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Decreasing IV Potassium in Pediatric Cardiac Intensive Care: Quality Improvement Project
Leslie A Rhodes1, Kevin M Wall, Staci L Abernathy
11Department of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama, Birmingham, AL. 2Department of Nursing Services, Children's of Alabama, Birmingham, AL. 3Department of Cardiothoracic Surgery, University of Alabama, Birmingham, AL.
Insights
A quality improvement project successfully reduced concentrated intravenous potassium chloride use in pediatric cardiac intensive care units. This protocol also decreased hyperkalemia incidence without increasing arrhythmias.
Area of Science:
- Pediatric Cardiology
- Intensive Care Medicine
- Clinical Quality Improvement
Background:
- Intravenous (IV) potassium supplementation is standard in pediatric cardiovascular ICUs.
- High concentrations of IV potassium chloride can cause severe, life-threatening complications.
Purpose of the Study:
- To implement and evaluate a quality improvement project focused on reducing exposure to concentrated IV potassium chloride in pediatric cardiac ICUs.
- To maintain serum potassium levels within a target range of 3.0-5.5 mEq/L.
Main Methods:
- A protocol was developed prioritizing early enteral potassium supplementation and limiting concentrated IV potassium chloride to specific low serum potassium levels.
- Retrospective evaluation compared outcomes before (April 2013-September 2013) and after (October 2013-April 2014) protocol implementation.
- Key metrics included serum potassium levels, IV potassium chloride administration, hyperkalemia, hypokalemia, and arrhythmia incidence.
Main Results:
- Concentrated IV potassium chloride administration decreased by 86% post-protocol.
- A significant decrease in hyperkalemia incidence was observed (11 vs 4/1,000 patient-days; p = 0.02).
- A trend towards decreased hypokalemia was noted, with similar arrhythmia incidence between groups.
Conclusions:
- Protocolized potassium management effectively reduced concentrated IV potassium chloride exposure in pediatric cardiac ICU patients.
- The protocol successfully lowered hyperkalemia incidence.
- Implementing a lower threshold for IV potassium chloride treatment did not elevate the risk of arrhythmias.
Objectives:
IV potassium supplementation is commonly used in the pediatric cardiovascular ICU. However, concentrated IV potassium chloride doses can lead to life-threatening complications. We report results of a quality improvement project aimed at decreasing concentrated IV potassium chloride exposure.
Design:
Retrospective evaluation of a quality improvement project aimed at reducing IV potassium chloride exposure.
Setting:
Pediatric cardiac ICU.
Patients:
All patients admitted to pediatric cardiac ICUs in April 2013 to September 2013 (preprotocol) and October 2013 to April 2014 (postprotocol).
Interventions:
A quality improvement team developed a potassium protocol aimed at maintaining serum potassium levels 3.0-5.5 mEq/L, via algorithm focused on early enteral supplementation. All patients receiving IV diuretics who had a serum potassium level less than 4.5 mEq/L and urine output more than 0.5 mL/kg/hr had protocol initiated with potassium chloride-containing IV fluids or enteral potassium chloride. Concentrated IV potassium chloride infusions were limited to asymptomatic patients with serum potassium less than 2.0 mEq/L and high-risk patients at less than 3.0 mEq/L. Serum potassium levels were measured once daily, and protocolized adjustments were made based on this level and concurrent diuretic therapy.
Measurements And Main Results:
Serum potassium, potassium chloride supplementation, patient cost, fluid administration, and arrhythmia incidence were compared pre and post protocol. Four hundred forty-three admissions were included (234 pre protocol and 209 post protocol). No significant differences were found in demographics. There was no difference in mean morning serum potassium after protocol implementation (3.85 [0.77] mEq/L before protocol and 3.89 [0.75] mEq/L after protocol; p = 0.90). Concentrated IV potassium chloride administration was decreased by 86% (331 vs 47 doses). With protocol, there was decreased incidence in days with one measured episode of hyperkalemia (11 vs 4/1,000 patient-days; p = 0.02) and a trend toward decreased hypokalemia (433 vs 400/1,000 patient-days; p = 0.05). Arrhythmia incidence was similar (p = 0.59).
Conclusions:
Protocolized potassium management in pediatric cardiac intensive care patients decreased concentrated IV potassium chloride exposure and incidence of hyperkalemia. Lower potassium treatment threshold for IV potassium chloride was not associated with increased arrhythmias.
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