Drug Utilization Review of Potassium Chloride Injection Formulations Available in a Private Hospital in Kuching, Sarawak, Malaysia

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1 Originl Article Drug Utiliztion Review of Potssium Chloride Injection Formultions Avilble in Privte Hospitl in Kuching, Srwk, Mlysi Mohmmd Hirmn Meliss 1, Srriff Azmi 2 Submitted: 24 Oct 2012 Accepted: 27 My Deprtment of Phrmcy, Normh Medicl Specilist Centre, Jln Tunku Abdul Rhmn, Petr Jy, Kuching, Srwk, Mlysi 2 School of Phrmceuticl Sciences, Universiti Sins Mlysi, Pulu Pinng, Mlysi Abstrct Bckground: The concentrted potssium chloride injection is high-lert mediction nd replcing it with pre-mixed formultion cn reduce the risks ssocited with its use. The im of this study ws to determine the clinicl chrcteristics of ptients receiving different potssium chloride formultions vilble t privte institution. The study lso ssessed the effectiveness nd sfety of pre-mixed formultions in the correction of hypoklemi. Methods: This ws retrospective observtionl study consisting of 296 cses using concentrted nd pre-mixed potssium chloride injections in 2011 in privte hospitl in Kuching, Srwk, Mlysi. Results: There were 135 (45.6%) cses tht received concentrted potssium chloride, nd 161 (54.4%) cses tht received pre-mixed formultions. The ptients clinicl chrcteristics tht were significntly relted to the utiliztion of the different formultions were dignosis (P < 0.001), potssium serum blood concentrtion (P < 0.05), nd fluid overlod risk (P < 0.05). The difference observed for the cses tht chieved or mintined normoklemi ws sttisticlly insignificnt (P = 0.172). Infusion-relted dverse effects were seen more in pre-mixes compred to concentrted formultions (6.8% versus 2.2%, P < 0.05). Conclusion: This study provides insight into the utiliztion of potssium chloride injections t this specific institution. The results support current recommendtions to use pre-mixed formultions whenever possible. Keywords: potssium chloride, electrolytes, hypoklemi, drug utiliztion evlution, drug-use review Introduction Concentrted potssium chloride injections re high-lert medictions with the potentil to cuse grievous hrm when misused. Hyperklemi, which cn led to ventriculr fibrilltion, is the min risk with the use of intrvenous potssium chloride (1 3). Rimmer JM et l., reported tht 58% of hyperklemi episodes were due to potssium chloride intrvenous supplementtion nd re more common in the elderly nd ptients with renl insufficiency (2). The mnufcturer lso dvises tht potssium chloride injections should be used with gret cre in renl impirment due to potentil potssium retention (4). In ddition to hyperklemi, concentrted potssium chloride injections re lso ssocited with medicl errors, with even ftlities being reported (5 8). Errors identified include incorrect identifiction of product nd incorrect preprtion or dilution (9,10). Therefore, risk-reduction strtegies hve included the implementtion of guidelines for the dministrtion of concentrted potssium chloride injections, seprtion of storge res, pplying high-lert lbelling, removl from ptient cre res, nd the use of pre-mixed formultions (11,12). In this privte hospitl, these steps hve been implemented in the interest of ptient sfety. The use of pre-mixed formultion ws introduced in 2010, which were specilly imported s it ws not registered in Mlysi. This study ws conducted to gin insight into the utiliztion of the different potssium chloride injections vilble t this institution nd to ssess the effectiveness nd Mlys J Med Sci. Jul-Oct 2013; 20(4): Penerbit Universiti Sins Mlysi, 2013 For permission, plese emil:mjms.usm@gmil.com 47

