concentrate intravenous solution and other strong potassium solutions

Transcription

1 Policy for the use of potassium chloride concentrate intravenous solution and other strong potassium solutions CLINICAL GUIDELINES ID TAG Policy for the use of potassium chloride Title: concentrate intravenous solution and other strong potassium solutions Jillian Redpath Author: Medicines Governance Pharmacist Speciality / Division: Pharmacy Acute Policy applicable to Acute, Mental Directorate: Health and Disability, Older People and Primary care & Children and Young People Date Uploaded: Medicines Optimisation / Drugs and Approved by: Therapeutics Committee 29 th September 2017 Review Date September 2020 Clinical Guideline ID CG0057[2] intravenous solution and other strong potassium solutions Page 1 of 12

2 1.0 Introduction Potassium chloride concentrate solution can be fatal if given inappropriately however potassium chloride is widely used and administered intravenously in diluted solutions to treat low potassium levels (hypokalaemia) in more seriously ill patients. Patients with low potassium levels may require intravenous potassium very quickly, within minutes. A delay in administering this therapy could compromise patient care and risk cardiac arrest. Some patients in critical care settings may require potassium in the form of a very small volume of the concentrated solution. Potassium chloride concentrate ampoules can look very similar to sodium chloride, water for injection and other injectable medicines. Reports from the United States of America, Canada and the UK have identified a number of incidents where potassium chloride concentrate has been accidentally administered to patients with fatal results. In July 2002, the National Patient Safety Agency issued a patient safety alert relating to the intravenous administration of potassium solutions 1. The purpose of the alert was 1. to reduce the risk of accidental overdose of intravenous potassium arising from use of potassium chloride concentrate solutions and other strong potassium solutions. 2. to ensure that seriously ill patients in critical care units who urgently require intravenous potassium as part of their treatment can continue to receive it promptly. 2.0 Aim This policy describes the action within the Southern Health and Social Care Trust (SHSCT) to ensure compliance with the requirements of the National Patient Safety Agency (NPSA) alert relating to the intravenous administration of potassium solutions 1. intravenous solution and other strong potassium solutions Page 2 of 12

3 3.0 Policy Statement 3.1 Concentrated intravenous potassium solutions Concentrated intravenous potassium solutions (>10%) at SHSCT are: potassium chloride concentrate 15% Addiphos No other concentrated intravenous potassium solutions must be purchased or supplied without consideration to this policy Concentrated intravenous potassium solutions may only be stocked by pharmacy and designated Critical Care Areas Designated Critical Care Areas in SHSCT are: Craigavon Area Hospital (CAH) Intensive Care Unit Coronary Care Unit Neonatal Unit Theatres and Recovery Emergency Department Daisy Hill Hospital (DHH) High Dependency Unit Coronary Care Unit Special Care Baby Unit Theatres Emergency Department Within CAH pharmacy, concentrated potassium (2mmol/ml potassium chloride or Addiphos ) is further diluted and used to prepare total parenteral nutrition solutions within the pharmacy aseptic unit Concentrated intravenous potassium solutions are treated as a Controlled Drug and staff must adhere to Trust Controlled Drug Procedures. intravenous solution and other strong potassium solutions Page 3 of 12

4 3.2 Use of intravenous potassium in Critical Care Areas A Critical Care Area must not transfer stocks of concentrated intravenous potassium solutions to any other area; all supplies must be made directly from Pharmacy In exceptional circumstances, the pharmacist may contact the following Critical Care Areas to authorise a potassium infusion to be prepared and labelled for a non-critical area Craigavon Area Hospital Coronary Care Unit for adult patients Neonatal Unit for paediatric patients Daisy Hill Hospital Coronary Care or High Dependency Unit for adult patients Special Care Baby Unit for paediatric patients See page 7 for further details Concentrated intravenous potassium solutions must only be used where a ready made infusion is unavailable (Appendix 1) Ready made potassium infusions should be stored separately from other infusion fluids. They should be stored in the outer cardboard box wherever possible. Where they cannot be stored in the outer cardboard box, ready made potassium infusion fluids must be stored separately from other infusions and segregated to avoid confusion between different potassium infusion fluids Concentrated intravenous potassium solutions will be used in critical care areas as follows: ICU and Theatres & Recovery, CAH Concentrated potassium chloride 2mmol/ml is infused intravenously via a rate controlled infusion device, for example a syringe driver or pump, through a central line with cardiac monitoring, rate adjusted according to serum potassium level. Concentrated potassium chloride 2mmol/ml is also added to dialysis fluids as part of renal intravenous solution and other strong potassium solutions Page 4 of 12

