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+...
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.
I only use pre-mix k riders and never over 20 meq in any of them, and every place that I have been requires that the 20 meq concentration be used only in a central line, never peripheral line. Burns way too much. Jcaho requires the pre-mix and with the red writing on it.
10 meq in 25 ml of fluid is just way too concentrated for me, and I would never let someone give me that. No sense in being uncomfortable. Burning is an issue and that is what concerns me. And what if the pump fails and unfortunately, we have all seen that happen.
There is literature that supports running K up to 40mEq per hour.
Does not matter what literature states can be done and not done, the issue is pain when infusing that much in a peripheral IV. And with that amount, it needs to be in a unit where they are monitored, never on a regular floor. Most are going to have central lines if they are requiring that much KCl in a rider.
I dont know dude, sounds like the potassium could be the culprit. Small increases in extracellular K+ by intravenous administration can cause large changes in the resting membrane potential of the myocaridum's Na+/K+ pump. Elevated K+ can result in membrane depolarization, inactivating Na+ channels. This causes a widening of the QRS to appear on the ECG and usually also decreased P wave amplitude. Basically, potassium whether it is already elevated or if it is given fast enough, makes the resting membrane potenial more negative and an action potential is harder to achieve. I wonder what her ionized Ca++ was? Might not have been a bad idea to give some of this stuff to better protect the myocaridum.
Thanks for everyone's comments. I really appreciate it. A lot of people wondered why I didn't just give the K+ PO. The reason is she was NPO and per our protocol we can give it PO or IV.
I agree that K+ in a 100cc bag is bound to burn but it seems common among hospitals. Thanks again everyone!
speaking of kcl..my co worker when we were having a STAT case in icu the doctor told us to incorporate kcl at the present iv,during that time i am busy paging and calling lab station,respiratory department and for the follow up results..in short i am doing all the paper works and answering doctors question and updating result and my co worker decided to do the bedside orders,,,i spotted her while im on the phone that she is preparing for skin test?????? and i said to myself skin test for what??? the next thing she did was,,she aspirated the kcl and suddenly ready to do skin test for kcl good thing i can able to stop her for that...
My floor's electrolyte policy calls for 40mEq of IV K for 3.5-3.9, so the replacement doesn't surprise me at all. I can't help with the burning, since we only have central lines. I also agree the crashing was unrelated, though.
suzanne4, RN
26,410 Posts
I only use pre-mix k riders and never over 20 meq in any of them, and every place that I have been requires that the 20 meq concentration be used only in a central line, never peripheral line. Burns way too much. Jcaho requires the pre-mix and with the red writing on it.
10 meq in 25 ml of fluid is just way too concentrated for me, and I would never let someone give me that. No sense in being uncomfortable. Burning is an issue and that is what concerns me. And what if the pump fails and unfortunately, we have all seen that happen.