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OPERATIONAL DIRECTIVE
Office of the Chief Medical Officer
Enquiries to:
Phone number: 9222 2072
Supersedes: Operational Circular OP 1969/05
Subject:
OD number:
Date:
File No:
OD: 0444/13
17 May 2013
F-AA-23156
POLICY FOR INTRAVENOUS POTASSIUM CHLORIDE
This policy is intended for use in all Western Australian public hospitals. Its purpose is to enhance
the safety of prescribing, administration, supply and storage of intravenous potassium chloride.
This policy has been developed by the Office of Safety and Quality in Healthcare, Performance
Activity Quality Division and has been endorsed by the WA Medication Safety Group and the WA
Therapeutic Advisory Group.
Professor Bryant Stokes
A/DIRECTOR GENERAL
DEPARTMENT OF HEALTH WA
This information is available in alternative formats upon a request from a person
with a disability.
1
Western Australian Policy for Use of Intravenous Potassium Chloride
PRESCRIBING ASPECTS

Intravenous potassium chloride will only be prescribed when the oral or enteral route is
unavailable or clinically inappropriate.

Intravenous potassium chloride must be prescribed in millimoles (mmol) of potassium, and must
specify the dose, fluid and volume. The rate of administration should also be prescribed and
expressed as millilitres per hour (mL/hour). The rate should not exceed the maximum rates
specified in this policy. Intravenous potassium chloride must be prescribed on the fluid order chart.

All other prescriptions not meeting the prescribing practice defined above will be considered
incomplete and must be clarified with the prescriber.

Bolus intravenous potassium chloride should only be prescribed in exceptional circumstances
under the direction of the consultant in charge / director of department.

Standard pre-mixed potassium chloride solutions are to be prescribed whenever possible in all
areas of the hospital. ( See 2. Pre-mixed intravenous potassium chloride products below).

Prescription of non-standard potassium chloride solutions is permitted only when the patient is
admitted to an intensive care unit or high dependency unit and with the agreement of the
consultant/director of department in charge of the unit. The name of the consultant providing the
approval must be documented on the intravenous fluid order chart. (i.e. Approved by Dr……..)

All hospitals should have protocols for potassium supplementation which must be readily
accessible throughout the hospital.
STORAGE AND SUPPLY ASPECTS
1. Potassium chloride ampoules

Only one strength and size of potassium chloride ampoules will be stocked within
hospitals. This will be 10mL ampoules containing 10 mmol potassium chloride.

Potassium chloride ampoules must not be stored on general wards.
o
Other forms of concentrated injectable potassium should not be stored on the
wards (e.g. potassium acetate concentrated solutions) and should only be accessible
through the pharmacy department

Potassium chloride ampoules should not be placed or stored on resuscitation trolleys.

Potassium chloride ampoules should not be borrowed from other areas of the hospital.

In those areas permitted to store potassium chloride ampoules, they must be stored in sealed
clearly marked red containers separated from all other ampoules stored on imprest.

Potassium concentrations other than those available in pre-mix solutions will not be available in
general ward areas.

If potassium chloride ampoules are required in particular ward areas (e.g. nephrology) for a specific
order for a specific patient:
o
The IV fluid order chart with written evidence that the prescription has been approved by the
consultant/director of the department must be forwarded to the pharmacy department in
advance
o
The Pharmacy Department will dispense the exact number of potassium chloride
2
ampoules required;

o
Alternatively the solution may be made up in the Pharmacy Department;
o
Where potassium chloride ampoules are dispensed to a general ward any unused
ampoules must be returned to Pharmacy immediately.
All hospitals should have in place local guidelines governing the provision of potassium chloride
ampoules outside normal pharmacy hours
2. Pre-mixed intravenous potassium chloride products

Pre-mixed potassium solutions will have red outer packaging and red printed labels.

Standard pre-mixed solutions of potassium chloride should be stocked by WA hospitals, where
appropriate:
o
Standard premix solutions should contain either 10 mmol, 20 mmol or 40 mmol of potassium
chloride.
o
Standard premix solutions should be made up in a solution of either sodium chloride or
glucose (or a combination of both sodium chloride and glucose).

