Potassium chloride

Dosage:

Over one month

Oral: 0.5 - 1mmoL/kg PO 12 hourly.  Total daily dose may be given in three divided doses. Adjust dose according to plasma potassium concentrations. 

Intravenous:

Replacement / supplementation: Initially 1- 2 mmoL/kg/day added to infusion fluid. Adjust according to plasma potassium levels. Usual maximum rate of infusion: 0.2mmoL/kg/hour or 10mmoL/hour, whichever is lower. Higher infusion rates may be permitted as an exception in certain clinical areas - see administration section for details.

Acute depletion (PICU ONLY): 0.5mmoL/kg (maximum 20mmoL) by IV infusion over 1-2 hours. Maximum rate of infusion 0.5mmoL/kg/hour via a central line; 0.2mmoL/kg/hour via a peripheral line.  Recheck potassium and repeat if necessary. Plasma potassium levels must be checked regularly. Cardiac monitoring mandatory. See administration section for full details. 

Monitoring:

Plasma potassium level, urinary output should be checked regularly. 

For intravenous administration continuous cardiac monitoring is recommended:

• For concentrations >40mmol/L
• For infusion rates >0.2mmol/kg/hour.

Total Parenteral Nutrition (TPN): In the case of TPN administration cardiac monitoring is recommended when the rate of administration of potassium exceeds 0.2mmoL/kg/hour

Administration:

Oral: 
Give with or after feeds /food. Potassium solutions are hypertonic and can damage the gastric mucosa.
Potassium solutions should be further diluted with water, fruit juice prior to administration to reduce gastric irritation.

Slow release tablets should only be used if patient is able to take the tablets while sitting upright or standing. The tablets should be swallowed whole, with plenty of water or other liquid. Slow release tablets should not be crushed. 

Intravenous:

Potassium supplementation /replacement suitable for general use in all areas:

• Maximum concentration: 40mmoL/L (20mmoL/500mL).
• Maximum rate of administration: 0.2mmoL/kg/hour or 10mmoL/hour, whicever is lower.
• May be administered via peripheral / central route.
• ECG monitoring not required.
• Monitor potassium levels regularly.
• Higher concentrations must not be used at ward level (see exceptions below)
• Potassium chloride must not be added to to hanging infusions due to the risk of pooling at the bottom of the bag and the risk of administration of a bolus dose of potassium.
• When preparing infusion bags, potassium chloride should be added with injection port pointing upwards.
• After the addition of potassium chloride, agitate bag (by 'kneading') and invert at least 10 times to thoroughly mix and avoid pooling. Bags should be 'kneaded' to mix and prevent settling at two hourly intervals during infusion. 
• Syringe and infusion bags must be clearly labeled with a 'medicine/drug added' label. 

Urgent correction of hypokalaemia in Children's Heart Centre, Nephrology, Haematology/ Oncology:

• Maximum concentration 60mmoL/L (30mmoL/500mL). For concentrations  >40mmoL/L administer via central route. Where urgent administration is required and a central line is unavailable, higher concentrations may be administered peripherally in the short-term using a large vein. This must be under the direction of a consultant. Monitor for signs of phlebitis.
• Maximum rate of administration 0.3mmoL/kg/hour or 15mmoL/hour, whichever is lower. For short term use. 
  Continuous ECG monitoring is mandatory if the potassium concentration >40mmoL/L (20mmoL/500mL) and/or where the rate of administration exceeds 0.2mmoL/kg/hour.
• Monitor potassium levels regularly.
• Patient to nurse ratio of 2:1
• Potassium chloride must not be added to to hanging infusions due to the risk of pooling at the bottom of the bag and the risk of administration of a bolus dose of potassium.
• When preparing infusion bags, potassium chloride should be added with injection port pointing upwards.
• After the addition of potassium chloride, agitate bag (by 'kneading') and invert at least 10 times to thoroughly mix and avoid pooling. Bags should be 'kneaded' to mix and prevent settling at two hourly intervals during infusion. 
• Syringe and infusion bags must be clearly labeled with a 'medicine/drug added' label. 

