Rhodes Leslie A, Wall Kevin M, Abernathy Staci L, Moellinger Ashley B, Borasino Santiago, Alten Jeffrey A
1Department 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.
Pediatr Crit Care Med. 2016 Aug;17(8):772-8. doi: 10.1097/PCC.0000000000000849.
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.
Retrospective evaluation of a quality improvement project aimed at reducing IV potassium chloride exposure.
Pediatric cardiac ICU.
All patients admitted to pediatric cardiac ICUs in April 2013 to September 2013 (preprotocol) and October 2013 to April 2014 (postprotocol).
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.
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).
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.
静脉补钾在儿科心血管重症监护病房中常用。然而，高浓度静脉注射氯化钾剂量可导致危及生命的并发症。我们报告了一项旨在减少高浓度静脉注射氯化钾暴露的质量改进项目的结果。
对一项旨在减少静脉注射氯化钾暴露的质量改进项目进行回顾性评估。
儿科心脏重症监护病房。
2013年4月至2013年9月（方案实施前）以及2013年10月至2014年4月（方案实施后）入住儿科心脏重症监护病房的所有患者。
一个质量改进团队制定了一项钾方案，旨在通过侧重于早期肠内补钾的算法将血清钾水平维持在3.0 - 5.5 mEq/L。所有接受静脉利尿剂治疗且血清钾水平低于4.5 mEq/L、尿量超过0.5 mL/kg/hr的患者，开始使用含氯化钾的静脉输液或肠内氯化钾实施该方案。高浓度静脉注射氯化钾仅限于血清钾低于2.0 mEq/L的无症状患者以及低于3.0 mEq/L的高危患者。每天测量一次血清钾水平，并根据该水平和同时进行的利尿剂治疗进行方案调整。
比较方案实施前后的血清钾、氯化钾补充量、患者费用、液体输注量及心律失常发生率。共纳入443例入院患者（方案实施前234例，方案实施后209例）。人口统计学特征无显著差异。方案实施后早晨平均血清钾水平无差异（方案实施前为3.85 [0.77] mEq/L，方案实施后为3.89 [0.75] mEq/L；p = 0.90）。高浓度静脉注射氯化钾的使用量减少了86%（331剂 vs 47剂）。实施该方案后，高钾血症单次测量发作天数的发生率降低（11 vs 4/1000患者 - 日；p = 0.02），低钾血症有降低趋势（433 vs 400/1000患者 - 日；p = 0.05）。心律失常发生率相似（p = 0.59）。
儿科心脏重症监护患者的方案化钾管理减少了高浓度静脉注射氯化钾的暴露及高钾血症的发生率。较低的静脉注射氯化钾治疗阈值与心律失常增加无关。
