Potassium Replacement Protocol
St. Anthony Hospital Protocol
Presented by: Kayla, Korri, Karan, Leyna
K+ Protocol >/= 3.5
Don't initiate if Creatinine >2mg/dL, Patient weight <45kg, Patient on dialysis or CRRT - OR - UOP <20ml/hr, 175ml per 8hr shift or 250ml per 12hr shift
Reminder: Verify lab value from earlier in day was not replaced earlier
On initiation of protocol, if no K+ in last 24hours, draw/order K+ level. On initiation and prior to any subsequent doses, if no creatinine in the last 48 hours, order using order set.
If K+ less than 3, order Magnesium levels
PO dosing is preferred. Give IV dosing only if has nausea, vomiting, diarrhea, NG to suction or NPO.
PROTOCOL
K< or =2.4
KCl 10 mEq IV Q1H x 10 doses via peripheral/central line and call MD.
KCl 20 mEq IV Q1H x 5 doses - Only in ICU. Administrate via central line only and call MD.
**Recheck level: 1 hour after last dose
Check Mg level if not already done.
K 2.5-2.9
KCl 40 mEq liquid (PO/NG) Q2H x 2 doses - OR - KCl 10 mEq IV Q1H x 8 doses via peripheral or central line.
KCl 20 mEq IV Q1H x 4 doses - Only in ICU. Administrate via central line only.
**Recheck level: 2 hours after last PO/NG dose
1 hour after last IV dose. Check Mg.
K 3-3.4
KCl 20 mEq liquid Q2H x 3 doses (PO/NG) - OR - 2 x 10 mEq capsules PO Q2H x 3 doses
- OR - KCl 10 mEq IV Q1H x 6 doses via peripheral/central line
KCl 20 mEq IV Q1H x 3 doses - Only in ICU. Administrate via central line only.
**Recheck level: ICU/Tele - 2 hours after last PO/NG or 1 hour after last IV dose
Med/Surg - 4 hours after last dose or with next lab if within 12 hours.
Application to Clinical Setting
Protocol Based Care
- Compare and Contrast
- Evidence tested IV infusions only
- Protocol in hospital allows PO form of replacement therapy within a specific range
- Implementation via HIT
- Changes/Limitations
- Computerized: have paper versions available for computer complications
- Encourage interdisciplinary participation and communication with abnormal lab values
- Educate on protocols to prevent missed episodes
- Goal: Helps healthcare providers to put evidenced based research into practice in order to reduce morbidity and mortality through early and efficient intervention, implements national standards in care
- Standardization – reduce variations in care and outcomes
- Extends roles – nurses, interdisciplinary care and participation
- Improve Patient experience and shorter hospital stays
- “What should be done, when, and by whom”
- Used:
- Conditions/diseases that are relatively predictable
- Large number of people acquire condition/disease
- Procedure would be high cost
- High risk area to hospital
Importance to Nursing Practice
Evidence and Studies
-The different protocols in place decrease the rate of mortality and morbidity rates
- Improves nurse satisfaction
-empowers nurses
-Decreases the risk for hypokalemia and hyperkalemia and the complications that are associated with them
-Hypokalemia: Weakness, fatigue, muscle cramps, pain, worsening diabetes
control, polyuria, palpitations, and other cardiac complications
-Hyperkalemia: Mostly Cardiac complications that can lead to renal
complications.
Implementation and evaluation of a nurse-centered computerized potassium regulation protocol in the intensive care unit - a before and after analysis.
Preventing Hypokalemia in Critially Ill Patients
Evaluation of An Electrolyte Replacement Protocol for Cardiac Surger Intensive Care Patients
Objective: evaluate effectiveness and safety of electrolyte replacement protocol (Potassium) in large group of postop patients (coronary artery bypass)
Design: Retrospective Study, Level 4
- Sample: Patients 18yrs and older admitted to ICU following coronary artery bypass surgery,
- Exclusions - renal replacement therapy, diabetic ketoacidosis, wt < 45kg, patients who died during and post surgery
- 627 included in the study: 312 control and 315 in protocol group
- Randomized computer generator to select patients for study
- 2 year study period
- Medical Staff remained unchanged
- Protocol: pre-printed order sheet with predetermined IV replacement doses according to electrolyte levels,
- Standard electrolyte monitoring (blood draws in the AM following replacement)
- Desired K range: 3.6-5.0mmol/L
Results: post 2 study periods of 325 patients each period
- Protocol group: 100% of Serum K within desired range
- No significant difference between protocol group and control group serum K morning values
- Multivariate analysis - optimal maintenence of serum potassium concentration within the desired range with replacement and monitoring of lab values post replacement
K+ Protocol of ICU study
- IV infusion for GFR <30ml/hr or UOP <30ml/hr : 3.6-4.3 Otherwise : 3.8-4.5
- Range – Lower: IV Infusion
- In range: Calculate predicted K+ clearance using GFR, diuresis, and presence of hemofiltration
- Higher: Give no potassium
Research Design
- Theoretical framework/ Conceptual basis for research: Process Improvement
- Design: Well-designed controlled trials without randomization
- Sample (size, target population, setting): 775 patients before and 1435 after the implementation of computerized
- potassium control over a period of 14917 patient-ICU days , 1300 bed tertiary university teaching hospital: a 12-bed surgical ICU and a 14-bed thoracic-surgical ICU
- Instrument used: Health Information Technology
- Level of evidence: Level III, no randomization
- Process Improvement
- Well-designed controlled trials without randomization
- 775 patients before and 1435 after the implementation of computerized potassium control over a period of 14917 patient-ICU days , 1300 bed tertiary university teaching hospital: a 12-bed surgical ICU and a 14-bed thoracic-surgical ICU
- Health Information Technology
- Level III, no randomization
What the Evidence Shows
Protocol Driven vs. Physician-driven electrolyte replacement in adult critically ill patients
- Objective: To determine if administering potassium preemptively in maintenance IV fluid would prevent episodes of hypokalemia and reduce the need to potassium boluses
- Design: 267 patient’s medical records reviewed and 156 patients chosen
- Purpose
- Limitations
- Sample size: 156 total patients in study. 76 received potassium maintenance; 80 were control
- Level III evidence
- Further research: Further studies with a prospective design and random assignment to allow for the generalizability of the results are needed. Such studies may indicate a need to update protocols to include provisions for preemptive administration for patients with high maintenance intravenous rates.
