concurrently!
IV Potassium Drip Auto-Generator
Delivered K⁺ Rate & Duration
10.0 hours per 1,000 mL bottle
4.0 mEq/hr
✓ Parameters within safe clinical limits for Peripheral line.
Bicarbonate Deficit & Dosing Planner f_VD: 0.5 (Std) / 0.8 (Severe)
Presets:
Calculated Total Body Deficit
--
-- mEq
⚡ Acute / Slow IV Push (Undiluted in Emergencies):

Give 1 - 2 ampules (50 - 100 mL = 44.6 - 89.2 mEq of 7.5% NaHCO₃) slow IV push over 2 - 5 min for acute severe instability.

💧 Isotonic Continuous Infusion Recipe (~150 mEq/L): 7.5% GPO

Add 3.5 ampules (175 mL = 156 mEq) of 7.5% NaHCO₃ into 825-850 mL D5W (or 2 ampules in 400-500 mL D5W) to yield ~150 mEq/L. Infuse at 100 - 250 mL/hr.

Evidence-Based Indication Filter & BICAR-ICU
BICAR-ICU Landmark Evidence (Lancet 2018): In severe acidemia (pH ≤ 7.20) with AKI Stage 2-3 (n=182), NaHCO₃ infusion significantly reduced 28-day mortality from 63% to 46% (p=0.0283, ARR 17%, NNT=6), reduced RRT requirement from 73% to 51% (p=0.002, ARR 22%, NNT=5), and increased RRT-free days to 24 vs 20 days (p=0.006).
🚨 Emergent Indications for Renal Replacement Therapy (RRT / Dialysis) — "AEIOU" Criteria
A - Acidemia: Severe metabolic acidosis (pH < 7.15 - 7.20) refractory to medical treatment.
E - Electrolytes: Severe hyperkalemia (K⁺ > 6.5 mEq/L or ECG changes) unresponsive to shifting/binders.
I - Ingestions: Toxic alcohols (Methanol, Ethylene glycol), Salicylate (> 100 mg/dL), Lithium, Theophylline.
O - Overload: Acute pulmonary edema / severe volume overload refractory to diuretics.
U - Uremia: Uremic encephalopathy, pericarditis, pleuritis, or uremic bleeding (BUN > 100 mg/dL).
⚠️ 5 Critical Hazards of IV Sodium Bicarbonate
🧠 1. Paradoxical CNS Acidosis

CO₂ crosses BBB rapidly while HCO₃⁻ crosses slowly, worsening intracellular acidosis if hypoventilating.

⚡ 2. Acute Severe Hypokalemia

Alkalinization drives K⁺ rapidly into cells, precipitating fatal cardiac arrhythmias. Keep K⁺ > 4.0.

🦴 3. Ionized Hypocalcemia

Higher pH increases calcium binding to albumin, sharply dropping ionized Ca²⁺ and depressing cardiac inotropy.

🌊 4. Hyperosmolar Overload

7.5% (1,785 mOsm/L) and 8.4% (2,000 mOsm/L) carry heavy sodium loads; can cause pulmonary edema.

🩸 5. Impaired O₂ Delivery

Alkalemia shifts the oxyhemoglobin curve to the left (decreases P50), impairing oxygen unloading to ischemic tissues.

IFCC/IOF/EFLM 2026 & KDIGO Consensus: Albumin-corrected calcium (Payne formula) has a 20-40% error rate. Direct Ionized Calcium (iCa²⁺ via blood gas) is the sole reliable critical care standard.
🦴 1. Calcium (Ca²⁺) Assessment
Presets:
Calcium Status
Enter lab values
--
Clinical Action:

Enter Direct Ionized Calcium or Total Calcium to see real-time clinical protocol.

⚡ 2. Magnesium (Mg²⁺) Assessment
Presets:
Magnesium Status
Enter lab values
--
Clinical Action:

Enter Serum Magnesium to calculate infusion rate and dosing.

🧪 3. Phosphate (PO₄³⁻) Assessment
Presets:
Phosphate Status
Enter lab values
--
Precipitation Gate: Ca × PO₄ = --

Enter PO₄ to evaluate precipitation gate and weight-adjusted dose.

Modern ISE Anion Gap & Delta-Delta Ratio
Albumin-Corrected Anion Gap
--
-- mEq/L
Delta-Delta Ratio (ΔAG / ΔHCO₃): --

Enter Na⁺, Cl⁻, and HCO₃⁻ to calculate Delta-Delta ratio.

Osmolar Gap & Urine Gaps
Serum Osmolar Gap
Normal ≤ 10 mOsm/kg
-- mOsm
Urine Anion Gap (UAG = U_Na + U_K - U_Cl):

Enter Urine Na⁺, K⁺, and Cl⁻ to calculate Urine Anion Gap.

