Should a patient with diabetic ketoacidosis (DKA) and hypokalemia continue receiving both intravenous (IV) potassium chloride (KCL) and oral potassium chloride (KCL) when not on lactated Ringer's (LR) solution, with a recent potassium level of hypokalemia?

From the Guidelines

I recommend discontinuing the IV potassium chloride (KCl) and continuing only the oral KCl at this time, as the patient's most recent potassium level of 3.9 mEq/L from this morning is within the normal range (3.5-5.0 mEq/L), indicating that the severe hypokalemia has been corrected 1. The Pyxis restriction specifying that IV KCl should only be given if the patient is on lactated Ringer's (LR) solution is likely a safety measure, as IV potassium administration requires appropriate dilution and monitoring.

According to the most recent guidelines, when glucose levels are between 150 and 200 mg/dL, IV fluids such as 0.9% NaCl can be used, and potassium can be given in each liter of IV fluid as needed to keep serum potassium between 4 and 5 mmol/L 1. However, since the patient is no longer severely hypokalemic and has a functioning GI tract (as evidenced by the order for oral KCl), the oral route is safer and adequate for maintenance therapy.

Oral potassium supplementation is preferred when possible because it has a lower risk of complications compared to IV administration. The patient's potassium level should be monitored closely to ensure it remains within the normal range, as patients with DKA often have total body potassium depletion despite normalizing serum levels during initial treatment 1. It is essential to document this decision and continue to monitor the patient's condition to prevent any potential complications.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION The dose and rate of administration are dependent upon the specific condition of each patient. Administer intravenously only with a calibrated infusion device at a slow, controlled rate Because pain associated with peripheral infusion of Potassium Chloride solution has been reported, whenever possible, administration via central route is recommended for thorough dilution by the blood stream and avoidance of extravasation. The patient's current serum potassium level is 3.9 mEq/L, which is greater than 2.5 mEq/L.

• The recommended administration rate should not usually exceed 10 mEq/hour.
• There is no direct information in the provided drug labels that addresses the specific question of whether to continue both IV KCL and oral KCL in this patient. However, based on the information provided, it seems that the patient is not on LR (Lactated Ringer's solution), but the Pyxis shows to only give the IV KCL if on LR. Given the patient's hypokalemia and DKA (Diabetic Ketoacidosis), it is crucial to manage their potassium levels carefully. Since the patient's serum potassium level is 3.9 mEq/L, which is not severely low, and considering the lack of direct information on continuing both forms of KCL, a conservative approach would be to consult with the healthcare team to determine the best course of action for this patient 2.

From the Research

Patient Treatment for DKA and Hypokalemia

• The patient is currently being treated for Diabetic Ketoacidosis (DKA) and hypokalemia, with scheduled IV KCL and oral KCL administration.
• The Pyxis system indicates that IV KCL should only be given if the patient is on Lactated Ringer's (LR) solution, but the patient is not currently on LR.
• The last potassium lab result was 3.9 mEq/L at 0541 this morning, indicating hypokalemia.

Potassium Repletion via Oral and Intravenous Routes

• According to the study 3, hypokalemia can be repleted via intravenous or oral routes, with oral administration preferred.
• The study 3 also notes that immediate release liquid KCl is optimal for inpatient use due to its rapid absorption and subsequent increase in serum K levels.
• Another study 4 recommends using the oral route whenever possible to treat or prevent hypokalemia.

Decision on Continuing Both Forms of KCL

• Given the patient's current hypokalemia and the preference for oral administration, it may be beneficial to continue both forms of KCL administration, as the oral route is preferred but the IV route may be necessary to rapidly correct the potassium level.
• However, the decision to continue both forms of KCL should be made in consultation with the patient's healthcare team, taking into account the patient's individual needs and medical history, as noted in the studies 3, 4.