5 replacement therapy. Addiphos (1.5mmol potassium/ml + 2mmol phosphate/ml) is infused intravenously via a rate controlled infusion device, for example a syringe driver or pump, through a central line with cardiac monitoring, rate adjusted to serum phosphate and potassium level. Coronary Care Unit, Emergency Department, CAH and Theatres, Coronary Care Unit, High Dependency Unit, Emergency Department, DHH Concentrated potassium (2mmol/ml potassium chloride or Addiphos ) is further diluted and used to prepare potassium infusions, not available as ready made infusions. Higher concentrations of potassium or faster infusion rates than detailed in guidelines for the Treatment of hypokalaemia in adults and Treatment of hypophosphataemia may be given in very severe depletion or fluid restriction but require senior clinician advice who must ensure the following are in place: ECG monitoring Central line Frequent monitoring of serum potassium Neonatal Unit, CAH and Special Care Baby Unit, DHH Concentrated potassium (2mmol/ml potassium chloride) is further diluted and used to prepare potassium infusions, not available as ready made infusions, in accordance with guidelines in the British National Formulary for Children and Medicines for Children Addition of concentrated intravenous potassium solutions to a larger infusion volume must follow the guidelines in Appendix Prescriptions for intravenous potassium must be expressed in millimoles of potassium and specify the rate of infusion ECG monitoring is required if the rate of administration is more than 20mmol/hour. intravenous solution and other strong potassium solutions Page 5 of 12

6 3.2.9 A central line is usually required if the concentration is more than 40mmol potassium per 1000ml (up to 80mmol/1000ml may be administered peripherally to fluid restricted patients on the advice of a senior clinician) Intravenous potassium must be infused via a rate controlled infusion device. 3.3 Use of intravenous potassium in other wards/units Administration of potassium solutions for intravenous administration should be in accordance with the guidelines for Treatment of hypokalaemia in adults (available on the Trust intranet), guidelines for Treatment of hypophosphataemia (available on the Trust intranet) for adults and with the British National Formulary for Children and Medicines for Children for paediatrics Other wards/units are not permitted to hold stock of concentrated intravenous potassium solutions. Critical Care Areas cannot transfer stocks of concentrated intravenous potassium solutions to other wards/units Other wards/units stock a range of ready made diluted solutions from an available list (Appendix 1) Ready made potassium infusions should be stored separately from other infusion fluids. They should be stored in the outer cardboard box wherever possible. Where they cannot be stored in the outer cardboard box, ready made potassium infusion fluids must be stored separately from other infusions and segregated to avoid confusion between different potassium infusion fluids A small number of more concentrated (>40mmol potassium/litre and < 10%) infusion solutions are available as part of this list. These infusion solutions must be treated as a Controlled Drug and as such documentation for ordering, receipt and administration should be completed. intravenous solution and other strong potassium solutions Page 6 of 12

7 3.3.6 Any requests for prescriptions for intravenous potassium, which cannot be met using these solutions, must be discussed with a pharmacist or the on-call pharmacist out of hours, who may: (1) Supply a solution prepared in Pharmacy (2) In exceptional circumstances, authorise the solution to be prepared on a Critical Area, in which case the pharmacist may contact the following critical area to authorise a potassium infusion to be prepared and labelled for a noncritical area. Craigavon Area Hospital Coronary Care Unit for adult patients Neonatal Unit for paediatric patients Daisy Hill Hospital Coronary Care or High Dependency Unit for adult patients Special Care Baby Unit for paediatric patients A nurse and a nurse/hospital at night co-ordinator/doctor from the non-critical area, on the authorisation of the pharmacist, will bring the prescription chart to the critical area and prepare and label the infusion with a nurse/doctor from the critical area. The preparation of the infusion is recorded in the Controlled Drug Register of the critical area by all three staff, with the non-critical area recorded beside the patient name in the register. The nurse and a nurse/hospital at night co-ordinator/doctor from the non-critical area then take the prepared and labelled infusion to the ward/unit and administer the infusion to the patient. The pharmacist will prepare a record of this event. 3) In exceptional circumstances, usually in a hospital without a critical area or where the critical area does not stock the required concentrated intravenous potassium solution (e.g. Addiphos ), dispense concentrated intravenous potassium intravenous solution and other strong potassium solutions Page 7 of 12

8 solution on an individual patient basis as a Controlled Drug. The pharmacist will deliver the concentrated potassium intravenous solution to the ward/unit and be the second check for preparation and administration of the infusion on the ward/unit so that no stock of concentrated potassium intravenous solution remains on the ward after the infusion has been prepared Patients requiring intravenous potassium within other wards/units that are unable to comply with the policy, for example administration of intravenous potassium via a rate controlled infusion device, will be transferred to an appropriate acute ward for treatment. 3.4 Summary of storage and handling of potassium solutions Ward/ Unit Stock Concentration greater than 10% potassium i.e. Potassium chloride ampoules 15%, Addiphos * CAH - ITU, NNU, CCU, Theatres & Recovery, ED DHH - Theatres, HDU, CCU, SCBU, ED Potassium solutions Concentrations > 40mmol potassium/ 1000ml and < 10% potassium All areas Solutions < 40mmol potassium/1000ml All areas Controlled YES YES NO drug requirements Borrowing of NO NO YES stock between areas On top-up NO NO YES intravenous solution and other strong potassium solutions Page 8 of 12