🧪 Fractional Excretions Suite (FE_Na, FE_Urea, FE_Urate, CCCR) KDIGO & Endocrine Society Reference
FE_Na (Sodium): -- %

Requires U_Na, S_Na, U_Cr, S_Cr

FE_Urea (Urea): -- %

Requires U_Urea, S_Urea, U_Cr, S_Cr

FE_Urate (SIADH vs CSW): -- %

Requires U_Urate, S_Urate, U_Cr, S_Cr

CCCR (Calcium Clearance): --

Requires U_Ca, S_Ca, U_Cr, S_Cr

💧 1. Hyponatremia Diagnostic Wizard

Step 1: Serum Tonicity

Step 2: Urine Osmolality

Step 3: Volume Status & Urine Na⁺

Etiology: Euvolemic Hyponatremia
SIADH (Malignancy, CNS, Pulmonary, SSRIs), Hypothyroidism, Secondary Adrenal Insufficiency.
🔥 2. Hypernatremia Diagnostic Wizard

Step 1: Urine Osmolality

Step 2: Desmopressin (DDAVP) Challenge Response

Etiology: Complete Central Diabetes Insipidus (CDI)
Neurosurgery, Pituitary lesion, Head trauma, Hypoxic injury. Treat with DDAVP + free water replacement.
⚡ 3. Hypokalemia Diagnostic Wizard (Spot U_K/U_Cr)

Step 1: Spot Urine K⁺/Cr Ratio (Replaces TTKG)

Step 2: Blood Pressure Status

Step 3: Acid-Base & Urine Chloride

Etiology: Chloride-Resistant Metabolic Alkalosis
Ongoing Diuretics, Gitelman Syndrome (Hypocalciuria), Bartter Syndrome (Hypercalciuria), Severe Hypomagnesemia.
⚡ 4. Hyperkalemia Diagnostic Wizard

Step 1: Artifact & Shift Screen

Step 2: Renal Function & Spot U_K/U_Cr

Etiology: Impaired Tubular K⁺ Secretion
Hypoaldosteronism (Type 4 RTA), RAAS inhibitors (ACEi, ARB, MRA), ENaC blockers (Trimethoprim), Calcineurin inhibitors.
🧪 5. Metabolic Acidosis Diagnostic Wizard

Step 1: Modern ISE Anion Gap

Step 2: Urine Anion Gap (UAG) & Urine pH

Etiology: High Anion Gap Metabolic Acidosis (HAGMA)
Lactic acidosis, Ketoacidosis (DKA/AKA), Uremia, Toxic alcohols (Methanol/Ethylene glycol), Salicylates.
🧪 6. Metabolic Alkalosis Diagnostic Wizard

Step 1: Urine Chloride (U_Cl)

Step 2: Blood Pressure & Volume

Etiology: Chloride-Responsive Metabolic Alkalosis
Vomiting, Nasogastric suction, Remote diuretics, Dehydration. Expand volume with 0.9% NaCl Normal Saline.
🦴 7. Calcium, Magnesium & Phosphate Diagnostic Wizard Interactive Decision Engine

Step 1: Primary Calcium Disorder

Step 2: Intact PTH (pg/mL)

Step 3: CCCR / Vitamin D

Etiology: Primary Hyperparathyroidism (PHPT)
Parathyroid Adenoma (85%), Hyperplasia (15%). Order Neck US / Sestamibi SPECT and refer for surgery.
Generated HIS Clinical Documentation (Smart Sparse Output)
📚 ข้อมูลอ้างอิงและแนวทางเวชปฏิบัติ (Electrolyte & Acid-Base Evidence & KDIGO/IFCC 2026) KDIGO 2024 / IFCC 2026 / BICAR-ICU / ADA 2024-2026
  • Direct Ionized Calcium Gold Standard (IFCC/KDIGO 2026): Payne total calcium correction formula carries a 20-40% error rate in hypoalbuminemia and critical illness. Direct Ionized Calcium (iCa²⁺ via point-of-care blood gas) is the only reliable clinical standard.
  • BICAR-ICU Trial Evidence: In severe metabolic acidemia (pH ≤ 7.20, HCO3- ≤ 20, PaCO2 ≤ 45) with AKI (AKIN 2-3), 4.2% Sodium Bicarbonate infusion reduces 28-day mortality and requirement for renal replacement therapy (Lancet. 2018;392:31-40).
  • Sodium Bicarbonate Formulations: Thailand GPO 7.5% NaHCO3 (44.6 mEq / 50 mL ampule = 0.892 mEq/mL) vs International 8.4% (50 mEq / 50 mL = 1.0 mEq/mL).
  • Hyponatremia Correction Limits: Maximum 6-8 mEq/L / 24 hours in chronic hyponatremia to prevent Osmotic Demyelination Syndrome (ODS). In acute symptomatic hyponatremia, give 3% NaCl 100-150 mL bolus over 10-20 min (repeat up to 3 times to raise Na by 4-6 mEq/L and abort herniation/seizure).
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