POTASSIUM CHLORIDE

Yasser GebrilInpatient Pharmacy

Learning Objectives

Importance of Potassium Chloride Pharmacokinetics Role of Potassium in the Human Body

Potassium Chloride Toxicity 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 Administration Physician and P&T Committee Nursing Units and Pharmacy

Importance of Potassium Chloride

1. Potassium is the primary intracellular ion in the human body.

2. The normal plasma potassium concentration range is 3.5 to 5 mEq/L.

3. Potassium regulates many biochemical processes in the body, and is a key ion for electrical action potentials across cellular membranes.

4. Potassium chloride is the preferred potassium supplement for the most common causes of hypokalemia.

5. Hyperkalemia commonly results in patients with acute or chronic kidney disease.

Pharmacokinetics

Potassium is the most abundant cation in the body, with estimated total body stores of 3,000 to 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 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 skeletal muscle; the remaining 30% is located 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 reflect the total body potassium content.

Role of Potassium Chloride

Potassium has many 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 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 potassium concentration.

Serum potassium concentrations outside the normal range can have disastrous effects on neuromuscular activity, in particular cardiac conduction.

Hypo- and hyperkalemia are both associated with potentially 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 according to its severity:

Mild (serum potassium 5.5 to 6 mEq/L).

Moderate (6.1 to 6.9 mEq/L); and

Severe hyperkalemia (>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

Related to the effects of excessive potassium on neuromuscular, cardiac, and smooth muscle cell function.

Symptoms Frequently asymptomatic; however, the patient may

complain of heart palpitations or skipped heartbeats.

Signs ECG changes

Laboratory Tests Serum potassium concentration >5.5 mEq/L.

Treatment of Hyperkalemia

DESIRED OUTCOME

The goals of therapy for the treatment of hyperkalemia are:1. to antagonize adverse cardiac effects2. Reverse any symptoms that may be present, and to 3. Return the serum and total body stores of potassium to normal.

Severe hyperkalemia (>7 mEq/L) or moderate hyperkalemia (6.1 to 6.9 mEq/L), when associated with clinical symptoms or electrocardiographic changes, requires immediate treatment.

Initial treatment of hyperkalemia is focused on antagonism of the membrane actions of hyperkalemia (Using Calcium).

Secondarily, one should attempt to decrease extracellular potassium concentration by promoting its intracellular movement (e.g., with glucose, insulin, β2-receptor agonists, or sodium bicarbonate).

Finally, removal of potassium from the body by hemodialysis and/or cation-exchange resins may need to be implemented.

The underlying cause of hyperkalemia should be identified and reversed, and exogenous potassium must be withheld.

Abnormal ECG? (peaked t-waves, widened QRS complex)

Administer Calcium gluconate

Continuous ECG monitoring

Hyperglycemia?Give insulin & Follow blood

sugar

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

Treatment Algorithm for HyperkalemiaYes

Yes

No

No

Medication Dose RouteOnset/Duration

of ActionAcuity Mechanism of action Expected Result

Calcium 1gm (1 Vial) IV over 5-10 min 1-2 min/10-30 min AcuteRaises cardiac Threshold

potential

Reverses cardiographic

effects

Furosemide 20-40 mg IV 5-15 min/4-6 hours AcuteInhibits renal N+ re-

absorptionIncreased urinary K+ Loss

Regular insulin 5-10 units IV- SubQ 30 min/2-6 hours AcuteStimulates K+ intracellular

uptakeIntracellular K+ redistribution

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 30 min/2-6 hour Acute Stimulates insulin release Intracellular K+ redistribution

Sodium Bicarb 50-100mEq IV over 2-5 min 30 min/2-6 hour Acute Raises serum pH Intracellular K+ redistribution

Albuterol 10-20 mg Nebulizer 10min 30 min/1-2 hour AcuteStimulates K+ intracellular

uptakeIntracellular K+ redistribution

Hemodialysis 4 hours NA Immediate/Variable Acute Removal from plasma Increased K+ elimination

Kayexalate 15-60 gm Oral or rectal 1 hour/variable Non Resin exchanges Na+ for K+ Increased K+ elimination

Therapeutic Alternatives for the Management of Hyperkalemia

Why Do We Need To Have Guidelines?

The following incidents with potassium chloride have been reported to

ISMP Canada:

1. 10 mL potassium chloride (KCl) concentrate was administered direct IV when the intended action was to flush an intravenous line with 10 mL 0.9% sodium chloride. Result: patient 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 cannot be given as a bolus but must be diluted in a minibag and given as an infusion. Result: patient 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, sodium chloride >0.9 percent) from patient care units; and

2. Standardize 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 Alert in July 2002 to all Chief 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.

In the Alert, one of the strategies suggested that: “Pharmacists should also remove potassium chloride concentrate from wards and clinical areas, use commercially prepared diluted potassium solution where possible, and store potassium chloride concentrate in a separate locked cupboard.”

SSH Potassium Dosing GuidelinesPOTASSIUM 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 Concentration and Rate

Moderate to Severe Deficiency:

K+ less than or equal 2.5mmol/L with or without symptoms e.g. cardiac arrythmias or conduction disturbances, respiratory muscle weakness, paralaysis OR patient on digoxin)

ECG monitoring for rates >5 mEq/hour, frequent potassium levels, and acid-base balance are recommended

IV Bolus:

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

IV infusion:

Adult and 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

Mild to Moderate Deficiency: K+ more than or equal 2.5mmol/L

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

II. Oral:

Oral

Status Dosage

Mild to Moderate Deficiency: K+ more than or equal 2.5mmol/L

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

Preventative Therapy: (e.g. Receiving Amphotericin B, Diuretics, Severe diarrhea, etc)

Adult: 20-40 mEq/day in 1-2 divided doses. Pediatrics: 1-2 mEq/kg/day in 1-2 divided doses

SAAD SPECIALIST HOSPITAL

ISMP KCl Safety Recommendations

Hospital Administration

Physicians And P&T Committee

Nursing Units and

Pharmacy

1- Hospital Administration

Create a high-level multidisciplinary team with a mandate to:

Reduce the error potential of potassium chloride (KCl).

Define an implementation strategy (including timelines).

Provide regular updates to the hospital board’s Quality & Risk Management Committee.

Include discussion of KCl injury and preventive system safeguards during orientation programs for nurses, physicians, and pharmacists and locum staff

Physicians 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 KCl 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 and P&T committee’ 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 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 access, 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 (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 the KCl 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 (e.g., “central line only”) and the recommended 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 in the pharmacy to reduce the likelihood of substitution errors.

THINK SAFETHINK TWICE

DOUBLE CHECK

THANK YOU