IV potassium

[limabean]

I have a question regarding the administration of IV potassium. I recently graduated from nursing school, so I am always trying to learn and I ask a lot of questions. I received an order from doctor to run a potassium bolus over 1 hour. When the potassium came down from pharmacy they had typed on the label to run it over 1 1/2 hrs. I had read somewhere that potassium should not run faster than 10meq/hr peripherally which at the concentration supplied would have been over 1 1/2 hrs. So I asked my preceptor which one I should go with. She said that I should always follow the MD's order, but that if I was worried about it then SHE would hang it. (I think she was tired of me asking questions.) So she goes into the room, hangs the potassium (which I had already primed), sets the pump to run it in over 1 hr, hooks it up to the patient, and she leaves the room. Well a few minutes later I heard the pump beeping so I went in to check it. In her rush, the preceptor had not hooked the tubing up to the pump (even though she had set the pump) and the potassium would have been running in at a wide open rate. Fortunately, for some reason, when I primed the tubing I had clamped it off and when the preceptor hung it she did not unclamp it which caused the pump to beep. So the K+ did not run in at the wide open rate that it would have. I told the preceptor about this and she said that I needed to stop worrying and that it is okay for potassium to run without a pump. (She did not mention anything about it running wide open). She said that there will be times when I dont have a pump and I will have to run it without one. So my question after all that is....can potassium run without a pump? Is it safe? If not what rate can it run in peripherally? Was the preceptor correct? Thanks.

[Burnt Out, ASN, RN]

I would never run any kind of IVPB or IVF with potassium in it without a pump-just too dangerous.

If you ever have a question about how long to run something like that, call the prescribing doctor and clarify after talking with the pharmacist.

[UM Review RN, ASN, RN]

A potassium bolus run too fast can cause an MI that would kill the patient. Potassium can also extravasate and cause necrosis to the surrounding tissue.

Even giving potassium at the prescribed rate, via a pump, causes a lot of irritation to the vein and patients c/o pain at the site.

Your hospital should have a policy on running IV Potassium. Call Pharmacy and have them print you a copy so you can show your preceptor.

Her patient got lucky this time, believe me.

[nursbee04]

You did the right thing. If YOU as a nurse had hung the K+ and it went in wide open and the pt developed an arrhythmia or arrested, in court YOU (not the doc who wrote the order) would be held to the standards of safe nsg practice. You are responsible for knowing whether an order is safe or not.

Don't ever worry about questioning things. I would rather go overboard and know that I protected my pt than brush it off and put my pt at risk.

Recently we had a pt c/o leg cramps. The doctor ordered Quinidine, which is an antiarrhythmic. This pt had no cardiac history, her only complaint was leg cramps. If we hadn't questioned the order and given the quinidine, the pt could have died. He was very thankful when we called back and asked if he meant Quinine, which is for leg cramps. That is a prime example of why you shouldn't always just follow the order and not question it.

[talaxandra]

She said that I should always follow the MD's order

Nope - if that were true you wouldn't need to have an education! While I'm sure there are a few doctors (and administrators) out there who would like a fleet of robot nurses, you learn about pathophysiology and pharmacology etc for a reason. As has been said before (on other threads), if a doctor writes up the wrong med/dose/route and a pharmacist doesn't pick it up, and you give it, it's your registration on the line. Saying 'but the doctor ordered it' will get you nowhere.

I understand that you're quoting her, but I just want to be crystal clear when I say that she's wrong!

You could run K+ without a pump, but only if you were prepared to sit and watch it for the duration of the infusion! The fact that she's so unconcerned about this if a bit troubling, frankly.

You, on the other hand, on the ball - bravo!

[kyti]

Our hospital has a policy. If a Dr. orders 30meq you will be sent 3 IVPB's with 10meq each, to run over one hour each. (alway on a pump)

[actioncat]

I am floored that anyone would tell you that a Potassium piggyback does not have to be run on a pump. We run 10 Meq over one hour, but we will go slower to make it easier on the vein. NEVER faster than that speed.

Myself, I would always follow the paharmacy's directions. They are the ones that really know what they are talking aobut when it comes to med administration. Often, I will call the paharmacy with a question before I call a doctor then let the doctor know what the pharmacist said. They always appreciate the input. Our pharmacists are pretty sharp.

[CritterLover, BSN, RN]

i think you will find that in general, most docs don't care if you run most of your piggy-backs (abx, electrolytes) slower than ordered. maybe there are some old-school docs who want it done their way, but most will defer to your judgement as an rn.(an exception would be iv dilantin, which can crystalize in solution if it is left mixed too long.)

i did have a resident once who didn't like how slowly i was pushing the cacl2. he took the syringe from me and pushed it on it.....and pushed the patient right on in to v-tach! doubt he will ever to that again.

as for potasssium, you can give it faster than 10 meq/hr in certain situations. most literature will tell you that you can run it at 20 meq/hr if the patient is on a monitor. lippincott's criticle care drug guide tells you that if the k level is

though i've worked in icu where my patients were always on a monitor, i never ran routine k boluses in at 20 meq/hr. however, i have run it at 40 meq/hr on a patient whose k level was way less than 2. i think it was somewere around 1.5, and he got the first 40 over an hour, the second 40 over 2 hours, and then we slowed down to 10/hr. (the level was rechecked somwhere in there, too.)

[mercenarynurse]

10 meq/hr peripheral and 20 meq/hr central line is the usual standard. yes boluses can kill, but I've also run in 40meq/100cc over 15 min x3 repeated doses (in codes) for severely hypokalemic patients - y'know to stop the VT and VF that I was shocking them for.

The bigger question is why does it always have to be IV?? literature reports better absorption via the po route-and it's clearly a whole lot safer.

Next time you might suggest the pharmacist clarify with the physician if you are uncomfortable addressing it with him/her yourself.

[barefootlady, ADN, RN]

Never run K+ without a pump. I would be very scared of this instructor. Sure there are ICU situations but on the floor no way.

[begalli]

I know I'll get spanked for this but sometimes I run K+ without a pump. I will use microtubing and administer it by gravity eyeballing (or timing) the drips to make sure it goes in over at least 30 minutes through a central line.

I do this very conscientiously and actually all meds I put into a patient through their vasculature gets the utmost attention. I may be replacing K+, Cacl, and mag all at the same time while pushing epi or neo or blood or whatever. I'm more inclined to hang the K+ piggyback on the pump and drip in the other two but sometimes it just doesn't work that way when things are moving fast in the ICU and all the ports of a central line are in use with drips, drugs that may be incompatible, etc, I just have to and I'm bedside the entire time of the infusion.

But normally I run all KCL replacement piggyback on the pump. And I would never do this on a patient who's able to move around which is rare to nonexistent in this situation.

[Tenesma]

one thing to remember is that it is a lot faster to replete K+ PO than it is to replete it IV.... :)