Since a merger into a large health care system my hospital is having a debate with our system partners about the wording of the administration comments for KCL infusions. Our practice prior to the merger had been to limit peripheral infusions to 10 mEq per 100 mL over 60 minutes. 20 mEq per 100 mL would only be given through a central line with cardiac monitoring, we included this comment in the admin instructions.
Currently the 20 mEq per 100 mL defaults to 50 mL per hour, requiring 120 minutes to infuse and does not include any comments about administering through a central line. We do not feel this is in the best interest of the patient. Patients do not tolerate this type of infusion through a peripheral IV.
Searching Micromedex…
It indicates central route is preferred and is required for concentrations of 300 and 400 mEq/l….
Intravenous
• Potassium chloride for injection is available as a concentrate for dilution [18] and as a highly concentrated ready-to-use solution [1].
• The injection concentrate for dilution must be diluted prior to administration [18].
• The highly concentrated, ready-to-use solution must be administered with a calibrated infusion device using a slow, controlled rate, preferably via a central route; central routes are required with concentrations of 300 and 400 mEq/L [1].
• Avoid administering IV with glucose solution for treatment of hypokalemia due to intracellular potassium shift and consequent lowering of serum potassium levels [19][20][21]
• Central line infusion, MAX concentration 200 mEq/L [22] and concentrations up to 400 mEq/L have been used safely in critically ill adult patients [23]
• Pediatric, peripheral IV infusion, concentration 40 mEq/L; MAX 60 to 80 mEq/L [24][13][25][10]
• Pediatric IV infusion rate, MAX 1 mEq/kg/hr [24][8] or 40 mEq/hr [2].
There is also an article from the America Journal of Health System Pharmacy Aug 2005 that speaks to the recommendation of limiting peripheral KCL infusion to 10 mEq.
What have others done to address this concern? At a minimum we would like the comment of infuse through a central line added back into the 20 mEq, and changed to 60 minute duration.
See the monograph on potassium infusion in the book Intravenous Medication by Gahart and Nazareno published by Mosby. 20 mEq in 100 ml is too concentrated for peripheral vein. Even 10 in 100 would require smallest Cath in largest vein and never use a vein in hand wrist or ACF due to high risk of Extravasation. Also assessing for blood return at least every 5-10 ml during infusion and not using a pump. This concentration is a dangerous vesicant. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree with your statement of checking for a blood return frequently with the administration of any vesicant, however, I would have a real problem infusing any electrolyte infusion without a pump.
Electronic infusion pumps do not cause an extravasation injury BUT, they easily make the problem a lot worse when it does happen. No vesicant should ever be infused with an infusion pump through a peripheral vein. The pump has no way to detect the fluid pathway, so it continues to pump the vesicant into the subq tissue. ONS now makes a similar statement and this is included in the INS Standard on antineopplastic therapy. Shortly the INS will release a series of resources on noncytotoxic vesicants that will say the same thing. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Fluids can also flow by gravity into an extravasated or infiltrated PIV, so I'm not really sure how taking an infusion off the pump helps. Modern pumps can be set to very sensitive pressure levels, much more sensitive that what is likely to be detected in normal clinical situations by infusing by gravity.
And infusing potassium without a rate controlling pump would rightly be considered grossly negligent.