- Obstacles?
- Protocol used vs. St. Anthony’s Protocol
- Results of study and application to practice setting: Compared with the control group, patients who were treated empirically with a potassium supplement added to maintenance intravenous fluid at a rate of 72 to 144 mmol/d received significantly fewer potassium boluses throughout their ICU stay
- Electrolyte replacement protocol: efficient, safe, effective
- Efficient: less missed episodes, quicker time for implementation of intervention
- Safe: no complications arose with use of protocol
- Effective: K levels returned to normal range with replacement
- Increases Nurse Satisfaction – empowerment
- Increase Patient Satisfaction – less complications, decreased hospital stays, better patient outcomes
Results
- Results: Computerized potassium control, integrated with a nurse-centered program for glucose regulation (GRIP) is safe, effective and reduces the prevalence of hypo- and hyperkalemia in the ICU
- Suggestions for further research:
- Relations between potassium and outcome can only be investigated when an adequate protocol and infrastructure for realizing potassium control are in place
- Several variables that influence the potassium regulation are not considered in this potassium regulation protocol
- Effect of acid-base disorders, insulin infusion and potassium administration route are possible extensions of K+ protocol
Results
- 2 month test
- First Month: Physician-Driven and Second Month: Protocol-Driven
- 43 patients the first month
- 44 patients the second month
- No significant difference in episodes of hypokalemia between two groups
- Time between two groups: P<0.0001 - significant
- reduction in mean time interval between recognizing low electrolyte values and implementing intervention
- Physician-Driven: 161 Minutes
- Protocol-Driven: 19 Minutes
- Missed Replacements
- Physician-Driven: 15 episodes
- Protocol-Driven: 6 episodes
- K Replacement Dose
- Physician-Driven: 31.6mmol
- Protocol-Driven: 24.5mmol
- Protocol is safe, efficient, and effective - decreasing mortality and morbidity rates
- Involves Interdisciplinary care improving patient care
- Increased nurse satisfaction
- Limitations/Improvement
- adjustment of potassium protocol to match or exceed physician dose to decrease occurence of post-replacement hypokalemia
- education to decrease missed episodes
- encourage interdisciplinary communication of abnormal lab values
Objective: Compare efficiency of protocol-driven electrolyte replacement with physician-driven orders for the correction of hypokalemia, hypomagnesemia, hypophosphatemia
Design: Retrospective, Level 5
- Conducted before and after implementation of protocol
- Sample: 600 Bed ICU, all patients >14 admitted to ICU were included in study, 2 groups (physician-driven and protocol driven)
- Exclusions: serum creatinine > 115, low urine output, dysrhythmias, diabetic ketoacidosis, seizures, weight <45kg, hypocalcemia
- Data Collection: demographics, daily electrolyte values (Mg, K, PO), time of results, time interval from identifying low values to implementing intervention, replacement doses, post replacement levels, dx
- ICU Protocol Physician-Driven:
- nurses chart lab values in flow sheet and communicate low values to physicians - physician order replacement
- Protocol-Driven:
- Nurses start replacement using preset dosing without communicating with ICU physicians for order
References
Couture, J., Létourneau, A., Dubuc, A., & Williamson, D. (2013). Evaluation of an Electrolyte Repletion Protocol for Cardiac Surgery Intensive Care Patients. CJHP The Canadian Journal of Hospital Pharmacy. 66(2), 96-103. doi: 2013 Mar-Apr. Retrieved November 11, 2015, from Evaluation of an Electrolyte Repletion Protocol for Cardiac Surgery Intensive Care Patients
Hijazi, M., & Al-Ansari, M. (2005). Protocol-driven vs. physician-driven electrolyte replacement in adult critically ill patients. Annals of Saudi Medicine, 25(2), 105-109. doi:2005 Mar-Apr
Hoekstra, M., Vogelzang, M., Drost, J., Janse, M., Loef, B., van der Horst, I., & ... Nijsten, M. (2010). Implementation and evaluation of a nurse-centered computerized potassium regulation protocol in the intensive care unit - a before and after analysis. BMC Medical Informatics & Decision Making, 10(1), 5-5 1p. doi:10.1186/1472-6947-10-5
Protocol Based Care. (2013). Retrieved November 11, 2015, from http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/protocol_based_care.html
Scotto, C. J., Fridline, M., Menhart, C. J., & Klions, H. A. (2014). PREVENTING HYPOKALEMIA IN CRITICALLY ILL PATIENTS. American Journal Of Critical Care, 23(2), 145-149 5p. doi:10.4037/ajcc2014946