2 Mlys J Med Sci. Jul-Oct 2013; 20(4): sfety of the new pre-mixed potssium chloride injection formultions. Mterils nd Methods This study ws conducted in privte hospitl in Kuching, Srwk, Mlysi, nd retrospectively reviewed the utiliztion of different potssium chloride injections in All cses using potssium chloride injections were selected for this study, with the exception of those involving ptients below the ge of 18. The formultions of potssium chloride injections tht were evluted were either concentrted form tht consisted of (1) potssium chloride concentrte (1 g, 13.4 mmol) in 10 ml injection or pre-mixed formultion tht consisted of (2) 20 meq of potssium chloride in 0.9% sodium chloride injection (1 L), (3) 40 meq of potssium chloride in 0.9% sodium chloride injection (1 L), or (4) 20 meq potssium chloride in 5% dextrose injection (1 L). These formultions were dministered ccording to the institution s policy for potssium chloride injections, which sttes tht pre-mixes should be used whenever possible nd tht if concentrted potssium chloride is used, it should be idelly diluted with 0.9% sodium chloride (unpublished work). The stted infusion rtes re 1 meq/kg/h or less thn 40 meq/h. A self-designed form ws used to collect dt. Dt tht were retrieved from ptient s medicl records included demogrphic dt; clinicl chrcteristics, such s min dignoses nd concurrent medicl problems; type of potssium chloride injection used; nd concurrent medictions. Effectiveness ws defined s chieving or mintining normklemi with or without reversl of hypoklemic symptoms. To ssess effectiveness, serum potssium levels before nd fter potssium chloride injection dministrtion, nd time to rech normoklemi fter potssium chloride injection dministrtion were recorded. Time to rech normoklemi ws recorded s less thn 12 h, between 12 to 24 h, nd more thn 24 h fter potssium chloride injection dministrtion. To ssess sfety, the presence of dverse effects from the potssium chloride dministrtion ws noted. Adverse effects included symptoms listed in the literture nd product leflet, which were presence of hyperklemi, fluid overlod symptoms (e.g. edem), nd infusion-relted dverse effects such s pin or phlebitis t infusion site, febrile response, nd extrvstion (1,13,14 ). Sttisticl nlysis ws performed by using the Sttisticl Pckge for the Socil Sciences Version (SPSS) Demogrphic dt were nlysed descriptively, nd results were presented in men or frequency (percentge). A chisqure test ws performed to determine whether there ws reltionship between the clinicl chrcteristics of the ptients receiving different potssium chloride injections. Fisher s exct test ws performed to evlute the differences of effectiveness mong different potssium chloride injections s more thn 20% of cells hve n expected frequency of less thn five. For the evlution of its sfety, chi-squre test or Fisher s exct test ws performed to evlute the differences of hyperklemi, fluid overlod symptoms, nd the frequency of infusion-relted dverse effects mong the concentrted nd premixed formultions. The sttisticlly significnt level ws set t P vlue of 5%. Results Out of the 296 cses in this study, 135 (45.6%) received concentrted potssium chloride nd 161 (54.4%) received one of the pre-mixed formultions. Demogrphic Dt The distribution of ptients with regrds to ge nd gender is presented in Tble 1. The men ge for ptients in this study ws 58 yers old, with rnge of 19 to 95 yers old. Gender distribution ws similr in the concentrted potssium chloride injection group nd the 20 meq potssium chloride in 0.9% sodium chloride injection group. Clinicl Chrcteristics A chi-squre test reveled tht the type of injection used ws relted to the ptient s dignosis (P < 0.001). Tble 2 lists the top five min dignoses for the ptients who received the concentrted or pre-mixed formultions. For ptients dignosed with stroke, cncer, nd gstrointestinl disorders, pre-mixed formultions were minly used (61.1%, 66.7%, nd 62.9%, respectively). For ptients dignosed with sepsis nd those undergoing invsive procedures, the concentrted formultion ws minly used (68.0% nd 95.8%, respectively). The use of the concentrted nd pre-mixed formultions ws relted to the presence of fluid overlod risks (P = 0.008) (Tble 3), such s congestive hert filure, renl impirment, nd edem. In the presence of these risks, the concentrted form ws mostly used compred to 48

