What is the appropriate care for a patient with infiltrated potassium (K+) replacement, particularly one with a history of hypokalemia?

Care for Infiltrated Potassium Replacement

Stop the infusion immediately and remove the IV catheter to prevent further tissue damage and pain. 1, 2

Immediate Actions

Discontinue the infusion and assess the infiltration site:

• Remove the peripheral IV catheter immediately upon recognition of infiltration 1
• Assess the extent of tissue involvement by examining for swelling, blanching, coolness, and pain at the site 2
• Document the volume of fluid infiltrated and the concentration of potassium chloride that extravasated 1
• Elevate the affected extremity to reduce swelling and promote venous drainage 2

Pain Management

Address infiltration-related discomfort:

• Apply warm compresses to the infiltrated area to promote vasodilation and enhance absorption of the infiltrated fluid 2
• Consider simple analgesics for pain control, as patients commonly report significant discomfort with potassium infiltration 2
• Monitor the site for development of tissue necrosis, which can occur with concentrated potassium solutions 1

Reestablishing IV Access and Continuing Replacement

Use central venous access for concentrated potassium solutions whenever possible:

• The FDA explicitly recommends central route administration for thorough dilution by the bloodstream and avoidance of extravasation, particularly for highest concentrations (300 and 400 mEq/L) which should be exclusively administered via central route 1
• If peripheral access must be used, limit concentration to ≤40 mEq/L and infusion rate to maximum 10 mEq/hour when serum potassium is >2.5 mEq/L 1, 3
• For severe hypokalemia (K+ <2.0 mEq/L with ECG changes or muscle paralysis), rates up to 40 mEq/hour can be administered via central line with continuous cardiac monitoring 1

Consider adding lidocaine to peripheral potassium infusions:

• Adding lidocaine 50 mg to potassium chloride 20 mEq/65 mL significantly reduces pain perception during peripheral infusion 4
• This approach improves patient tolerance when peripheral administration is necessary 4

Monitoring Requirements

Implement continuous surveillance during replacement therapy:

• Use continuous cardiac monitoring for patients receiving concentrated potassium solutions or those with severe hypokalemia 1
• Check serum potassium and renal function frequently during aggressive replacement to avoid hyperkalemia and cardiac arrest 1
• For patients requiring fluid restriction who need concentrated potassium solutions, maintain continuous cardiac monitoring and frequent testing for serum potassium concentration and acid-base balance 1

Special Considerations for Patients with History of Hypokalemia

Address underlying causes to prevent recurrence:

• Correct hypomagnesemia first, as it is the most common reason for refractory hypokalemia and must be corrected before potassium levels will normalize, with target magnesium >0.6 mmol/L 5
• For patients on potassium-wasting diuretics with persistent hypokalemia, consider adding potassium-sparing diuretics (spironolactone 25-100 mg daily, amiloride 5-10 mg daily, or triamterene 50-100 mg daily) rather than chronic oral supplementation 5
• Target serum potassium 4.0-5.0 mEq/L, as both hypokalemia and hyperkalemia increase mortality risk, particularly in patients with heart disease 5

Common Pitfalls to Avoid

Critical errors that compromise patient safety:

• Never use flexible containers in series connections, as this could result in air embolism 1
• Do not add supplementary medication to potassium chloride solutions 1
• Avoid administering digoxin before correcting hypokalemia, as this significantly increases risk of life-threatening arrhythmias 5
• Do not combine potassium supplementation with potassium-sparing diuretics without specialist consultation due to severe hyperkalemia risk 5
• Failing to use a final filter during administration when possible increases risk of particulate matter infusion 1