Yasser Gebril

Inpatient Pharmacy

POTASSIUM CHLORIDE
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 effects
2. 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.
Treatment Algorithm for Hyperkalemia
Abnormal ECG? (peaked t- Yes
Administer Calcium gluconate
waves, widened QRS complex)
No
Continuous ECG monitoring

Yes Give insulin & Follow blood

Hyperglycemia? sugar

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
 Therapeutic Alternatives for the
Management of Hyperkalemia
Onset/Duration
Medication Dose Route Acuity Mechanism of action Expected Result
of Action
Raises cardiac Threshold Reverses cardiographic
Calcium 1gm (1 Vial) IV over 5-10 min 1-2 min/10-30 min Acute
potential effects
Inhibits renal N+ re-
Furosemide 20-40 mg IV 5-15 min/4-6 hours Acute Increased urinary K+ Loss
absorption
Stimulates K+ intracellular
Regular insulin 5-10 units IV- SubQ 30 min/2-6 hours Acute Intracellular K+ redistribution
uptake

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

Stimulates K+ intracellular
Albuterol 10-20 mg Nebulizer 10min 30 min/1-2 hour Acute Intracellular K+ redistribution
uptake

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
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 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
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
Mild to Moderate Deficiency:
K+ more than or equal 2.5mmol/L
Route Concentration and Rate
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
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
Mild to Moderate Deficiency:
K+ more than or equal 2.5mmol/L
Preventative Therapy: (e.g. Receiving
Amphotericin B, Diuretics, Severe
diarrhea, etc)
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:
20-40 mEq/day in 1-2 divided doses.
Pediatrics:
1-2 mEq/kg/day in 1-2 divided doses
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 SAFE
THINK TWICE
DOUBLE CHECK
THANK YOU