Yasser Gebril Inpatient Pharmacy
POTASSIUM CHLORIDE
Learning Objectives
Importance of Potassium Chloride
Potassium Chloride Toxicity
Pharmacokinetics Role of Potassium in the Human Body Epidemiology Causes of Hyperkalemia Diagnosis of Hyperkalemia Treatment of Hyperkalemia
The Need for KCl Guidelines JACHO Recommendation UK Guidelines SSH Potassium Chloride Dosing Guidelines ISMP Recommendations
Hospital Administra Administration tion Physician and P&T Committee Nursing Units and Pharmacy
Importance of Potassium Chloride Potassium um is the primary intracellular ion in the 1. Potassi 2. 3.
4.
5.
human body. The normal plasma potassium concentration range range is 3.5 to 5 mEq/L. Potassium regulates many biochemical processes in the body, and is a key ion for electrical action potentials across cellular membranes. Potassium chloride is the preferred potassium supplement for for the most common causes of hypokalemia. Hyperkalemia commonly results in patients with acute or chronic kidney disease.
Pharmacokinetics
Potassium is the most abundant cation in the body, body, with estimated estimate d total body stores stores of 3,000 to 4,000 4,000 mEq, 98% of this amount is contained within the intracellular compartment, and the remaining 2% is distributed within the extracellular compartment. The Na+-K+-ATPase pump located in the cell membrane is responsible for the compartmentalization of potassium. This pump is an active transport system that maintains increased intracellular stores stores of potassium by transporting sodium out of the cell and potassium into the cell at a ratio of 3:2. Consequently the pump maintains a higher concentration of potassium inside the cell.
Pharmacokinetics
The normal serum concentration range for potassium is 3.5 to 5.0 mEq/L, whereas the intracellular potassium concentration is usually about 140 mEq/L. Approximately 70% of the intracellular potassium is located in Approximately skeletal ske letal muscle; the remaining 30% is located l ocated in the liver and red blood cells. Extracellular potassium is distributed throughout the serum and interstitial space. Potassium is dynamic in that it is constantly moving between the intracellular and extracellular compartments according to the body’s needs. Thus the serum potassium concentration alone does not accurately accurat ely reflect the total body potassium content.
Role of Potassium Chloride
Potassium has many physiologic physiologic functions within cells, including protein and glycogen synthesis and cellular metabolism and growth. It is also a determinant of the electrical action potential across the cell membrane. The ratio of the intracellular to extracellular potassium concentration concentration is the major determinant of the resting membrane potential across the cell membrane. Thus the resting membrane potential is greatly affected by variations in extracellular extrac ellular potassium concentration. Serum potassium concentrations outside the normal range can have disastrous effects effects on neuromuscular activity, activity, in particular cardiac conduction. Hypo- and hyperkalemia hyperkalemia are both associated associated with potentially potentially fatal fatal cardiac arrhythmias, along with other neuromuscular disturbances.
Potassium Chloride Toxicity
Hyperkalemia:
Hyperkalemia is defined as a serum potassium concentration greater than 5.5 mEq/L.
It can be further classified accor according ding to its severity:
Mild (serum potassium 5.5 to 6 mEq/L).
Moderate (6.1 to 6.9 mEq/L); and
Severe hyperkalemia (>7 (>7 mEq/L).
Epidemiology
Hyperkalemia is much less common than hypokalemia. The incidence of hyperkalemia in hospitalized patients has been estimated to be 1.4% to 10%. Most cases of hypokalemia are the result of overcorrection of hypokalemia with potassium supplements. Severe hyperkalemia occurs more commonly in elderly patients with renal insufficiency who receive potassium supplementation.
Causes of Hyperkalemia 1. Increased potassium intake 2. Decreased potassium excretion 3. Tubular unresponsiveness to aldosterone. 4. Redistribution of potassium into the
extracellular space.
Diagnosis of Hyperkalemia Clinical Presentation Of Hyperkalemia General
Symptoms
Frequently asymptomatic; however, the patient may complain of heart palpitations or skipped heartbeats.
Signs
Related to the effects of excessive potassium on neuromuscular, cardiac, and smooth muscle cell function.
ECG changes
Laboratory Tests
Serum potassium concentr concentration ation >5.5 mEq/L.
Treatment of Hyperkalemia DESIRED OUTCOME
The goals of therapy for the treatment of hyperkalem hyperkalemia ia are: 1. 2. 3.
to antagonize adverse cardiac effects Reverse Rever se any symptoms that may be present, and to Return the serum and total body stores of potassium to normal.
Severe hyperkalemia (>7 (>7 mEq/L) or moderate hyperkalemia (6.1 to 6.9 mEq/L), when associated with clinical symptoms or electrocardiogr electrocardiographic aphic changes, requires immediate treatment. Initial treatment treatment of hyperkalem hyperkalemia ia is focused on antagonism of the membrane actions of hyperkalemi hyperkalemia a (Using Calcium). Secondarily, one should attempt to decrease extracellular potassium Secondarily, concentration concentra tion by promoting its intracellular movement movement (e.g., with glucose, insulin, β2-receptor 2-receptor agonists, agonists, or sodium bicarbonate). Finally, removal of potassium from Finally, from the body by hemodialysis and/or cationexchange resins may may need to be implement implemented. ed. The underlying cause of hyperkalemi hyperkalemia a should be identified and reversed, and exogenous exog enous potassium must be withheld.