Most premixed solutions are NOT isotonic; exceptions are: 10mmol KCl in NaCl 0.29% (100mL
minibags), 10mmol KCl in NaCl 0.45% and Glucose 0.25% (500mL)

Concentrations of potassium chloride greater than 30 mmol in 1000mL in non-isotonic solutions
(e.g. sodium chloride 0.9%) may cause pain and phlebitis on administration.

Potassium chloride 10 mmol in 100 mL is an isotonic solution as it is prepared with a lower
concentration of sodium chloride (0.29%) and hence can be administered peripherally.

Contact your Pharmacy Department for advice on preparations available at your health service.

For appropriate intravenous potassium replacement in paediatric patients, refer to Child and
Adolescent Health Service, Princess Margaret Hospital, Department of Pharmacy Intravenous
Potassium Chloride Policy or local hospital guidelines.
Caution must be taken to ensure that maximum rate of intravenous potassium replacement does
not exceed 0.2 mmol/kg/hour for paediatric patients.

Hospitals may stock alternative potassium containing intravenous solutions in addition to the
standard premix solutions listed above with the provision that they are adequately labeled, stored
and administered in accordance with this Operational Directive and the prescription is guided by
hospital-approved policy/protocols.
PREPARATION ASPECTS

Preparation of infusions using potassium chloride ampoules should follow a safe on-site
preparation protocol, which is compliant with all the existing standards for the preparation and
labelling of intravenous solutions. (Local Nursing Drug Policy: Preparation of Intravenous
Medications. National Recommendations for User-Applied Labelling of Injectable Medicines, Lines
and Fluids – Operational Directive 0385/12)

Where potassium chloride solutions are prepared from potassium chloride ampoules, the solution
must be inverted at least 10 times to ensure t h a t t h e s o l u t e ( potassium chloride) is
thoroughly mixed throughout the solution.
Unshaken bags are prone to layering of added concentrate and are extremely hazardous.

Extra potassium must not be added to pre-mixed solutions containing potassium.

Potassium chloride ampoules must never be added to a hanging bag.
3
ADMINISTRATION ASPECTS
1.
Peripheral intravenous administration

Administration of the intravenous potassium chloride regimens that differ from this directive must be
approved in advance by the treating physician/specialist and documented on the intravenous fluid
order chart. (For smaller sites and rural hospitals with no treating specialist, consultation with an ED
or ICU consultant is recommended.) The maximum rate of potassium infusion must be observed in
all circumstances: that is, any variation in regime must remain in the range of delivery rates known
to be non-hazardous.

When using standard bags (500 or 1000 mL), a rate-limiting device must be used to prevent
unintentional bolus doses of solutions containing potassium chloride.
o For infusion concentration ≤ 20 mmol per 1000 mL, a rate controlled pump is
preferred, however an infusion burette is an acceptable alternative;
o
For ALL concentrations > 20 mmol per 1000 mL (which includes 10 mmol in 100 mL isotonic
solution), an infusion pump must be used.

The maximum rate of potassium chloride administration via peripheral lines is 10 mmol per hour.
(Maximum rate is 0.2 mmol/kg/hour for paediatric patients)

The maximum potassium chloride concentration for administration via peripheral lines is
40 mmol/L.
Exception: 10 mmol in 100 mL sodium chloride 0.29% pre-mixed mini-bags (isotonic solution).

..
2
Deviation from the recommendations for critical care areas must be supported by local hospital
policy.
Central administration

For Concentrations greater than 40mmol/L or infusion rates greater than 10mmol/hour, the solutions
should be infused via a central line (CVC). Admission to a high dependency unit or intensive care
unit is advisable. (In an emergency situation the infusion may be started through peripheral line until
a central venous line is inserted)

This must conform with safe local guidelines for high dependency areas.

Continuous ECG monitoring is recommended when the rate is faster than 10 mmol/hour.

