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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.