PICU ONLY:

1. Acute depletion (urgent correction of hypokalaemia):

Central line administration

• Where appropriate the ready mixed bag should be used: Sodium chloride 0.9%w/v + 20mmoL potassium in 100mL (flexible bag). Administer via central line only. 
  
  
• Concentrations >40mmoL/L (20mmoL/500mL) must be administered via central route. Where urgent administration is required and a central line is unavailable, concentrations >40mmoL/L (20mmoL/500mL) may be administered peripherally in the short-term using a large vein. This must be under the direction of a consultant. Monitor for signs of phlebitis.
  
  
• Maximum rate of administration:
  • Acute depletion (Central administration): Maximum rate of administration 0.5mmoL/kg/hour or 20mmoL/hour, whichever is lower. For short term use.
• Administer via the CHI Smart-pump Standard Concetration Infusion drug library.

Peripheral line administration: Maximum concentration for administration is 1mmoL/25mL (0.04mmoL/mL).

2. Replacement therapy in PICU (as an addition to IV fluids): 

• Maximum concentration 80mmoL/L (40mmoL/500mL). For concentrations  >40mmoL/L administer via central route. 
• Maximum rate of administration 0.5mmoL/kg/hour or 20mmoL/hour, whichever is lower. For short term use.
• Continuous ECG monitoring is mandatory if the potassium concentration >40mmoL/L (20mmoL/500mL) and/or where the rate of administration exceeds 0.2mmoL/kg/hour.
• Monitor potassium levels regularly.
• See 'potassium supplementation /replacement suitable for general use in all areas' aboce for preparation of IV fluid bags. 

Compatible infusion fluids: Sodium Chloride 0.9%w/v, Glucose 5%w/v (Glucose not recommened in initial potassium replacement therapy in hypokalaemic patients because glucose may cause a further decrease in the plasma-potassium concentration.)

Summary Table: 

Interactions:

Adverse Effects:

Oral use: abdominal pain, diarrhoea, flatulence, nausea, vomiting. With modified-release preparations, bleeding, gastro-intestinal obstruction, ulceration may occur.

Intravenous use: cardiac toxicity with rapid infusion - ECG monitoring may be required. See Monitoring section. 

Preparations:

Oral preparations: (preferred route)

Kay-Cee-L® Liquid 1mmol/mL.  Contains sorbitol - high doses can cause diarrhoea.
Potassium Chloride Oral Solution 2mmol/mL – made by Pharmacy. Contact Pharmacy prior to discharge.
Sando-K® Tablets (effervescent)  [contain 12mmol K⁺, 8mmol chloride per tab] (unlicensed)
KCL-retard (modified release) contain 8mmol K⁺ per tab.  Avoid unless liquid or effervescent tablets are unsuitable. (Spanish Astellas brand)
 

Intravenous preparations - HIGH RISK MEDICINE:

Pre-mixed bags:

• Sodium chloride 0.9% + 20mmoL potassium in 1L (flexible bag) available for use in Haematology / Oncology
  
  
• Sodium chloride 0.45% + Glucose 2.5% + 20mmoL potassium in 1 Litre (flexible bag) available for use in Haematology/Oncology Unit in CHI at Crumlin. 
  
  
• Sodium chloride 0.9% + 10mmoL potassium in 500mL (rigid plastic bottle) available in CHI at Crumlin. 
  
  
• Sodium chloride 0.9% + 20mmoL potassium in 100mL (flexible bag). FOR USE IN PICU ONLY. MUST NOT BE USED IN ANY OTHER LOCATION.

Concentrated Potassium chloride injection (miniplasco):

• Concentrated Potassium Chloride injection 15%w/v 10mL miniplasco contains potassium 2mmol/mL.   MUST BE DILUTED BEFORE USE.  Must be stored in controlled drugs press.