Rates in excess of 20 mmol/hour are potentially hazardous and are permitted only when the patient
is admitted to a high dependency unit with the agreement of the consultant/director in charge of the
unit and the prescription is guided by local policy/protocols.
4
Summary of Changes Made to Intravenous Potassium OD
PRESCRIBING ASPECTS

Intravenous potassium chloride must be prescribed on the fluid order chart.

The name of the consultant providing the approval must be documented on the intravenous
fluid order chart. (i.e. Approved by Dr……..)
STORAGE AND SUPPLY ASPECTS

Potassium concentrations other than those available in pre-mix solutions will not be available
in general ward areas.

If potassium chloride ampoules are required in particular ward areas (e.g. nephrology) for a
specific order for a specific patient:

o
The IV fluid order chart with written evidence that the prescription has been approved
by the consultant/director of the department must be forwarded to the pharmacy
department in advance
o
The Pharmacy Department will dispense the exact number of potassium chloride
ampoules required;
o
Alternatively the solution may be made up in the Pharmacy Department;
o
Where potassium chloride ampoules are dispensed to a general ward any unused
ampoules must be returned to Pharmacy immediately.
Standard pre-mixed solutions of potassium chloride should be stocked by WA
hospitals, where appropriate:
o
Standard premix solutions should contain either 10 mmol, 20 mmol or 40 mmol of
potassium chloride.
o
Standard premix solutions should be made up in a solution of either sodium chloride
or glucose (or a combination of both sodium chloride and glucose).

Most premixed solutions are NOT isotonic; exceptions are: 10mmol KCl in NaCl 0.29%
(100mL minibags), 10mmol KCl in NaCl 0.45% and Glucose 0.25% (500mL)

Concentrations of potassium chloride greater than 30 mmol in 1000mL in non-isotonic
solutions (e.g. sodium chloride 0.9%) may cause pain and phlebitis on administration.

Potassium chloride 10 mmol in 100 mL is an isotonic solution as it is prepared with a
lower concentration of sodium chloride (0.29%) and hence can be administered
peripherally.

Contact your Pharmacy Department for advice on preparations available at your health
service.

For appropriate intravenous potassium replacement in paediatric patients, refer to
Child and Adolescent Health Service, Princess Margaret Hospital, Department of
Pharmacy Intravenous Potassium Chloride Policy or local hospital guidelines.
Caution must be taken to ensure that maximum rate of intravenous potassium
replacement does not exceed 0.2 mmol/kg/hour for paediatric patients.
 Hospitals may stock alternative potassium containing intravenous solutions in addition to
the standard premix solutions listed above with the provision that they are adequately
labeled, stored and administered in accordance with this Operational Directive and the
prescription is guided by hospital-approved policy/protocols.
PREPARATION ASPECTS

Preparation of infusions using potassium chloride ampoules should follow a safe
on-site preparation protocol, which is compliant with all the existing standards for the
preparation and labelling of intravenous solutions. (Local Nursing Drug Policy: Preparation of
Intravenous Medications. National Recommendations for User-Applied Labelling of Injectable
Medicines, Lines and Fluids – Operational Directive 0385/12)
ADMINISTRATION ASPECTS
Peripheral intravenous administration
1.

Regimens that differ from this directive must be approved in advance by the treating
physician/specialist and documented on the intravenous fluid order chart.

For smaller sites and rural hospitals with no treating specialist, consultation with an
ED or ICU consultant is recommended.

The maximum rate of potassium infusion must be observed in all circumstances: that
is, any variation in regime must remain in the range of delivery rates known to be nonhazardous.
2.
Central administration

Admission to a high dependency unit or intensive care unit is advisable. (In an emergency
situation the infusion may be started through peripheral line until a central venous line is
inserted)

Continuous ECG monitoring is recommended when the rate is faster than 10 mmol/hour.

Rates in excess of 20 mmol/hour are potentially hazardous and are permitted only when
the patient is admitted to a high dependency unit with the agreement of the
consultant/director in charge of the unit and the prescription is guided by local
policy/protocols.