IV Potassium Replacement

[slycaper]

What do you guys think about replacing K+, 10 mEq per hour X 2 AC peripheral IV's for a total of 20 mEq per/hr for those with critically low K+ (can't go PO)? In those situations where a central line isn't necessary/possible.

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[Hernandez]

Define critically low. And if it is critically low, a cental line is necessary, I can count on one hand the times I couldn't central venous access in someone.

 

[deuist]

Is the GI tract working? You can pour in potassium through an NG tube.

 

[Hamhock]

What's the fastest potassium you have put in through a central line?

HH

 

[Hernandez]

What's the fastest potassium you have put in through a central line?

HH

~80-100meq/ hour us the most pharm would let us, if I needed that much I'd double up and use the gut as well

 

[Hamhock]

Great. Thanks, Hernandez.

Any idea where this came from? Is it based on any studies?

Are there a bunch of dead people or study animals after giving more?

Of course, assuming the potassium is 1.8 (pretty damn low), even 100/hr would be pretty helpful.

HH

 

[Hernandez]

Great. Thanks, Hernandez.

Any idea where this came from? Is it based on any studies?

Are there a bunch of dead people or study animals after giving more?

Of course, assuming the potassium is 1.8 (pretty damn low), even 100/hr would be pretty helpful.

HH

"Because 100meq is the dose they use in capital punishment."

 

[Bostonredsox]

Define critically low. And if it is critically low, a cental line is necessary, I can count on one hand the times I couldn't central venous access in someone.

Can count them on one hand with no fingers....

Agree. Critically low K gets a CVC, 40-60meq IV over an hour and I give another 60meq po in the first hour if possible. Low k kills people. They are by definition sick enough to get a line.

Of shoot question.... Do you put lines in your DKA pts who are very acidotic but ventilating well and hemodynamicly stable? I have found if I have to wait on my lab techs to draw q2h or even sometimes q4h bmps, they take atleast an extra 90 minutes beyond what I order. If I put in a line he nurses will draw the labs themselves and they will get sent q2h down to the minute. Turn around still slow but atleast they're drawn and in the lab. Hard to titrate insulin and make drip changes when I'm getting me labs much later than needed. And any finger stick > 500 here has to be verified with venous draw as > 500 could be 501 or 1100, which then takes another hour. So I put lines in a lot of these pts.

 

[deleted547339]

Can count them on one hand with no fingers....

Agree. Critically low K gets a CVC, 40-60meq IV over an hour and I give another 60meq po in the first hour if possible. Low k kills people. They are by definition sick enough to get a line.

Of shoot question.... Do you put lines in your DKA pts who are very acidotic but ventilating well and hemodynamicly stable? I have found if I have to wait on my lab for q2h or even sometimes q4h bumps, they take atleast an extra 90 minutes. If I out in a linens nurses will draw the labs themselves and they will get sent q2h down to the minute. Turn around still slow but atleast they're drawn and in the lab.

Lets not get cocky now....

 

[Bostonredsox]

Lets not get cocky now....

Fair enough my N for inability to get central access is 1/250-275. And neither surgery nor IR ended up getting in either so his HD catheter became his picc as well until he died.

 

[Hernandez]

Lets not get cocky now....

That just means he hasn't done enough.......

Can count them on one hand with no fingers....

Agree. Critically low K gets a CVC, 40-60meq IV over an hour and I give another 60meq po in the first hour if possible. Low k kills people. They are by definition sick enough to get a line.

Of shoot question.... Do you put lines in your DKA pts who are very acidotic but ventilating well and hemodynamicly stable? I have found if I have to wait on my lab techs to draw q2h or even sometimes q4h bmps, they take atleast an extra 90 minutes beyond what I order. If I put in a line he nurses will draw the labs themselves and they will get sent q2h down to the minute. Turn around still slow but atleast they're drawn and in the lab. Hard to titrate insulin and make drip changes when I'm getting me labs much later than needed. And any finger stick > 500 here has to be verified with venous draw as > 500 could be 501 or 1100, which then takes another hour. So I put lines in a lot of these pts.