3 Originl Article Drug Utiliztion Review of Potssium Chloride Injection pre-mixed formultion (60% versus 40%). The differences in the type of injection used in reltion to different serum potssium levels before the potssium chloride injection were sttisticlly significnt (P = 0.013) (Tble 4). For cses tht received the concentrted injection, the mjority hd mild hypoklemi levels (42.4%), while the mjority of cses tht received the pre-mixed formultions were normoklemic (40.1%). Tble 1: Demogrphic chrcteristics of ptients Chrcteristics Formultion A B C D Number of cses, no. (%) 135 (45.6) 133 (44.9) 5 (1.7) 23 (7.8) Age, men yers ± SD (SD 17.5) (SD 15.98) (SD 24.05) (SD 9.57) Age rnge (yers), no. (%) (6.7) 11 (8.3) 3 (60.0) 0 (0.0) (17.9) 40 (30.3) 0 (0.0) 3 (13.0) (32.8) 42 (31.8) 1 (20.0) 11 (47.8) 65 nd bove 57 (42.5) 39 (29.5) 1 (20.0) 9 (39.1) Gender, no. (%) Mle 66 (49.3) 62 (47.0) 0 (0.0) 7 (30.4) Femle 68 (50.7) 70 (53.0) 3 (100.0) 16 (69.6) A: potssium chloride concentrte 1 g (13.4 mmol) in 10 ml injection, B: 20 meq potssium chloride in 0.9% sodium chloride injection 1 L, C: 40 meq potssium chloride in 0.9% sodium chloride injection 1 L, D: 20 meq potssium chloride in 5% dextrose injection 1 L. Tble 2: Proportion of top five min dignosis in concentrted nd pre-mixed group Top Five Min Dignosis (%) Type of Injection Concentrted (%) Pre-mixed (%) Stroke (18.2) Cncer (18.2) Gstrointestinl disorders (11.8) Sepsis (8.4) Invsive Procedures (8.1) Chi-squre test (n = 296): P < Concentrted group consist of potssium chloride concentrte 1 g (13.4 mmol) in 10 ml injection. Pre-mixed group consist of 20 meq potssium chloride in 0.9% sodium chloride injection 1 L, 40 meq potssium chloride in 0.9% sodium chloride injection 1 L nd 20 meq potssium chloride in 5% dextrose injection 1 L. Tble 3: Frequency of cses present with fluid overlod risks mong concentrted nd pre-mixed formultions Presence of Fluid Overlod Risks Type of Injection Concentrted, n (%) Pre-mixed, n (%) Person s Chi-Squre Test (n = 296) Present 39 (60) 26 (40) P = b Not Present 96 (41.6) 135 (58.4) Concentrted group consist of potssium chloride concentrte 1 g (13.4 mmol) in 10mL injection. Pre-mixed group consist of 20 meq potssium chloride in 0.9% sodium chloride injection 1 L, 40 meq potssium chloride in 0.9% sodium chloride injection 1 L nd 20 meq potssium chloride in 5% dextrose injection 1 L. b P <

4 Mlys J Med Sci. Jul-Oct 2013; 20(4): Effectiveness To mesure the effectiveness of the different potssium chloride injections, the frequency of cses chieving or mintining normoklemi were observed (Tble 5). The number of cses chieving or mintining normoklemi ws similr mong those who received the concentrted formultion nd those who received the pre-mixed formultion; no sttisticl difference ws observed (P = 0.172). Most cses tht received the concentrted formultion chieved normoklemi between 12 to 24 h, while those who received the pre-mixed formultions took longer. However, the difference mong the different formultions ws lso not sttisticlly significnt (P = 0.518). Sfety Hyperklemi were seen more in those who received the concentrted injection compred to pre-mixed formultions (Tble 6). However, the difference of the frequency of hyperklemi in those who received the concentrted nd pre-mixed formultions ws not sttisticlly significnt (P = 0.065). Conditions ssocited with potssium retention properties, such s renl impirment, dehydrtion, nd dibetes mellitus, were relted to the frequency of hyperklemi (P = 0.007) (Tble 7). The concurrent use of other mediction with potssium retention properties in the cses with hyperklemi ws not sttisticlly significnt (P = 0.314). There were lso some cses with normoklemic levels Tble 4: Distribution of serum potssium levels before potssium chloride injection dministrtion mong cses using concentrted nd pre-mixed formultions Serum Potssium Levels Before Potssium Chloride Administrtion Mild Hypoklemi ( mmol/l) Moderte Hypoklemi ( mmol/l) Severe Hypoklemi (below 2.5 mmol/l) Normoklemi ( mmol/l) Concentrted, n (%) Type of Injection Pre-mixed, n (%) Person s Chi-Squre