KCl max clarification

[RoninX]

General rule of thumb for KCl infusion in peripheral line is maximum of 10 mEq per hour, accounting for cumulative KCl from multiple sources.

A provider brought up a question: If patient has multiple separate peripheral lines, one in right wrist, one in left wrist, can you still run 10 mEq KCl in each peripheral line separately? Cumulatively it would be 20 mEq per hour of KCl, however they are in separate lines. Is this possible? Would there still be cardiac issues?

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[deleted547339]

General rule of thumb for KCl infusion in peripheral line is maximum of 10 mEq per hour, accounting for cumulative KCl from multiple sources.

A provider brought up a question: If patient has multiple separate peripheral lines, one in right wrist, one in left wrist, can you still run 10 mEq KCl in each peripheral line separately? Cumulatively it would be 20 mEq per hour of KCl, however they are in separate lines. Is this possible? Would there still be cardiac issues?

Its fine. You give 20mEq/h via CVL. The reason to not go faster than 10 via PIV is pain/vessel sclerosis. You’re not going to get into trouble at that rate.

 

[turkeyjerky]

What's a provider?

I always thought the rule of thumb was 10 meq/kr for peripherals due to vascular sclerosis, w/ 20 meq okay in a central line (but no more than this due to risk of cardiotoxicity). I would see no reason why giving a total of 20 meq/hr from two lines would be a problem. I think I recall seeing this an an option during med school learnings...

Anyone else do what I do? For really severe hypokalemia (<2.2 or so) I usually give 40 PO and 40 IV (nurses'll always hang it at 10/hr). I've never had any issues w/ this.

 

[deleted547339]

What's a provider?

I always thought the rule of thumb was 10 meq/kr for peripherals due to vascular sclerosis, w/ 20 meq okay in a central line (but no more than this due to risk of cardiotoxicity). I would see no reason why giving a total of 20 meq/hr from two lines would be a problem. I think I recall seeing this an an option during med school learnings...

Anyone else do what I do? For really severe hypokalemia (<2.2 or so) I usually give 40 PO and 40 IV (nurses'll always hang it at 10/hr). I've never had any issues w/ this.

I’ll do 80 PO, 40IV at 20/h then recheck at 2h. If they’re having cardiac arrhythmias and severely hypoK I’ve done 40/h x1h.

edit: the nurses did NOT like it.

 

[ShockIndex]

These patients with a potassium in the toilet almost always need multiple points of access. Their magnesium is generally low too and that is going to tie up one IV for hours (days). So, I often will put a triple lumen in these patients if there are any other issues that will need an IV such as antibiotics. Yes, I’ll treat isolated hypoK/hypoMg with just 2-3 peripheral IVs but it is a PITA for nurses when it comes to multiple non-compatible drips and frequent blood draws. This is especially true for those 10% of DKA patients who have profoundly low plasma K on arrival. They needs lots of real access.

Just be careful with your wires with an IJ or subclavian as myocardium exposed to a K of 2 does not like to be tickled. I generally put in a femoral for the first 24 hours just to get caught up and then pull it ASAP once the K is closer to 3.

 

[MoMoGesiologist]

These patients with a potassium in the toilet almost always need multiple points of access. Their magnesium is generally low too and that is going to tie up one IV for hours (days). So, I often will put a triple lumen in these patients if there are any other issues that will need an IV such as antibiotics. Yes, I’ll treat isolated hypoK/hypoMg with just 2-3 peripheral IVs but it is a PITA for nurses when it comes to multiple non-compatible drips and grew blood draws. This is especially true for those 10% of DKA patients who have profoundly low plasma K on arrival. They needs lots of real access.

Just be careful with your wires with an IJ or subclavian as myocardium exposed to a K of 2 does not like to be tickled. I generally put in a femoral for the first 24 hours just to get caught up and then pull it ASAP once the K is closer to 3.

Yea... not putting in a femoral central line to give K

 

[jw3600]

Yea... not putting in a femoral central line to give K

If it's critically low with EKG changes or partial/complete paralysis I think it is 100% reasonable to.

 

[ShockIndex]

If it's critically low with EKG changes or partial/complete paralysis I think it is 100% reasonable to.

Perhaps I took for granted that people understood what I meant by multiple electrolytes in the toilet requiring ICU level care. I wasn’t referring to floor patients with just a K of 2.5 and a Mg of 1.3. I think that we have all seen those patients with K‘s less than 1.5 and Mg‘s less than 1 who are have profound neuromuscular complications as well as being in and out of wide complex tachycardia / TDP. A couple of peripherals ain’t gonna cut it in those patient - especially when factoring in the need for other parenteral med infusions, frequent lab draws, etc. Keep in mind that these patients will needs days of IV Mg to replenish their stores as well as hundreds of milliequivalents of potassium.

