The Order...

RedCell · Jan 29, 2008

Get the calcium going as soon as possible, it will protect the resting membrane potential of the heart while the K+ Is jacked.

Everything else can be slammed in one right after the other. Ideally the glucose/insulin combo will be the best thing to quickly get the K+ out of the extracellular space.

Flush in between giving each med if it makes you feel better.

The bicarbonate issue really only helps to temporarily correct metabolic acidosis if it is present, recent studies have shown that it doesnt actually do as much as previously believed to correct K+.

Assume you meant 60mg lasix (F.Y.I. the correct dose of lasix is BUN + age according to a dude named Samuel Shem, you should read his book if you work in the ER). Push it as fast or slow as you feel comfortable with. I know people all have their own opinion on this so if you are new, just follow "protocol" or according to what the nurse edumakator says.

Whatever order you choose, I wouldnt give that Kayexalate until the the patient was enroute to either the dialysis unit or a bed upstairs. No sense in adding more work to yourself or your coworkers. That stuff definitely causes mass explosions.

RunnerRN, BSN, RN · Jan 29, 2008

Alright...I've seen many different RNs give dialysis pts. the following medication in various orders. I question all of you other nurses how you administer these medications for this kind of patient.
You have:
Kayeaxalte PO
Calcium gluconate 10 ml c. 50 mL 0.9 NS to go over 15-20 minutes via pump
Amp of D50
Amp of Sodium Bicarb
10 U of insulin
60 mL Furosemide (how many min. to push over?)
Flushes...flushes...flushes..when do they go after or before each med?
It bothers me that I don't know what order is correct or standard. Please educate me. Thank you.

Ok, so I'm sure you know that these meds are used to correct K+ imbalance as well as fluid retention. Here is my order:

-Calcium first, over 5-10 minutes...for the same reason as the PP. Plus, it is the one most likely to cause problems so you will still be in the room for close to 5-10 more minutes after it to watch the monitor.

-Insulin-I always dilute my insulin in 1 cc of NS (draw up your insulin with an insulin syringe, have it verified, then draw up 1 cc of NS in a different syringe and add your insulin - this just makes it easier to give) No real rate for insulin, just give it.

D50-your big limitation on the rate for D50 is how fast you can actually push the med. It is thicker than NS and more difficult to push in the amp. I've found that if I push it at a rate comfortable for my hand, it is not too fast or too slow, and goes in over a little more than a minute.

-NaHCO3-Same as D50.

-Lasix-I push each 20mg over 2-3 minutes, so 60mg would go over about 5 minutes. Monitor your BP.

Obviously flush in between each med.

Then you have Kayexalate.....one of the meaner drugs to give. I think it is super mean to give it just before a patient goes home (if you're sending this patient home....we've done just Kayexalate for mild K+ increases and sent them home) So if we do have to do that, I tell them it will cause the runs and tell them they can make the choice between staying in the WR for a while or heading home. In giving to an admit pt, it is bad karma to give it just before going up, but I will admit that I've done it too. Hope this helps!

Blee O'Myacin, BSN, RN · Jan 29, 2008

Alright...I've seen many different RNs give dialysis pts. the following medication in various orders. I question all of you other nurses how you administer these medications for this kind of patient.
You have:
Kayeaxalte PO
Calcium gluconate 10 ml c. 50 mL 0.9 NS to go over 15-20 minutes via pump
Amp of D50
Amp of Sodium Bicarb
10 U of insulin
60 mL Furosemide (how many min. to push over?)
Flushes...flushes...flushes..when do they go after or before each med?
It bothers me that I don't know what order is correct or standard. Please educate me. Thank you.

Well, be sure to put that foley in!

I'd start the calcium, establish a second IV and then do the insulin, d50 and bicarb. (flush with amount of NSS as per your facility policy - and yes, inbetween each med.)

Then I'd do the lasix and then the k exelate.

Push that lasix over a minute or so. Not too fast, but it doesn't have to go in slow like cardizem or dig.

And ditto about not sending them to the floor while drinking the K+ exelate - or if it does work out that you have to send them up (ie - full waiting room patients laying in hallway stretchers moaning, etc. Warn the accepting nurse while giving report and tell her why you cannot wait until the patient has a bowel movement before transferring. Being upfront about it saves you from the bad karma!)

Blee

ERRNTraveler, RN · Jan 31, 2008

Screw Karma- give the kayexalate right before they leave the ER!

berry · Jan 31, 2008

Alright...I've seen many different RNs give dialysis pts. the following medication in various orders. I question all of you other nurses how you administer these medications for this kind of patient.
You have:
Kayeaxalte PO
Calcium gluconate 10 ml c. 50 mL 0.9 NS to go over 15-20 minutes via pump
Amp of D50
Amp of Sodium Bicarb
10 U of insulin
60 mL Furosemide (how many min. to push over?)
Flushes...flushes...flushes..when do they go after or before each med?
It bothers me that I don't know what order is correct or standard. Please educate me. Thank you.

I would grab a 250 cc bag of NS pull out 100 cc put a amp of Ca gluconate the amp of bicarb the insulin and the D50 in it and put it on a minidripper and let it go. Some sources will say that Ca++ and Bicarb will precipitate in the same line but I have never seen it. (2 hospitals I worked at mixed it this way when a K lowering cocktail was ordered) then give the Lasix then the kayexalate PO. The kayexalate while messy and not fun to give also is more of a long term thing the drug mix will lower the pts K+

CritterLover, BSN, RN · Jan 31, 2008

if you are giving all of this through a peripheral line, please give the d50 before the insulin.

ERRNTraveler, RN · Jan 31, 2008

if you are giving all of this through a peripheral line, please give the d50 before the insulin.

yes, because if you give the insulin first, then, god forbid, lose your line, your pt's sugar is going to drop without iv access to give that d50!

CritterLover, BSN, RN · Jan 31, 2008

yes, because if you give the insulin first, then, god forbid, lose your line, your pt's sugar is going to drop without iv access to give that d50!

and we all know how well peripheral veins tolerate d50 :)

RNcDreams · Feb 1, 2008

Ahh, I was just wondering about that whole D50-through-a-peripheral topic...

Is it wrong to push an amp of that stuff in an emergency, if all you have is a peripheral?

I had a pt the other day with a fingerstick of 40 (still A+Ox3, talking up a storm, stable vitals, etc), and I gave her the D50 IV push into a #20 because it's all she had, with a bag of NS running to help flush it through.

Was that out of line?

CritterLover, BSN, RN · Feb 1, 2008

ahh, i was just wondering about that whole d50-through-a-peripheral topic...
is it wrong to push an amp of that stuff in an emergency, if all you have is a peripheral?
i had a pt the other day with a fingerstick of 40 (still a+ox3, talking up a storm, stable vitals, etc), and i gave her the d50 iv push into a #20 because it's all she had, with a bag of ns running to help flush it through.
was that out of line?

well, no, not really.

in an emergency, you use what you have. paramedics push d50 through peripheral lines all the time, because that is all they have. it isn't good for the veins, but you do what you have to do.

a better option, though, would have been to give her food. since she was awake and alert and talking, a snack (or meal tray) would have been the better option. unless, of course, she was npo.

most hospitals have a hypoglycemia protocol. the more "progressive" (for lack of a better term) facilities allow you to feed the patient, rather than giving d50, if they are alert and tolerating a diet. if your facility doesn't have this provision, you might want to think about suggesting the change.