Test 50 (42.4%) 42 (28.6%) P = (n = 265) b 34 (28.8%) 36 (24.5%) 8 (6.8%) 10 (6.8%) 26 (22.0%) 59 (40.1%) Concentrted group consist of potssium chloride concentrte 1 g (13.4mmol) in 10mL injection. Pre-mixed group consist of 20 meq potssium chloride in 0.9% sodium chloride injection 1 L, 40 meq potssium chloride in 0.9% sodium chloride injection 1 L nd 20 meq potssium chloride in 5% dextrose injection 1 L. b Among the 296 cses using potssium chloride injections, 265 cses hd records of serum potssium levels before potssium chloride injection dministrtion. Tble 5: Effectiveness of different potssium chloride injection formultions Number of cses with normoklemi chieved or mintined mong different formultions Normoklemi chieved Normoklemi not chieved Formultion A B C D Fisher s exct test P = (n = 181) b Number of different times to rech normoklemi or reversl of hypoklemi symptoms mong different formultions Below 12 h P = Between h (n = 76) c More thn 24 h A: potssium chloride concentrte 1 g (13.4 mmol) in 10mL injection, B: 20 meq potssium chloride in 0.9% sodium chloride injection 1 L, C: 40 meq potssium chloride in 0.9% sodium chloride injection 1 L, D: 20 meq potssium chloride in 5% dextrose injection 1 L. b Among the 296 cses using potssium chloride injections, 181 cses hd records for serum potssium levels fter potssium chloride injection dministrtion. c Among the 296 cses using potssium chloride injections, 76 cses hd records for time to rech euklemi or reversl of hypoklemi symptoms. 50

5 Originl Article Drug Utiliztion Review of Potssium Chloride Injection before dministrtion of the potssium chloride injection. Due to the nture of this study, it ws not possible to determine the reson for this sitution, but it is possible tht the potssium chloride injection ws dministered for prophylctic purposes. The frequency of hyperklemi in these normoklemic cses ws 12%, but this ws not sttisticlly significnt (P = 0.594) (Tble 8). The frequency of fluid overlod symptoms ws 1.5% in the concentrted group nd 1.9% in the pre-mixed group, nd the difference between the two groups were sttisticlly insignificnt (P = 0.166) (Tble 6). The ge rnge of ptients presenting with these symptoms were between 50 to 64 yers (n = 3) nd 65 yers nd bove (n = 2). Only one cse hd risk for fluid overlod symptoms, nd this ws due to renl impirment. The difference in the number of infusionrelted dverse effects (such s pin t infusion site, phlebitis, nd febrile response) between the two formultions ws sttisticlly significnt (P = 0.024) with more seen in the pre-mixed group (Tble 6). Age ws relted to the presence of infusion-relted dverse effects (P = 0.05); this ws most common in the ge group. Tble 6: Frequency of dverse effects from potssium chloride dministrtion mong concentrted nd pre-mixed formultion Adverse Effect Presence of hyperklemi fter potssium chloride injection dministrtion Type of Injection Concentrted Pre-mixed Totl 15 (16.7%) 7 (7.7%) Fluid Overlod Symptoms n = 90 n = 91 Person s Chi-Squre Test: P = (n = 181) b Pulmonry edem 0 2 Fisher s exct test: Peripherl edem 2 0 P = (n = 296) Other edem 0 1 Totl 2 (1.5%) 3 (1.9%) Infusion relted dverse effects Pin t infusion site 1 2 Fisher s exct test: Phlebitis t infusion site 1 8 P = (n = 296) Febrile Response 1 1 Totl 3 (2.2%) 11 (6.8%) Concentrted group consist of potssium chloride concentrte 1 g (13.4 mmol) in 10 ml injection. Pre-mixed group consist of 20 meq potssium chloride in 0.9% sodium chloride injection 1 L, 40 meq potssium chloride in 0.9% sodium chloride injection 1 L nd 20 meq potssium chloride in 5% dextrose injection 1 L. b Among the 296 cses using potssium chloride injections, 181 cses hd records for serum potssium levels fter potssium chloride injection dministrtion. Tble 7: Conditions ssocited with potssium retention in hyperklemi cses Conditions ssocited with potssium retention (renl impirment, dehydrtion, dibetes mellitus) Concurrent mediction with potssium retention properties (ACE inhibitors, ARBs, potssium spring diuretics, NSAIDs) Number of cses (N = 296) Frequency of hyperklemi cses, n (%) (8.3) b (2.2) c Totl number of cses using potssium chloride injections. b Chi-squre test: P = c Chi-squre test: P = ACE (ngiotensin converting enzyme); ARB (ngiotensin receptor blocker); NSAID ( non-steroidl nti-inflmmtory gent). 51