Treatment Algorithm for Hyperkalemia Hyperkalemia Abnormal ECG? (peaked twaves, widened QRS complex)
Yes
Administer Calcium gluconate
No Continuous ECG monitoring
Yes Hyperglycemia?
No Administer insulin & glucose
Consider albuterol
Consider bicarbonate if acidotic
Give exchange resin or consider dialysis
Follow potassium level every two hours until <5.5 mEq/L
Give insulin & Follow blood sugar
Therapeutic Alternatives for the Management of Hyperkalemia Medication
Dose
Route
Onset/Duration of Action
Acuity
Mechanism of action
Expected Result
Raises cardiac Threshold
Reverses cardiographic
potential
effects
Calcium
1gm (1 Vial) IV over 5-10 min 1-2 min/10-30 min
Acute
Furosemide
20-40 mg
IV
5-15 min/4-6 hours
Acute
Regular insulin
5-10 units
IV- Su S ubQ
30 min/2-6 hours
Acute
Dextrose 10%
1000 ml
IV over 1-2 hour 30 min/2-6 hour
Acute Stimulates insulin release
Intracellular K+ redistribution
Dextrose 50%
50 ml
IV over 5 min
Acute Stimulates insulin release
Intracellular K+ redistribution
Sodium Bicarb
50-100mEq IV over 22-5 mi min 30 mi min/2-6 ho hour
Acute Raises se serum pH pH
Intracellular K+ redistribution
Albuterol
10-20 mg
Nebulizer 10min 30 min/1-2 hour
Acute
Hemodialysis
4 hours
NA
Immediate/Variable
Acute Removal from plasma
Kayexalate
15-60 gm
Oral or rectal
1 hour/variable
30 min/2-6 hour
Non
Inhibits renal N+ reabsorption Stimulates K+ intracellular uptake
Stimulates K+ intracellular uptake
Resin exchanges Na + for K+
Increased urinary K+ Loss Intracellular K+ redistribution
Intracellular K+ redistribution Increased K+ elimination Increased K+ elimination
Why Do We Need To Have Guidelines? The following incidents with potassium chloride have been reported to ISMP Canada: 1.
10 mL potassium chloride c hloride (KCl) concentrate concentrate was administered direct IV when the intended action was to flush an intravenous intravenous line with 10 mL 0.9% sodium chloride. Result: patient Death Death..
2.
10 mL KCl concentrate was used to reconstitute a drug for parenteral administration when the intended diluent was sterile water. Result: Near miss (error was noted before administration).
3.
10 mL KCl concentrate was administered as a bolus injection by a health care professional who was unaware that KCl concentrate concentrate cannot be given as a bolus but must be diluted in a minibag and given as an infusion. Result: patient Death Death..
4.
A one-liter IV solution was prepared with 400 mEq of potassium chloride and although it was administered at a very low rate, the incident was felt to be a near miss because of the potential for accidental overdose.(error was noted during administration).
5.
IV solutions containing KCl were administered as a fluid replacement in a patient requiring several liters of fluid in a short time frame. Result: hyperkalemia Death
JCAHO Recommendations JCAHO high priority national patient safety goals includes: “Improve the Safety of Using High-Alert Medications” with the recommendations to: 1. Remove concentrate electrolytes (including, but not limited to, potassium chloride, potassium phosphates, phosphates, sodium chloride >0.9 percent) from patient care units; and 2. Standar Standardize dize and limit the number of drug concentrations available in the organization
United Kingdome
the National Patient Safety Agency established by the National Health Service (NHS ) issued a Patient Safety Safety Alert in July 2002 to all Chief Executives Executives of National Health Service Trusts and Primary Care Trusts in Britain. It required actions in all centers of the National Health Service to reduce the potential for patient injury with the use of potassium chloride by October 31, 2002. 20 02. In the Alert, one of the strategies suggested suggested that: “Pharmacists should also remove potassium chloride concentrate from wards and clinical areas, use commercially prepared prepared diluted potassium solution where possible, and store potassium chloride concentr concentrate ate in a separate locked cupboard.”