9 The potassium content of ready made potassium infusions will be labelled in red print. 4.0 Scope of policy The scope of this policy extends to all staff that prescribe, supply or administer concentrated intravenous potassium solutions and potassium infusions. 5.0 Roles and Responsibilities 5.1 All staff that prescribe, supply or administer concentrated intravenous potassium solutions and potassium infusions must adhere to this policy. 5.2 Managers must ensure this policy is included in medical, nursing & midwifery and pharmacy staff induction programs. 5.3 The SHSCT Drugs and Therapeutics Committee is responsible for monitoring adherence to this policy, identifying if review is required earlier than otherwise indicated and advising SHSCT Senior Management Team. 6.0 Equality and Human Rights Considerations 6.1 This policy has been screened for equality implications as required by Section 75 and Schedule 9 of the Northern Ireland Act Equality Commission guidance states that the purpose of screening is to identify those policies which are likely to have a significant impact on equality of opportunity so that greatest resources can be devoted to these. 6.2 Using the Equality Commission's screening criteria, no significant equality implications have been identified. The policy will therefore not be subject to an equality impact assessment. 6.3 Similarly, this policy has been considered under the terms of the Human Rights Act 1998, and was deemed compatible with the European Convention Rights contained in the Act. intravenous solution and other strong potassium solutions Page 9 of 12

10 7.0 Alternative formats This document can be made available on request in alternative formats, e.g. plain English, Braille, disc, audiocassette and in other languages to meet the needs of those who are not fluent in English. 8.0 Records Management The supply of information under the Freedom of Information does not give the recipient or organisation that receives it the automatic right to re-use it in any way that would infringe copyright. This includes, for example, making multiple copies, publishing and issuing copies to the public. Permission to re-use the information must be obtained in advance from the Trust. 9.0 References 1. Patient Safety Alert 01: Concentrated potassium solutions, 23 July 2002, National Patient Safety Agency. Available online at: intravenous solution and other strong potassium solutions Page 10 of 12

11 Appendix 1 Potassium content (mmol/bag) Ready to use dilute potassium chloride solutions Volume Diluent 10mmol 500ml Sodium chloride 0.9% 20mmol 1000ml Sodium chloride 0.9% 20mmol 500ml Sodium chloride 0.9% 40mmol 1000ml Sodium chloride 0.9% 20mmol 1000ml Glucose 5% 20mmol 500ml Glucose 5% 40mmol 1000ml Glucose 5% Unlicensed solutions Suggested use 10mmol 500ml Sodium chloride 0.45% Paediatrics / Peri-operative and Glucose 5% management of diabetes 20mmol 500ml Sodium chloride 0.45% Paediatrics and Glucose 5% 10mmol 500ml Sodium chloride 0.45% Haematology and Glucose 2.5% 10mmol 500ml Sodium chloride 0.45% Paediatrics and Glucose 10% 10mmol 500ml Sodium chloride 0.9% and Paediatrics Glucose 5% 20mmol 500ml Sodium chloride 0.9% and Paediatrics Glucose 5% 10mmol 500ml Glucose 10% Paediatrics 20mmol 500ml Sodium chloride 0.9% with 10mmol phosphate Hypophosphataemia More concentrated solutions treat as Controlled Drug Suggested use 40mmol 500ml Sodium chloride 0.9% Fluid restricted patients 40mmol 500ml Glucose 5% Fluid restricted patients N.B. Sodium chloride 0.9% is the preferred diluent since glucose solutions can cause hyperglycaemia and be associated with a shift of potassium into cells. intravenous solution and other strong potassium solutions Page 11 of 12

12 Appendix 2 Guidelines for the addition of concentrated intravenous potassium solution to larger volume infusions (Trissell 1, 2007) 1. Hold the additive port uppermost. 2. Inject concentrated intravenous potassium solution downwards into the bag. 3. Invert and agitate the bag repeatedly to mix the contents squeezing the bag is ineffective. 4. Concentrated intravenous potassium solution must never be injected into a hanging bag. 5. Concentrated intravenous potassium solution must never be added to an infusion solution that already contains potassium, with the exception of renal dialysis or haemodialysis fluid. 1 Trissel, L.A., Handbook on Injectable Drugs. 14 th Ed. Bethesda: American Society of Health System. Pharmacists intravenous solution and other strong potassium solutions Page 12 of 12