6 Mlys J Med Sci. Jul-Oct 2013; 20(4): Discussion From this retrospective observtion, the use of potssium chloride injections in either concentrted nd pre-mixed formultion ws found to be similr. These results differ from nother observtionl study on intrvenous potssium chloride prescribing nd dministrtion prctices in Victori, Austrli, where more thn 80% of prescriptions for potssium chloride injections were dispensed with pre-mixed formultions (15). This difference my be becuse the Austrlin Council for Sfety nd Qulity in Helth Cre recommends the removl of concentrted potssium chloride mpoules in ptient cre res nd replcing them with premixed infusions. Another reson my be due to the fct tht in Mlysi, the pre-mixed formultions were not redily vilble t the time of this study, nd the privte institution ws forced to import it independently. Currently there is no generl consensus regrding the use of prticulr potssium chloride formultions ccording to ptients clinicl chrcteristics. However, the product informtion leflet for the pre-mixed formultion sttes tht it is to be used with gret cre in ptients with congestive hert filure, severe renl insufficiency, nd the presence of edem (4,16). In this study, min dignoses in the pre-mixed formultions group were minly cncer, stroke, nd gstrointestinl disorders. For ptients dignosed with sepsis nd those undergoing invsive procedures, the concentrted formultion ws minly used. However, this study did not exmine the differences of the wrd settings of these ptients. The decision to use the concentrted injection for ptients with sepsis or who were undergoing n invsive procedure my be due to the fct tht fluid overlod is compliction of these conditions (17). It ws lso found tht the concentrted form ws mostly used when risk of fluid overlod ws present, such s congestive hert filure, renl impirment, nd edem. Another observtion ws tht these potssium chloride injections were used even for ptients with normoklemic levels. A potssium chloride injection is not indicted for prophylxis, lthough it is common prctice tht intrvenous (IV) dministrtion is used in mild to moderte hypoklemi cses (18). It is known tht there re those t prticulr risk of hypoklemi, such s the elderly with chronic diseses nd those undergoing surgery. Therefore, this prctice my be reflection of the concern of dverse outcomes in those with risk of hypoklemi. More study is needed on the use of potssium chloride injections s prophylxis of hypoklemi or in normoklemic sttes. As there re no vilble published dt on the effectiveness of pre-mixed potssium chloride injections, one of the objective of this study ws to evlute the effectiveness of this diluted formultion in the tretment of hypoklemi or for mintining normoklemic levels. However, s this study ws n uncontrolled observtionl study, mking generl sttements regrding the effectiveness nd sfety of certin prctice my not be convincing. Therefore, the effectiveness nd sfety of pre-mixed potssium chloride injections in this study cn only be compred to the concentrted form. Results suggest tht the pre-mixed formultions re s effective s the concentrted form in Tble 8: Frequency of hyperklemi cses fter potssium chloride injection dministrtion mong different serum potssium levels before potssium chloride injection dministrtion Serum Potssium Levels Before Potssium Chloride Injection Administrtion Mild hypoklemi ( mmol/l) Moderte hypoklemi ( mmol/l) Severe hypoklemi (below 2.5 mmol/l) Normoklemi ( mmol/L) Frequency of Hyperklemi Cses After Potssium Chloride Injection Administrtion Fisher s exct test (n = 176) 4 (6.7%) P = (13.5%) 2 (14.3%) 6 (12.0%) Among the 296 cses using potssium chloride injections, 176 cses hd records for serum potssium levels before nd fter potssium chloride injection dministrtion. 52