SSH Potassium Dosing Guidelines SAAD SPECIALIST HOSPITAL
POTASSIUM DOSING GUIDELINES Developed by the DIPC; Pharmacy Department November 2006 Approved by the P&T 2006 This Guideline serves as suggested
I
Parenteral 1. Indicated for patients unable to tolerate or receive oral replacement, patients with urine output > 1 ml/kg/hour and serum Cr < 1 mg/dl, and for patients with renal impairmen. 2. All patients require cardiac monitoring for concentrated Potassium doses Concentrations >80 mEq/l or doses > 0.2 mEq/kg/hour
Parenteral Status
Route
Moderate to Severe Deficiency:
IV Bolus:
K+ less than or equal 2.5mmol/L with or without symptoms e.g. cardiac arrythmias or conduction disturbances, disturbances, respiratory muscle weakness, paralaysis OR patient on digoxin)
Adult: Central line: 20mEq/100mL over 1 hour Peripheral line: 10mEq/100mL over 1 hour Pediatrics: 0.5-1mEq/kg over 2 hour (same as adult concentration) Fluid restriction Central line:40mEq/100mL over 1 hour
ECG monitoring for rates >5 mEq/hour, frequent potassium levels, and acid-base balance are recommended
Mild to Moderate Deficiency: K+ more than or equal 2.5mmol/L
II.
Concentration and Rate
IV infusion: Adult and Pediatrics: Pediatrics: Peripheral line: usual 20-40mEq/L infused at max rate of 10mEq/hour Central line: usual 20-60mEq/L infused at max rate of 20mEq/hr Adult: Central line: 20mEq/100mL over 1 hour Peripheral line: 10mEq/100mL over 1 hour Pediatrics: 0.5-1mEq/kg over 2 hour (same as adult concentration) Fluid restriction Central line:40mEq/100mL over 1 hour
Oral:
Oral Status Mild to Moderate Deficiency: K+ more than or equal 2.5mmol/L
Dosage Adult: 60-80 mEq/day plus additional amounts if needed. (Check serum K+ levels daily) Pediatrics: 1-2 mEq/kg initially, then as needed based on frequently obtained lab values. If deficits are severe or ongoing losses are great, I.V. route should be considered Adult:
ISMP KCl Safety Recommendations
Hospital Administration
Physicians And P&T Committee
Nursing Units and
Pharmacy
1- Hosp Hospit ital al Admin Adminis istr trati ation on
Create a high-level multidisciplinary team with a mandate to:
Reduce the error potential of potassium chloride (KCl). Define an implementation strategy strategy (including timelines). Provide regular updates to the hospital board’s board’s Quality & Risk Management Committee. Comm ittee.
Include discussion of KCl injury and preventive system system safeguards during orientation programs for nurses, physicians, physici ans, and pharmacists and locum staf staff f
Physicians Phy sicians and P&T committee 1. Pharmacy and Therapeutics Committee to develop
clear guidelines for the use of KCl, including:
Use of oral, instead of IV, KCl whenever clinically feasible. Standardization of prescribing practices to match available premixed KCl solutions. Maximum concentration of KCl allowable in an IV solution. Proper mixing to avoid pooling. Maximum hourly and daily limits of KC KCll that a patient may receive. Maximum infusion rate. Requirements for infusion rate and patient monitoring. Evaluation of need and/or feasibility of automatic substitution policy.
Physicians Phy sicians and and P&T committ committee’ ee’ Cont. Cont. 2. Identify that orders such as “KCl 40 mEq IV now” or “give KCl 20 mEq IV bolus” should be
considered incomplete and unacceptable . Orders require instructions for dilution and infusion rate. 3. If it is deemed necessary that concentrated KCl products be available in a critical care area, create policies to restrict and safeguard their use. Consider a locked cupboard and/or a double sign-out procedure for obtaining the concentrated concentrat ed product
NURSING UNIT
Have each patient care unit, program, department, and clinic undertake a review by physicians, nurses and pharmacists with the following aims: Identify if concentrated KCl products are in patient care areas. Plan and organize actions to remove concentrated KCl products from patient care areas. Have standardized premixed KCl IV solutions available in adequate quantities. Store premixed KCl solutions separately from plain IV solutions. If concentrated KCl products must be available in a critical care area, follow P&T policies regarding regarding access, e.g., e. g., locked cupboard and/or a double sign-out procedure for obtaining the product.
Pharmacy 1.
Work with the appropriate department(s), e.g., Stores and Nursing, to arrange for storage and distribution of premixed KCl IV solutions.
2.
Consider purchasing only the 40 mEq /20 mL size concentrate concentrate (not 20 mEq/10 mL size) to minimize the chance of mix-up with other commonly used products such as 10 mL sterile water and 10 mL normal saline.
3.
Pharmacy should prepare any nonstandard solutions that are deemed absolutely necessary but are unavailable commercially in a premixed format.
4.
Minibag products containing KCl should be dispensed and controlled by the pharmacy only.
5.
Add an auxiliary fluorescent warning label to t he KCl concentrate concentrate product at the time of receipt of the drug into inventory in the pharmacy.
6.
Add auxiliary warning label to premixed minibags containing KCl, providing the recommended route of administration administration (e.g., “cen “central tral line only”) and the recomm recommended ended duration of infusion (e.g., “infuse over at least 1 hour”).
7.
Have pharmacists intervene when nonstandard orders for IV solutions with KCl are prescribed. Prescribing practices must take into consideration the premixed KCl IV solutions that are available.
8.
Choose a designated area for storing concentrated KCl products products in the pharmacy to reduce the t he likelihood of substitution errors.
THINK SAFE THINK TWICE DOUBLE CHECK
THANK YOU