For those who don’t like putting in a femoral for 24 hours, feel free to use a dual lumen midline. Although, I’m much faster with a femoral and you really only need it for the first 24 hours.

 

[WheezyBaby]

I'd need to hunt for the article, but in arrest that's presumed secondary to hypokalemia, I remember seeing emergency dosing of 10 meq over 10 minutes (that's how I remembered the dosing to make it easy, but the referenced dosing was slightly more nuanced, eg 6 meq over 5 minutes then 4 meq over 5 minutes).

Otherwise agree with the others

 

[DrDrummer]

I'd need to hunt for the article, but in arrest that's presumed secondary to hypokalemia, I remember seeing emergency dosing of 10 meq over 10 minutes (that's how I remembered the dosing to make it easy, but the referenced dosing was slightly more nuanced, eg 6 meq over 5 minutes then 4 meq over 5 minutes).

Otherwise agree with the others

https://www.ahajournals.org/doi/full/10.1161/circ.102.suppl_1.I-217

This is one reference where they discuss rapid administration of potassium for arrest.

 

[WheezyBaby]

https://www.ahajournals.org/doi/full/10.1161/circ.102.suppl_1.I-217

This is one reference where they discuss rapid administration of potassium for arrest.

That was the study I had in mind, thanks!

 

[RoninX]

Thanks for all the great input! Much appreciated.

What's a provider?

Provider = healthcare provider

 

[chocomorsel]

Thanks for all the great input! Much appreciated.



Provider = healthcare provider

Seriously?
What the question was referring to was tongue in cheek. As in, let’s stop calling ourselves “providers”.
We are idiots for grouping ourselves with midlevels no matter how administration and said midlevels try to keep shoving that term down our throats.
The fact that you seem not to have gotten it goes to show how brainwashed the younger generation has become.

 

[crafted222]

Seriously?
What the question was referring to was tongue in cheek. As in, let’s stop calling ourselves “providers”.
We are idiots for grouping ourselves with midlevels no matter how administration and said midlevels try to keep shoving that term down our throats.
The fact that you seem not to have gotten it goes to show how brainwashed the younger generation has become.

You assume the op is not a midlevel? (until otherwise stated)

 

[chocomorsel]

You assume the op is not a midlevel? (until otherwise stated)

Absolutely correct.
I forget we get so many others on here and it’s not just docs.

 

[lymphocyte]

do you get the same repletion if you bolus LR which has 20mEq K?

It has 4-5, not 20. It's also been shown to reduce serum potassium in several prospective randomised control trials and is my crystalloid of choice in hyperkalemia.

Effects of normal saline vs. lactated ringer's during renal transplantation - PubMed

Compared with NS, LR infusion may lead to a lower serum potassium level and a lower risk of acidosis, while there is major concern of the hypercoagulable state in these patients.

pubmed.ncbi.nlm.nih.gov

 

[emapplicant2021]

It has 4-5, not 20. It's also been shown to reduce serum potassium in several prospective randomised control trials and is my crystalloid of choice in hyperkalemia.

Effects of normal saline vs. lactated ringer's during renal transplantation - PubMed

Compared with NS, LR infusion may lead to a lower serum potassium level and a lower risk of acidosis, while there is major concern of the hypercoagulable state in these patients.

pubmed.ncbi.nlm.nih.gov

we can order LR with 20 KCl in our institution; can you give it over an hour peripherally to lessen pain. i just wonder if the extra volume can cause force diuresis vs KCl on its own

 

[deleted171991]

we can order LR with 20 KCl in our institution; can you give it over an hour peripherally to lessen pain. i just wonder if the extra volume can cause force diuresis vs KCl on its own

The extra volume will "force" hypervolemia, not necessarily diuresis. It depends on the patient how elastic/inflamed his interstitium is, what his hormonal status is, what his natremia is etc. Most healthy people can easily accommodate an extra few liters in their extravascular space (hence the water loss during the first days of fasting). One shouldn't assume that extra IV fluid will be eliminated.

The main reason to use LR + 20 KCl is not to replenish potassium, but as a low rate maintenance fluid (in NPO patients with normal kidney function).

It may take a lot of IV fluid to replenish potassium peripherally (20 mEq of IV KCl will raise serum potassium by about 0.25 mEq/L). It may be better to use mostly PO potassium, or a central line.