Patient crashing / K+ Rider

[zacarias, ASN, RN]

Hey all,

Had a busy night last night but one patient I had admitted for chest pain (hurts with laughter and palpation) decides to crash on me in the morning. She had basically perfect labs and trops/CKs were normal, SR on monitor.

Because she had a K+ of 3.7, I hung 20mEq of KCL per replacement protocol. It was set to run at 50cc/hr, it was a 100cc bag. She felt burning at her good AC IV and so from the proximal port, I flushed it a little and she said it stopped burning. The burning came back again and so I lowered the rate to 25cc/hr. I flushed it again. It burned and she wanted me to stop it and take it off, so I did. She got really pale and made funny movements. At this point a nurse comes in and checks on us and shows me a tele strip where she essentially had these HUGE pauses with a wide qrs coming up every so often. It looked almost like ventricular standstill. Pt was white as a sheet, responsive but different. Vitals obtained, EKG, Rapid Response called. Vitals were stable. Rapid response thinks this event happening at the same time as me giving K+ was only a coincidence.

I called the Dr. and told him about her and at that point she coded, well sorta, they cancelled the code. We ran her to CVICU and she's ok Now apparently.

I don't know what could have happened to her. I feel like me giving the K+ was the precipitant. I know that K+ max is 10mEq on a regular floor, but it was a bag of K+ and it was going slow. Most of the bag was still full when I stopped it. I did flush a couple times at the proximal port, but the tubing is only 5 inches or so to the hub at that point. Could that have caused it? That is so little K+ though.

Nobody was sure that the K+ and this event were related and actually, the Dr's wrote nothing about the the K+ being given in their progress notes.

I just don't want something like that, and I I'm always careful about K+ but I feel like my hanging the K+ was the cause and that makes me upset.

Any comments please? BTW, she has a million allergies, but I don't think you can be allergic to K+...

Zach

[All_Smiles_RN]

I wouldn't think the K+ caused it. you certainly had it going slow enough. if there's not a contraindication, you can run NS at low rate and then connect your K+ at the proximal port. Dilutes it even further and less complaints from pts. Of course make sure when setting it up this way that the K+ is on a pump.

Me personally, I disconnect the bag of K+ and do my saline flush directly into the IV as opposed to flushing the tubing. I always tell myself better to be safe than sorry.

[southern rn]

I have always been taught the max concentration of KCL should be 10meq per every 100 cc of fluid so the concentration was most assuredly not dilute enough to

keep from having the burning your pt was describing. Not sure why with a K of 3.7 extra po doses weren't ordered but anyway... maybe next time if slowing the rate doesn't help ask the pharmacy to remix in a larger bag of fluids to further dilute the KCL. NEVER NEVER NEVER flush thru a line of KCL or other drugs like that. Regardless of the amount you were giving you were essentially giving a straight KCL push bolus each time you did that.Straight IV push KCL can cause ventricular standstill and asystole, that's why it's not done. Hope your pt. is feeling better.

[Altra, BSN, RN]

The general rule of thumb is 10mEq of K+ per hour, so there was nothing wrong with the rate of K+ administration. I do always run it piggyback through NSS though, to avoid burning.

I also would have disconnected the tubing before flushing.

I agree that with a K+ of 3.7, not sure why p.o. wasn't ordered.

[Spidey's mom, ADN, BSN, RN]

We add lidocaine to K+ :balloons:

Since normal potassium is 3.5 to 5 meq/L I too wonder about the IV potassium.

And I agree with disconnecting and flushing.

However, I doubt you caused her heart trouble.

steph

[suzanne4, RN]

20 mEq in 100 ml is always going to cause burning in a peripheral line. You do not want to use more than 10 mEq in 100 ml. Many facitilies actually have a policy that the stronger concentrations should only be thru the central line.

Save the 20 for the central lines only.

Doubt if it were the KCl rider per say, but pain can exacerbate anything, and that is where the problem may have come from. Just a coincidence that you were giving the KCl at the same time. Your patient was already admitted for chest pain, chances are this was going to happen no matter what was going on with the patient. Just their time to so something.

[GilaRRT]

Need more information on this patient. Potassium replacement is not uncommon on patients with a normal serum potassium level. For example, if I had an acidotic patient with a K of 3.7, I would expect some type of K replacement. Unsure about a K run; however, K replacement would still be indicated.

[CritterLover, BSN, RN]

suzanne4 said:

20 meq in 100 ml is always going to cause burning in a peripheral line. You do not want to use more than 10 meq in 100 ml. Many facitilies actually have a policy that the stronger concentrations should only be thru the central line.
Save the 20 for the central lines only.

Doubt if it were the kcl rider per say, but pain can exacerbate anything, and that is where the problem may have come from. Just a coincidence that you were giving the kcl at the same time. Your patient was already admitted for chest pain, chances are this was going to happen no matter what was going on with the patient. Just their time to so something.

Unfortunately, many hospitals are moving towards pre-mixed k riders.

This wasn't something I ever saw until I moved to this part of the country.

(when I lived in the west, the k riders were always 10meq/100 cc, and always were mixed with lidocaine unless contraindicated).

The premixed bags come 20meq/100 cc, and 40 meq/100 cc. There isn't a single hospital that I have worked at in this city (and I've worked at most of them ) that have a different concentration. There also isn't a single hospital that will let the pharmacy mix them less concentrated. They also won't let them use lido.

It never really affected me, because I worked icu and almost always had a central line.

However, now that I work er, I almost never have a central line, and I run into the issue quite frequently, esp on the n/v patients that can't hold down po kcl.

The only way I have found around the whole thing is to get the kcl mixed in a liter bag (and I do that fairly often, but it probably wouldn't work for a cp patient, where the fluid might be a consideration). Our pharmacy carries premix bags of ns with 40meq kcl in it. I'll get that and run it over 4hrs when I need 40 k+, or run 1/2 a bag in over 2 hours if I only need 20 k+. And of course, I run it in on a pump.

Eta: I do get an order for this -- our er docs have always been willing to order it this way, as long as the patient can tolerate the fluid.

[meandragonbrett]

There is literature that supports running K up to 40mEq per hour.

[CaLLaCoDe, BSN, RN]

If she was able to speak why didn't you just give her oral k+? It absorbs much faster (the best route) and requires no burning limbs!

Ps did you check her magnesium level?

[CritterLover, BSN, RN]

meandragonbrett said:

there is literature that supports running k up to 40meq per hour.

doesn't that depend on what the k+ level is?

i've run kcl at 40meq/hr when the k+ level is

are they now saying it is safe to infuse at 40meq/hr as long as the patient is on a monitor?

[KR]

I agree with everyone else that the K rider had nothing to do with the change in patient condition.