Who can administer
POTASSIUM phosphate
- Infusions prepared at ward level using ampoules
- May be administered by registered competent doctor or nurse/midwife, PROVIDED the guidelines below (in Methods of Administration) have been adhered to
Important information
- There are two separate monographs for IV phosphate- sodium phosphate or potassium phosphate- please ensure you are using the correct monograph
- Caution with rate of administration (due to potassium content)
- Suggest: Senior doctor review before administration of intravenous phosphate, as it's use can be dangerous
- Caution: the response to any given dose cannot be predicted, and IV use can cause hypocalcaemia (tetany), calcium-phosphate precipitation in the kidneys, and fatal arrhythmias (ref 1)
- Patients with HYPOcalcaemia should have their calcium corrected before replacing phosphate (ref 5)
- Patients with severe HYPERcalcaemia who require phosphate replacement: seek specialist advice (ref 4)
- Renal impairment: Requires dose adjustment- see below
- Give in a dedicated line as it may precipitate with other drugs
Available preparations
Phosphate salt |
Volume |
Phosphate content per vial/ampoule/bag |
Sodium content per vial/ampoule/bag |
Potassium content per vial/ampoule/bag |
Potassium phosphate ampoule (Braun) |
20ml |
12mmol |
nil |
20mmol |
Phosphate polyfusor pre-mixed bag - very severe hypophosphataemia. Supplied only on request. |
500ml |
50mmol |
81mmol |
9.5mmol |
Reconstitution
Already in solution
Ampoules should be diluted further prior to administration
Addition of potassium phosphate concentrate to infusion bags
- Preparation must be done jointly by a doctor and a nurse in the clinic room.
- Both the Controlled Drug register, and the Additive label must be signed by the SAME doctor and nurse
- UNUSED ampoules must immediately be returned to the CD press and signed back into the CD register by the SAME doctor and nurse
- Clearly over-label the infusion bag to reflect the TOTAL amount of mmol of potassium phosphate
- After adding potassium phosphate concentrate to an infusion bag, squeeze and invert bag a MINIMUM of ten times to avoid inadvertent administration of a toxic bolus
Infusion fluids
Sodium chloride 0.9% (preferred)
Glucose 5% may also be used if clinically appropriate
Methods of intravenous administration
Intermittent intravenous infusion (using an electronically controlled infusion device)
- Administer as per guidelines below
Dose in adults
Table 1: Guidance on route given below but clinical judgement is always required (ref 1) |
Route of administration |
Phosphate level |
Oral/enteral replacement |
PREFERRED if >0.32mmol/L and asymptomatic
or
if level >0.48mmol/L and symptomatic
|
Intravenous route preferred |
<0.32mmol/L
or
<0.48mmol and symptomatic
or
if unable to tolerate oral supplementation
|
Table 2: POTASSIUM PHOSPHATE via peripheral line
|
- Consider ONLY IF co-existing hypokalaemia
- Preferable to treat hypophosphataemia and hypokalaemia separately using two individual infusion bags - rather than using Potasssium phosphate vial at all. This allows for the greatest amount of flexibility in the doses of both electrolytes
- It is difficult to provide concrete guidelines for the treatment of severe hypophosphataemia as regimens vary greatly across hospitals in the UK and Ireland - we have tried to provide guidelines below but clinical judgment is always required
- Use caution when interpreting phosphate levels. Changes in phosphate levels may be transient - treating underlying causes may be sufficient to correct level. Review medications which may contribute e.g. sevelamar, antacids, diuretics (ref 5)
- The response to any given dose cannot be predicted, and IV use can cause hypocalcaemia (tetany), calcium-phosphate precipitation in the kidneys, and fatal arrhythmias (ref 1)
- Prescribe dose in terms of phosphate dose required and then the phosphate salt required
- eg '12mmol phosphate as potassium phosphate'
|
Gentle replacement
|
Dose: 9mmol phosphate over 12 hours, and repeat as necessary (ref 2,3)
|
More individualised dosing (ref 1)
|
Level (mmol/L) |
Phosphate dose |
Maximum initial dose |
less than 0.32 |
0.4mmol/kg |
48mmol
phosphate
|
0.33 to 0.44 |
0.3mmol/kg |
30mmol
phosphate
|
>0.45 |
0.2mmol/kg |
20mmol
phosphate
|
Preparation |
Doses up to 24mmol phosphate (40mmol potassium)
- Add to 500mL infusion fluid
Doses 25 to 48mmol phosphate (40 (approx) to 80mmol potassium)
- Add to 1000mL infusion fluid
- For fluid restricted patients
- May be added to less volume provided the final concentration does not exceed 40mmol POTASSIUM per 500mL
|
Administration |
- Administer the required dose over 12 hours
- May administer more quickly - however cannot exceed a rate of administration of the POTASSIUM element of 10mmol/hour
- Doses of 36mmol phosphate or less may be administered over minimum 6 hours if clinically appropriate
- Doses greater than 36mmol phosphate MUST be administered over minimum 8 to 12 hours
|
Renal impairment |
Use with great caution, consider specialist advice
Generally avoid in severe renal impairment (ref 6)
|
Critical care/Fluid restriction |
Higher doses and rates may apply in the Critical Care setting
|
Polyfusor |
Available in Critical care areas- note however- only contains 9.5mmol potassium per polyfusor |
Repeated doses |
- May require repeat infusions over subsequent days.
- Usual maximum is 50mmol phosphate per 24 hours
|
Switch to oral route |
Consider switch to oral route once level >0.48mmol/L |
Renal impairment
- Use reduced doses with caution- see tables above
Monitoring
- Monitor the following electrolytes every 6 to 12 hours: phosphate, calcium, potassium, sodium, magnesium
- Monitor fluid balance and blood pressure
- Monitor ECG
Storage
- Potassium phosphate ampoules are treated as a controlled drug in GUHs (as it is a potasisum concentrate as well as containing phosphate). The routine supply of potassium phosphate is restricted to designated wards which are likely to be caring for critically ill patients
- Phosphate Polyfusor is NOT treated as a controlled drug
- Store below 250C
References
- Uptodate. Hypophosphataemia: Evaluation and Treatment March 2024. Accessed online 23/01/2025
- Martindale- accessed online 23/01/2025
- BNF- accessed online 23/01/2025
- UpToDate Potassium Phosphate monograph - accessed March 2025
- Maidstone and Tunbridge Wells NHS Trust 'Treatment of acute hypophosphataemia in adults. Review date August 2027
- Local specialist opinion - email on file25/06/2025
These local guidelines were also consulted in the preparation of guide (to try and create a consensus from different sources)
- Grampian staff guideline for the management of hypophosphataemia in adults July 2024
- Worcestershire acute hospitals NHS Trust 'guideline for the treatment of hypophosphataemia in adults, March 2023
- Liverpool University Hospitals NHS Trust
- UKMI Leeds hospital 'How is acute hypophosphataemia treated in adults
- Adults Therapeutic Handbook (NHS Greater Glasgow and Clyde), May 2023 Management of hypophosphataemia