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Safety, Efficacy, and Timeliness of Intravenous Potassium Chloride Replacement Protocols in a Pediatric
Rambod Amirnovin1,2,3, Phuong Lieu4, Flerida Imperial-Perez3
1Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
Insights
A new tiered-dosing protocol for potassium (K+) replacement in pediatric cardiac surgery patients effectively and safely reduced supplemental doses without increasing hyperkalemia risk. This nurse-driven approach also ensured timely administration of essential K+ therapy.
Area of Science:
- Pediatric Cardiac Surgery
- Intensive Care Medicine
- Clinical Pharmacy
Background:
- Hypokalemia is common in children post-cardiac surgery, increasing arrhythmia risk.
- Renal insufficiency post-cardiopulmonary bypass necessitates cautious potassium (K+) administration.
- Optimizing K+ replacement protocols is crucial for patient safety and effective treatment.
Purpose of the Study:
- To evaluate the safety, efficacy, and timeliness of nurse-driven potassium (K+) replacement protocols.
- To compare a high-dose and a tiered-dosing K+ protocol against a historical low-dose protocol.
- To identify an optimal K+ regimen for pediatric patients following cardiac surgery.
Main Methods:
- Retrospective cohort review and prospective single-blinded review of pediatric patients receiving intravenous K+.
- Comparison of historical low-dose, high-dose, and tiered-dosing K+ protocols.
- Efficacy defined by fewer supplemental doses; safety by serum K+ levels ≥4.8 mEq/L; timeliness by administration speed.
Main Results:
- The tiered-dosing protocol showed a trend towards lower incidence of serum K+ levels ≥4.8 mEq/L compared to the high-dose protocol (0.5% vs 2.2%).
- The tiered-dosing protocol resulted in a higher ratio of protocol to total K+ doses compared to the low-dose protocol.
- Protocol doses were administered significantly faster (45 minutes) with the tiered-dosing approach.
Conclusions:
- The tiered-dosed, nurse-driven K+ protocol is effective and safe for treating hypokalemia in pediatric cardiac surgery patients.
- This protocol reduces the need for supplemental K+ doses without elevating hyperkalemia risk.
- The tiered-dosing approach ensures timely administration of K+ compared to individually ordered doses.
Objective:
Hypokalemia in children following cardiac surgery occurs frequently, placing them at risk of life-threatening arrhythmias. However, renal insufficiency after cardiopulmonary bypass warrants careful administration of potassium (K+). Two different nurse-driven protocols (high dose and tiered dosing) were implemented to identify an optimal K+ replacement regimen, compared to an historical low-dose protocol. Our objective was to evaluate the safety, efficacy, and timeliness of these protocols.
Design:
A retrospective cohort review of pediatric patients placed on intravenous K+ replacement protocols over 1 year was used to determine efficacy and safety of the protocols. A prospective single-blinded review of K+ repletion was used to determine timeliness.
Patients:
Pediatric patients with congenital or acquired cardiac disease.
Setting:
Twenty-four-bed cardiothoracic intensive care unit in a tertiary children's hospital.
Interventions:
Efficacy was defined as fewer supplemental potassium chloride (KCl) doses, as well as a higher protocol to total doses ratio per patient. Safety was defined as a lower percentage of serum K+ levels ≥4.8 mEq/L after a dose of KCl. Between-group differences were assessed by nonparametric univariate analysis.
Results:
There were 138 patients with a median age of 3.0 (interquartile range: 0.23-10.0) months. The incidence of K+ levels ≥4.8 mEq/L after a protocol dose was higher in the high-dose protocol versus the tiered-dosing protocol but not different between the low-dose and tiered-dosing protocols (high dose = 2.2% vs tiered dosing = 0.5%, P = .05). The ratio of protocol doses to total doses per patient was lower in the low-dose protocol compared to the tiered-dosing protocol (P < .05). Protocol doses were administered 45 minutes faster (P < .001).
Conclusion:
The tiered-dosed, nurse-driven K+ replacement protocol was associated with decreased supplemental K+ doses without increased risk of hyperkalemia, administering doses faster than individually ordered doses; the protocol was effective, safe, and timely in the treatment of hypokalemia in pediatric patients after cardiac surgery.
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