7 Originl Article Drug Utiliztion Review of Potssium Chloride Injection the tretment of hypoklemi or for the mintennce of normoklemi levels, s no sttisticl differences were observed. This supports the recommendtion of using premixed formultions whenever possible (6,15,19,20). It offers prcticl lterntive to mixing solutions in ptient cre res (7). In ddition, other pre-mixed products hve been ssocited with fewer mistkes, with n error rte of less thn 1% compred to n error rte of 9% in IV mixtures requiring compounding (12,20). The min concern with dministrting potssium through n IV is hyperklemi, which cn led to ventriculr fibrilltion (1 3). Rimmer JM et l. reported tht 58% of hyperklemi episodes re due to potssium chloride intrvenous supplementtion. This study found tht the frequency of hyperklemi ws lower in the pre-mixed formultion group but tht its difference from the concentrted group ws not sttisticlly significnt (P > 0.05). Thus, the results suggest tht when using pre-mixed potssium chloride formultions in the tretment of hypoklemi or for mintining normoklemi, the frequency of hyperklemi should not be different from the use of the concentrted form. Among the hyperklemi cses in this study, conditions with potssium-retention properties tht were present included renl impirment, dehydrtion, nd dibetes mellitus. Rimmer JM et l., lso reported tht renl dysfunction ws the most common predisposing disese stte in hyperklemi. Other disese sttes identified were glucose intolernce nd metbolic cidosis. However, study on the rpid correction of hypoklemi with concentrted potssium chloride reveled no cler reltionship between the differences of pre-/post-infusions nd serum cretinine levels. Also, none of the subjects with renl impirment developed hyperklemi. The investigtors dvise extreme cution, but rigid recommendtions should be voided s they re not universlly pplicble (21). The use of pre-mixed formultions does not come without risk. Fluid overlod from IV fluid therpy is one problem, especilly in fril nd elderly ptients due to their reduced bility to excrete excess wter (22,23). Cses of fluid overlod, such s pulmonry edem nd peripherl edem, from IV fluid dministrtion hve been reported, even leding to deth in rre cses (24,25). In this study, the frequency of fluid overlod symptoms in the both concentrted nd pre-mixed groups ws low, but it still occurred, even in the bsence of fluid overlod risks. Currently, there re no vilble reports regrding fluid overlod from the use of pre-mixed potssium chloride formultions. However, the prescriber should lwys keep in mind the risk of fluid overlod when using premixed formultions, especilly in the elderly. Other possible dverse effects re infusion relted, such s pin nd phlebitis t the infusion site, febrile response, nd extrvstion (4,16,26). Documented incidences of infusion-relted phlebitis re between 25% to 35% (27,28). In this study, the frequency of infusion-relted dverse effects ws significntly more in the pre-mixed group. The ge group hd the most infusion-relted dverse effects. This result differs from other studies tht hve identified old ge s one of the risk fctors (27,29,30). The only study tht seems to support this ge group ws study on infusion-relted dverse effects seen in vncomycin, where n ge below 40 yers ws significnt risk fctor (31). Conclusion The results of this explortory nd descriptive study provide insights into the utiliztion of premixed nd concentrted solutions of potssium chloride in specific privte hospitl. No sttisticl differences were observed between the concentrted nd pre-mixed formultions groups for chieving normoklemi. This suggests tht the pre-mixed formultions re s effective s the concentrted form in chieving normoklemi. Nevertheless, it should be noted tht this ws bsed on routine clinicl dt. Despite the limittions of the study, these observtions support other recommendtions to use pre-mixed formultions whenever possible s the concentrted potssium chloride injection is ssocited with serious mediction errors nd is ctegorised s high-lert drug. The institution phrmcists cn ply role in promoting the use of pre-mixed formultions whenever pplicble. However, s the pre-mixed formultions re not currently registered in Mlysi, this cuses brrier in obtining stock for this prticulr institution. Acknowledgement This reserch project would hve not been possible without support from mny people. First nd foremost I would like to thnk Dr Azmi Sriff for his guidnce nd dvice throughout this reserch. My deepest grtitude to the mngement of privte institution for grnting n pprovl of 53