Define acidotic.....and how low is their PaCO2? Usually no, 98% if DKA can be managed without q2 labs, even the real sick ones I probably don't do more than q4 lytes. If your glucometers are reliable over 500 and you'd need q1 blood sugars, sure, most of the units I've been in would go up to 700ish before verifying as long as the numbers made sense based off previous lytes, but yes, frequent lab draw (which I define as q6 or more frequent) gets a line most of the time

 

[Bostonredsox]

That just means he hasn't done enough.......





Define acidotic.....and how low is their PaCO2? Usually no, 98% if DKA can be managed without q2 labs, even the real sick ones I probably don't do more than q4 lytes. If your glucometers are reliable over 500 and you'd need q1 blood sugars, sure, most of the units I've been in would go up to 700ish before verifying as long as the numbers made sense based off previous lytes, but yes, frequent lab draw (which I define as q6 or more frequent) gets a line most of the time

Heh I figure that would draw you out for a rebuttals comment

And I agree I usually write q4 lytes. But even then q4 becomes q5.5 with my lab. And my glucometers peak at 500 so from the 900 or so they came in at until they are <500 the bedside finger sticks don't immediately help me. But you answered what I was getting at. Frequent labs results in a line. I do this for my bad ards pts and such who I know will get multiple abgs daily for several days. Without the art line all the bag sticks turns there wrists into hamburger.

 

[jdh71]

Heh I figure that would draw you out for a rebuttals comment

And I agree I usually write q4 lytes. But even then q4 becomes q5.5 with my lab. And my glucometers peak at 500 so from the 900 or so they came in at until they are <500 the bedside finger sticks don't immediately help me. But you answered what I was getting at. Frequent labs results in a line. I do this for my bad ards pts and such who I know will get multiple abgs daily for several days. Without the art line all the bag sticks turns there wrists into hamburger.

If you trust your O2 sat why waste time getting gases in the first place?

 

[Hernandez]

Heh I figure that would draw you out for a rebuttals comment

And I agree I usually write q4 lytes. But even then q4 becomes q5.5 with my lab. And my glucometers peak at 500 so from the 900 or so they came in at until they are <500 the bedside finger sticks don't immediately help me. But you answered what I was getting at. Frequent labs results in a line. I do this for my bad ards pts and such who I know will get multiple abgs daily for several days. Without the art line all the bag sticks turns there wrists into hamburger.

Do you really need an ABG daily if you have EtCO2 and a pulse ox? Unless they're hemodynamically unstable, I don't put in a-lines for frequent ABGs, I just don't do. ABGs, I'll use a vbg with pulse ox and periodic ABGs if I don't believe the other data.

 

[Bostonredsox]

Do you really need an ABG daily if you have EtCO2 and a pulse ox? Unless they're hemodynamically unstable, I don't put in a-lines for frequent ABGs, I just don't do. ABGs, I'll use a vbg with pulse ox and periodic ABGs if I don't believe the other data.

Probably not but it's part of our units vent protocol. They get daily chest X-rays and abgs. A lot are not necessary, but they're not my rules. But yes a vbg and pulse lx are probably sufficient though I don't have much experience with this yet

 

[Hernandez]

Probably not but it's part of our units vent protocol. They get daily chest X-rays and abgs. A lot are not necessary, but they're not my rules. But yes a vbg and pulse lx are probably sufficient though I don't have much experience with this yet

You should pull the daily X-rays articles and do a pro-con debate.

 

[ORL10]

i put an a-line in patients with DKA so labs can be drawn and it avoids a central line. I don't care about the pa02 or the CO2 usually, but getting stuck Q 4 hours sucks and putting in a central line in a usually a young patients neck is less than ideal. If they are super sick as in they are on pressors/infected etc obviously i have central access.

you are taking care of a different pt population than me if you haven't had the occasional hard time finding a place to put a line or maybe haven't had patients with enough devices who seem to be the culprits (PACs, ECMO, artificial hearts..)

