D5w KCl IV fluid in hyperkalemic infant

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    The other day during my peds rotation I had a 2 month old infant born prematurely. who was diagnosed with bacteremia and urosepsis. The original labs showed she had a slightly elevated potassium of 6.1 The 2nd draw showed the K+ at 4.1. The 3rd showed it at 5.6. The fluids hanging were D5w 10 mEq KCl ordered at 5cc/hrI asked the RN why the baby was receiving that when she had hx of elevated potassium and 3 RN's jumped down my throat, saying that there's barely any potassium in that and she's only getting 5cc/hr. I still don't understand why she would be getting that. True it's only 5cc/hr but she's only 3.405 kg and according to her labs her K+ is rising again.Can someone please help me with the rationale of this because I'm lost.
    Last edit by nickieph on Nov 21, '12
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  4. 0
    did you get a chance to check the name on the bag? was it, in fact, supposed to be running on that patient?
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    Well, first let's address your question about giving potassium in hyperkalemia. It may sometimes be appropriate, even life saving, to supplement K+ in someone with a high serum potassium. The most common situation that comes to mind is in metabolic acidosis (particularly DKA, but sometimes even in septic pts who for one reason or another are deficient in total body K) since it creates a state of relative hyperkalemia as hydrogen ions displace intercellular potassium. This can get you into trouble when you correct the pH without preemptively replacing K.That said, 5ml/hr of that solution doesn't add up to much. Which begs the question, why is it even in the fluid?Honestly, no one's going to be able to answer your question without a whole lot more information to provide context. It's unfortunate that your preceptor reacted so defensively, and missed out on a teaching opportunity.Hope I at least gave you something to think about. Knowing that tidbit about potassium shifts in acidosis prompted me to question an order that would've killed a pt. last year. Good stuff.
    Esme12 and nickieph like this.
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    Most likely, the means of obtaining the sample needs to be considered.

    In newborns (in fact, up to about a year of age) it is common to obtain lab samples via heelstick. A falsely elevated serum potassium is COMMON from heelstick samples, due to cell lysis from squeezing the heel to obtain blood.

    In our PICU, we do not consider a potassium level 'valid' unless obtained from a venipuncture or arterial or venous catheter.
    EricJRN, KelRN215, and Esme12 like this.
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    The bag was ordered and labeled correctly for the patient and the blood was taken via venipuncture. I'm not very familiar with IV fluids and appropriate rates as of yet. we get to do that next semester, however I am trying to at least get somewhat familiarized with it now.My preceptor wasn't the RN who was defensive, it was the RN assigned to that patient along with a couple others who were sitting next to her.My preceptor said she would have asked the Dr. I agree that there needs to be more info to fully understand the scenario.Thank you all for your help
  8. 1
    Quote from nickieph
    The other day during my peds rotation I had a 2 month old infant born prematurely. who was diagnosed with bacteremia and urosepsis. The original labs showed she had a slightly elevated potassium of 6.1 The 2nd draw showed the K+ at 4.1. The 3rd showed it at 5.6. The fluids hanging were D5w 10 mEq KCl ordered at 5cc/hrI asked the RN why the baby was receiving that when she had hx of elevated potassium and 3 RN's jumped down my throat, saying that there's barely any potassium in that and she's only getting 5cc/hr. I still don't understand why she would be getting that. True it's only 5cc/hr but she's only 3.405 kg and according to her labs her K+ is rising again.Can someone please help me with the rationale of this because I'm lost.
    You might want to take a look at what happens to potassium levels during sepsis, specifically, what happens when the body becomes a little bit acidotic. There is a shift of potassium levels in the blood that occur during acidosis. It is entirely possible that this particular patient had a low potassium level overall, yet had a high serum potassium level because of the sepsis. The fluid maintenance level for this patient would be approximately 11 mL/HR, 5 mL per hour isn't even close to that. There has to be another reason why this patient was on D5W with 10 mEq/L at that rate.

    I'm relatively new at this myself, I am still a student, just a bit farther along than you are. The only thing I can figure is that perhaps as they correct the acidosis, that would tend to drive potassium back into the cell, and may result in a hypokalemia, therefore they are providing some potassium to prevent that from occurring. If you are able to follow the case, it might be kind of interesting, see what ultimately happened, and perhaps all of us can learn from it!

    Something that just struck my mind, is that it is entirely possible that the fluids that were ordered could be specifically to counteract a side–effect of some other medication that they also have ordered for patient.

    Please, if you do figure out what the rationale was, please let me know, I really do want to learn for myself.
    Esme12 likes this.
  9. 0
    Quote from nickieph
    The bag was ordered and labeled correctly for the patient and the blood was taken via venipuncture. I'm not very familiar with IV fluids and appropriate rates as of yet. we get to do that next semester, however I am trying to at least get somewhat familiarized with it now.My preceptor wasn't the RN who was defensive, it was the RN assigned to that patient along with a couple others who were sitting next to her.My preceptor said she would have asked the Dr. I agree that there needs to be more info to fully understand the scenario.Thank you all for your help
    AND how much fluid was the potassium mixed in??? 10meq KCL in one liter (1000cc) is a different concentration when mixed in 500 cc's
  10. 0
    very interestng reading....we start our OB rotation in march and havent even begun IV solutions,so I find this interesting.
    I hope you will come back and tell your findings with ratonale
  11. 0
    Can you give us a little more information regarding what's going on with this patient?

    5 mL/hr isn't even maintenance fluid requirements for this baby, not even half maintenance. Maintenance IVF for pediatrics is 4 mL/kg/hr for the first 10 kg of body weight... so a baby who weighs 3.405 kg should be getting 14 mL/hr as maintenance. Is the baby POing adequately? Straight D5W is an odd order for an infant to me and I've NEVER given it as maintenance IVF in pediatrics. No 1/4 or 1/2 Normal Saline in there? I agree with your instructor, I would have questioned the MD about this order. Although, perhaps the nurses DID and there was some rationale to it.
  12. 0
    Sounds like the baby was NPO?

    The rate is strange, sure it was 5cc/hr?


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