8 Mlys J Med Sci. Jul-Oct 2013; 20(4): this study. Lst but not lest, mny thnks to my collegues for their constnt support nd help. Conflict of Interest None. Fund(s) This reserch received no specific grnt from ny funding gency in the public, commercil, or notfor-profit sectors. Authors Contributions Conception nd design: MHM, SA Anlysis nd interprettion of the dt, drfting of the rticle, nd collection nd ssembly of dt: MHM Criticl revision of the rticle for the importnt intellectul content nd finl pprovl of the rticle: SA Correspondence Ms Meliss Mohmmd Hirmn BPhrm (UM), MS Clinicl Phrmcy (USM) Deprtment of Phrmcy Normh Medicl Specilist Centre Jln Tunku Abdul Rhmn Petr Jy 93050, Kuching Srwk, Mlysi Tel: Fx : Emil: kustik81@yhoo.com References 1. Weiner ID, Wingo CS. Hypoklemi-Consequences, cuses nd correction. J Am Soc Nephrol. 1997;8(7): Rimmer JM, Horn JF, Gennri FG. Hyperklemi s Compliction of Drug Therpy. Arch Intern Med. 1987;147(5): Crop MJ, Hoorn EJ, Lindemns J, Zietse R. Hypoklemi nd subsequent hyperklemi in hospitlized ptients. Nephrol Dil Trnsplnt. 2007;22(12): AstrZenec. Sterile Potssium Chloride Concentrte [Leflet]. Mlysi (MY): AstrZenec Globl; Clbrese AD, Erstd BL, Brndl K, Brlett JF, Kne SL, Shermn DS. Mediction dministrtion errors in dult ptientsin ICU. Intens Cre Med. 2001;27(10): Dvid U, Sylvi Hylnd. Mediction Sfety Alerts. CJHP. 2002;55(4): Dvid U. Mediction Sfety Alerts. CJHP. 2000;53(5): Reeve JF, Allinson YA, Stevens A. High-risk mediction lert: intrvenous potssium chloride. Aust Prescr. 2005;28(1): Sinh Y, Crnswick NE. Prescribing sfely for children. J Peditr Child H. 2007;43(3): Argo AL, Cox KK, Kelly WN. The ten most common lethl mediction errors in hospitl ptients. Hospitl Phrmcy. 2000;35(5): Shlom EA, My SK. Mnging High-Risk Medictions: Implementing Mediction Mngement Stndrd Hospitl Phrmcy. 2006;41(5): Ruble J. Impct Sfety, Efficiency nd the Bottom Line with Premixed IV Products. Phrmcy, Purchsing & Products. 2008;5(2): Pice BJ, Pterson KR, Onyng-Omr F, Donnelly T, Gry JM, Lwson DH. Record linkge study of hypoklemi in hospitlized ptients. Postgrd Med J. 1986;62(725): Textor SC, Brvo EL, Foud FM, Trzi RC. Hyperklemi in zotemic ptients during ngiotensin-converting enzyme inhibition nd ldosterone reduction with cptopril. Am J Med. 1982;73(5): Vn de Vreede MA, Wilson SG, Dooley MJ. Intrvenous potssium chloride prescribing nd dministrtion prctices in Victori: n observtionl study. MJA. 2008;189(10): Bxter. Potssium Chloride in Sodium Chloride Injection, USP [Leflet]. USA: Bxter Helthcre Corportion; Rimmele T, Kellum JA. Oliguri nd Fluid Overlod. Contrib Nephrol. 2010;164: Hemstreet BA, Stolpmn N, Bdesch DB, My SK, McCollum M. Potssium nd phosphorus repletion in hospitlized ptients: implictions for clinicl prctice nd the potentil use of helthcre informtion technology to improve prescribing nd ptient sfety. Curr Med Res Opin. 2006:22(12); Joint Commision On Accredittion Of Helthcre Orgniztions (JCAHO). Ptient Sfety Alert: High Alert medictions nd ptient sfety. Int J Qulity Helth Cre. 2001;13(4): Grissinger M. Potssium Chloride Injection Still Poses Threts to Ptients. P&T. 2011;36(5): Kruse JA, Crlson RW. Rpid Correction of Hypoklemi Using Concentrted Intrvenous Potssium Chloride Infusions. Arch Intern Med. 1990;150: Cmeron PD. Intrvenous Potssium Chloride. Aust Prescr. 2005;28(4): Rolls BJ, Phillips PA. Aging nd Disturbnces of Thirst nd Fluid Blnce. Nut Rev. 1990;48(31):

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