 

[Hernandez]

i put an a-line in patients with DKA so labs can be drawn and it avoids a central line. I don't care about the pa02 or the CO2 usually,

Agreed....usually but if they're super acidotic and their bicarb is <5 and they're blowing their PaCO2 down to 10 or less, then their acidosis is really bad despite what the pH is, I'd have a lower threshold to put in lines/tubes. But thankfully, these are getting less and less common.

 

[VCU07]

What do you guys think about replacing K+, 10 mEq per hour X 2 AC peripheral IV's for a total of 20 mEq per/hr for those with critically low K+ (can't go PO)? In those situations where a central line isn't necessary/possible.

We do 10/hr peripheral and 20/central. I guess it depends on how low the level is, but I don't know about running in any more than 40/hr otherwise (that's the most i've seen in my setting). Also, with a questionable level, we will obviously redo the level and run in a 20meq bag in the meantime. Its hard to determine exactly how pts. will react...esp our renal pts. When I'm asked to replete in this scenario I usually give them a run and redraw a level 2hrs post infusion. I'm also a pharmacist, so my perspective might be different lol.

 

[inspirationmd]

What do you guys think about replacing K+, 10 mEq per hour X 2 AC peripheral IV's for a total of 20 mEq per/hr for those with critically low K+ (can't go PO)? In those situations where a central line isn't necessary/possible.

If low enough then 60 through a central line and 40 PO is my usual go to with another 40 in another hour IV + redose PRN later in day either IV or PO. Of course will also make sure the Mag is good. This usually gets me at least close to where I want to be.

Hypokalemia will kill people and I know not fixing it aggressively enough will result in mortality. Most ICU pharmacists get that and leave me be though 80 is the most through CVL at once I have ever done and was a bit nervous w that one.

 

[Idiopathic]

Hypokalemia will kill people and I know not fixing it aggressively enough will result in mortality. Most ICU pharmacists get that and leave me be though 80 is the most through CVL at once I have ever done and was a bit nervous w that one.

Yeah, it will...and ive seen hypokalemic arrest, but ive also never had anyone die from hypokalemia. Hyperkalemia, on the other hand...

An important variable to consider is the delta for potassium. If you dont know where a patient lives and you correct them from 2.5 to 4.5 quickly you run the risk of problems. Now obviously most of that K will be taken up by the cells, but if the patient arrests in the interim...

Ive never sweated hypokalemia in the non-arresting patient who wasnt also in a-fib. I replace slowly through multiple routes and keep a close eye on pH while i do it. Admittedly I take care of more surgical patients than DKA, etc.,

edit: i just cant see the utility in giving 80meq/hour to the non-arresting patient. anyone else do this? educate me

 

[Hernandez]

edit: i just cant see the utility in giving 80meq/hour to the non-arresting patient. anyone else do this? educate me

It isn't 80/hr, it's 80meg in an hour, I've never placed anyone on a continuous replacement that high, but I have given 80-100meq in an hour, mostly to a anorexic in torsades on methadone with a k of 1, the other pt I gave a crapmton to was a hyperparathyroidism to who had a calcium of 15 which was given bisphosphenates and calcitonin, we could barely keep up with mag, phos and potassium replacement and were getting labs q8 and subsequently giving very large k + phos loads! I wanna say 60mmol phos and 80meq total of k 3 times a day is what we ended up doing for 3 days

 

[Idiopathic]

okay so technically 80meq/hour is the same thing as 80meq in an hour, i get that you wouldnt continue to give that much every hour. also, i would argue that someone in torsades qualifies as "arresting"

 

[Hernandez]

okay so technically 80meq/hour is the same thing as 80meq in an hour, i get that you wouldnt continue to give that much every hour. also, i would argue that someone in torsades qualifies as "arresting"

If I write an order for 80meq/hour it would be hung as a drip without stop until I changed the order or unless I write 80meq/hour times 1 hour. I agree on the torsades being an arrest although a...slow intermitant arrest on that case, on the only other times I gave that much in an hour, I was only doing 40-60meq IV with 20-60 more down the gut at the same time. It's a very uncommon situation that would need that much.

 

[Idiopathic]

we are arguing semantics. im mainly just glad to see that people arent routinely replacing potassium that fast.