![]() This need causes the pharmacy to compound patient-specific 40 mEq/L potassium IV fluids, possibly interrupting typical workflow and extending the time from ordering to administration of the fluids.Īccording to the DKA treatment protocol, initial serum potassium concentration is determined upon presentation to the ED using a point of care (POC) handheld blood analyzer (iSTAT, Princeton, NJ) and a basic metabolic panel (BMP). It is important to note potassium is ordered in mEq of potassium given from KPhos, not mmol of phosphate (conversion factor of 4.4 mEq potassium and 3 mmol phosphate per mL). Patients who present with a serum potassium concentration of <5 mEq/L should receive IV fluids containing 40 mEq/L potassium, according to the DKA treatment protocol. The fluids are given a beyond-use date of 9 days in accordance with USP 3 and are compounded during the overnight shift. These fluids are stored in the main pharmacy refrigerator in preparation for use in the ED. Our current practice at CHKD is to stock pre-made IV fluids containing 20 mEq/L KAc. The potassium salt added to the IV fluids is driven by protocol and may change based on serum potassium and phosphorous concentrations.ĬHKD, Children's Hospital of The King's Daughters D10, dextrose 10% KAc, potassium acetate KPhos, potassium phosphate NS, 0.9% sodium chloride PO4, phosphorous test Unless a serum phosphorous concentration is available, patients at CHKD are first initiated on IV fluids containing KAc. The total concentration of potassium is either 20 mEq/L or 40 mEq/L, with two potassium salt options, potassium acetate (KAc) or potassium phosphate (KPhos). ![]() The first bag of the 2-bag system consists of 0.9% sodium chloride with potassium supplementation, and the second bag consists of dextrose 10% and 0.9% sodium chloride with potassium supplementation. 1, 2Īfter initial fluid expansion with a 0.9% sodium chloride fluid bolus, a 2-bag IV fluid system is used in the ED per the DKA treatment protocol ( Table 1) at the Children's Hospital of The King's Daughters (CHKD). 1, 2 After initiation of insulin therapy and potassium-containing IV fluids, serum potassium concentrations should be monitored and replaced based on serum potassium concentrations. Because this phenomenon, potassium replacement is recommended by the ISPAD and ADA to include administration of fluids with a concentration of 40 mEq/L potassium. 1 After completion of an initial IV fluid bolus, and once insulin is administered and acidosis is corrected, potassium will shift intracellularly, causing even greater hypokalemia. 1 Additionally, potassium is lost through urinary excretion due to secondary hyperaldosteronism from volume depletion. 1, 2 During DKA, potassium is lost from the intracellular pool because of hypertonicity and is then removed from the body through emesis and osmotic diuresis. 1, 2 The ISPAD and ADA guidance statements include specific recommendations for potassium replacement because of total body deficits ranging from 3 to 6 mEq/kg. 1, 2 This is because of severe fluid and electrolyte losses from dehydration and deficits in sodium, potassium, chloride, calcium, and phosphate. ![]() ![]() 1, 2 Both the International Society for Pediatric and Adolescent Diabetes (ISPAD) and the American Diabetes Association (ADA) recommend fluid and electrolyte replacement in addition to insulin therapy. The diagnosis of diabetic ketoacidosis (DKA) includes hyperglycemia of >200 mg/dL, venous pH of <7.3 or serum bicarbonate of <15 mmol/L, and the presence of ketones in the blood, as indicated by moderate to large ketonuria. ![]()
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