Running KCL without knowing the pt's baseline K

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So. The patient presents to the ED with a chief complaint of dizziness and generally feeling unwell over the past few days. No chest pain, no shortness of breath and his ECG shows a left bundle branch block only. He's a little tachy, a little hypotensive, but he's alert and in no acute distress, just appears dry. The physician orders an NS 1L bolus followed by NS with 20KCL 1L (into a peripheral line) over an hour. I take issue (politely) with him ordering a bolus of 20 meq of KCl over one hour without a single lab test having been drawn on this patient (we have no idea what his baseline potassium level is, never mind his creatinine, urea, or anything else). He assures me that it would take 200 mEq of potassium to boost this patient's potassium by a single mmol/L (his words) and therefore I'm making too big a deal over nothing. The other nurses who overhear this part of the conversation agree and tell me it's safe to go ahead. What do you think?

P.S. The patient's potassium came back at 4.7 mmol/L (normal range in our hospital 3.5-5).

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Specializes in Cardiac Telemetry, ED.

10mEqs will raise the serum K+ by 0.1mmol/L, so 100mEqs would increase the serum K+ by 1mmol/L. Also, since K+ is contraindicated for acute dehydration, unless the doc had some other reason for giving K+, I'm with you.

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Specializes in Cardiac, ER.

You can't really state that 100meq will raise the serum level by one,.without taking other things into consideration,.for instance I can lower all your electrolytes by dumping large amounts of fluids or you can have technically high levels of electrolytes (per lab values) if you are dry,..then add some fluids and you might even be low,...I can't imagine 20meqs of KCl along with 2000ml of fluid could harm anyone with normal renal function,.I think I'd ask the Dr to explain his thought process.

I see this theory of dilution/concentration alot with GI bleeds. Person comes in vomitting huge amounts of frank blood,.pale, diaphoretic,.tachy, hypotensive,..the H&H comes back normal and you're thinking no way,..well then you find out the pt had been vomiting for 4 days with very little oral intake before the bleeding started,...give them a couple liters of fluids and recheck the H&H to get a more acurate picture of what's going on.

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Drawing bloodwork is standard in E.D. Regardless of any theories, this patient should have had blood drawn to rule out any other issues.

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Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.

I'm w/you , no K+ unless you know the basics, serum k+ and renal function. BTW what was the rush, couldn't the NS go in while labs were sent off? He was wrong anyway, with a therapeutic serum k+, how on earth could he rx someone w/out basic labs/chemistry?? It is JULY, keep those you love out of the ED til at least late september!!! (I wonder what the m+m stats are for july and august in our hospitals, good grief!!!

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Agree. With this clinical presentation; labs while rehydration.

Treatment w/o dx = malpractice.;)

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Specializes in ICU.

in the good 'ol days, most inpatients were given D51/2 with 20meq KCL as base line fluids. chasing their low K rarely happened. hmmmmm.

in older folks we'd rather keep their K levels towards the higher end of normal for better cardiac function but i agree, knowing basic lytes, considering there were no dysrthymias would have been better practice.

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Specializes in OB, NICU, Nursing Education (academic).

It is JULY, keep those you love out of the ED til at least late september!!! (I wonder what the m+m stats are for july and august in our hospitals, good grief!!!

Oh my goodness....so true! Your post and user-name made me smile this morning, and I haven't even finished my 1st cup of coffee yet.:bow:

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Ok, thanks, everyone. I agree, it's not that the pt was likely to be harmed, but it just seemed like sloppy practice. Anyway, I appreciate the info. Next time I'll be able to more confidently make my point.

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Hate to be a kill joy, I know flaming doctors is fun and all :D; however, I just want to have a couple of things cleared up?

You say no labs were ordered, then you say the potassium came back at 4.7? I am a bit confused on that point.

Obviously, the doctor was not a total idiot. He/she realized the signs and symptoms of a fluid voulme deficit and ordered fluid replacement. So, we are not talking about somebody who has no idea how to take care of a patient.

Did the doctor have a reason for the order? What were his thoughts on what was going on, I am sure he/she had some reason for the order. Sometimes rewording a question will be more helpful. For example, "I see you ordered potassium in the second liter of NS, do you have some concerns with his/her potassium? What do you think is going on with this patient? Should I be looking for any signs and symptoms that may help you come up with a diagnosis?"

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I don't think this doctor's an idiot at all and it was never my intent to suggest otherwise. It's not that labs hadn't been ordered, just that they hadn't yet been drawn and so the bolus was ordered with no regard for the results, which were received 2 hours later. I asked for his rationale and it was, in effect, that it wouldn't hurt. This is where I'm unsure and why I posted this question in the first place. I agree, in theory, that the patient would likely not have been harmed but the rationale seems to me to be inadequate. You could give me 20 mEq of KCL over an hour and I'm sure I'd be fine but why bother? He couldn't give me a better reason than that and so I was wondering if any of you could. If not, forget it. I'd hold the KCL and just bolus NS till I get the results back next time and we can make an informed decision as to whether or not the patient really needs it.

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the docs have far more education and experience working with patient problems than do nurses. so, i say to do what he wants, unless it's something totally out of this world.

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