What is the proper protocol for ordering intravenous (IV) potassium?

Protocol for Ordering Intravenous Potassium

IV potassium should be administered using a calibrated infusion device at a controlled rate, with central venous administration preferred for concentrations ≥300 mEq/L and for all rapid infusions to minimize pain and risk of extravasation. 1

Dosing Guidelines

Standard Administration

• Maximum rate: 10 mEq/hour for routine replacement 1
• Maximum daily dose: 200 mEq/24 hours when serum potassium >2.5 mEq/L 1

Urgent Administration

• For severe hypokalemia (serum potassium <2.5 mEq/L or with ECG changes/muscle paralysis):
  • Rates up to 40 mEq/hour may be used 1
  • Maximum daily dose: 400 mEq/24 hours 1
  • Requires continuous ECG monitoring and frequent serum potassium measurements 1

Administration Route Selection

Central Venous Access (Preferred)

• Mandatory for:
  • High concentrations (300-400 mEq/L) 1
  • Rapid infusion rates (>10 mEq/hour) 1
  • Severe hypokalemia requiring urgent correction 1
• Benefits: Better dilution by bloodstream, reduced pain, lower risk of extravasation 1

Peripheral Venous Access

• Only for lower concentrations (<300 mEq/L) 1
• Only for standard infusion rates (≤10 mEq/hour) 1
• Higher risk of pain and extravasation 1

Safety Protocols

Required Monitoring

• Continuous cardiac monitoring for all patients receiving:
  • Central line infusions
  • Rates >10 mEq/hour
  • Patients with moderate to severe hypokalemia 2
• Serum potassium monitoring:
  • Before initiating therapy
  • During therapy (frequency based on infusion rate)
  • After completion of infusion 1
• ECG monitoring to detect early signs of hyperkalemia:
  • Peaked T waves (earliest sign, at 5.5-6.5 mmol/L)
  • Prolonged PR interval, flattened P waves (at 6.5-7.5 mmol/L)
  • Widened QRS (at 7.0-8.0 mmol/L) 2

Double-Check Safety Measures

• Institute a double-check policy for every step of potassium administration 3
• Two healthcare providers should verify:
  • Correct product
  • Correct dose
  • Correct dilution
  • Correct labeling
  • Correct route
  • Correct rate 3

Preparation Guidelines

1. Use pharmacy-based IV admixture systems when possible 3
2. Use premixed solutions rather than concentrated potassium vials 3
3. Ensure all prescriptions include specific instructions for:
   • Dilution concentration
   • Infusion rate
   • Duration 3
4. Avoid using the term "bolus" for IV potassium orders 3

Special Considerations

Renal Impairment

• Use extreme caution in patients with renal insufficiency 1
• Consider dose reduction and more frequent monitoring 1
• Consider dialysis for severe hyperkalemia in patients with renal failure 2

Cardiac Patients

• Use extra caution in patients on digitalis 1
• Monitor for signs of digitalis toxicity 1

Pediatric Patients

• For hyperkalemia: 0.1 unit/kg insulin with 400 mg/kg glucose 3
• Adjust doses based on weight and age 3

Pitfalls to Avoid

1. Never administer IV potassium as a direct IV push or bolus
2. Never exceed recommended infusion rates without appropriate monitoring
3. Never use flexible containers in series connections 1
4. Never add supplementary medications to potassium infusions 1
5. Avoid rapid infusion which can lead to fatal hyperkalemia 1
6. Avoid peripheral administration of high concentration solutions due to pain and risk of extravasation 1

Emergency Management of Hyperkalemia

If hyperkalemia develops during potassium administration:

1. Stop potassium infusion immediately
2. Administer calcium (calcium gluconate 10%: 15-30 mL IV over 2-5 minutes) 2
3. Shift potassium into cells:
   • Insulin with glucose: 10 units regular insulin with 25g glucose IV 2
   • Sodium bicarbonate: 50 mEq IV over 5 minutes 2
   • Nebulized albuterol: 10-20 mg over 15 minutes 2
4. Remove potassium from body:
   • Diuresis: furosemide 40-80 mg IV 2
   • Consider dialysis if severe or refractory 2

By following these protocols, the risk of adverse events related to IV potassium administration can be minimized while effectively treating hypokalemia.