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Abbreviations:
K+
KCl
PVC
potassium
potassium chloride
polyvinyl chloride
835
Statistical Analysis
+
Intended K concentrations as noted on the uid bags adhesive label for uid additives and measured K+ concentrations were
assessed for normality by a Shapiro-Wilk normality test and were
not normally distributed. A Wilcoxon matched-pairs signed rank
test was used to compare the median intended K+ to median measured K+ concentration in clinical samples. The agreement of
expected and measured K+ concentrations in stock solutions
supplemented with KCl under controlled circumstances were
compared using Bland-Altman analysis. For potassium supplementation without mixing area under the curve analysis was performed
for the rst hour of potential delivery. Statistical analyses were
performed using commercially available software.j Results were
considered statistically signicant when P < .05.
Results
Potassium Supplementation in Hospitalized Dogs and
Cats
A total of 210 bags of uids administered IV in clinical
use were evaluated. Nine of the 210 samples needed to be
diluted 10-fold in order to be able to measure K+ concentration. Crystalloid uid types included lactated Ringers
(n = 170), Plasma-Lyte 148 (n = 38), and 0.9% NaCl
(n = 2). Fluid bag sizes were 5000 mL (n = 1), 3000 mL
(n = 1), 1000 mL (n = 185), and 500 mL (n = 23). Nine
of the sampled bags were supplemented with KCl as
partial bag volumes, at time of supplementation ranging
836
1
152
31
12
4
7
0
3
0.5
72.4
14.8
5.7
1.9
3.3
0
1.4
Discussion
In the 210 clinical samples, the comparison of measured to intended K+ concentration showed measured
K+ was signicantly higher although undersupplementation was also present. In 28% of the samples, measured K+ concentration was 5 mmol/L above or
below the intended concentration. In 11% of all samples, measured K+ exceeded the target K+ concentration by 20 mmol/L to 179 mmol/L and in 3 of 210
samples, the K+ concentration was >280 mmol/L more
than desired. As inadvertent administration of K+
boluses from uid bags with such high K+ concentrations can lead to life threatening or even fatal impairment of cardiac conduction, this variability in K+
concentration could have an important clinical
impact.2,79 Several factors likely contribute to inaccuracies in K+ supplementation, such as inadequate mixing
of additives in nonrigid uid containers, manufacturer
variability in bag uid volumes and K+ addition, KCl
injection technique, as well as human error such as miscalculations or labeling errors leading to repeat supplementation of the same bag.
Of the 210 clinical uid bags sampled, 9 had KCl
added to a partially used bag and 6 of these bags were
over supplemented with excess in K+ ranging from
8 mmol/L to 154 mmol/L. Two of the 3 highest K+
concentrations found in all clinical samples were measured in bags supplemented as partial bags at
174 mmol/L and 156 mmol/L respectively. The setting
of adding KCl to a bag that is already in use may make
it more likely that calculation errors to determine the
quantity of KCl for addition will occur. It also seems
more likely that KCl addition would be performed with
the bag in a hanging position when bags are already in
use and that insucient attempts to adequately mix
these bags would occur.
The occurrence of inadequate mixing when supplementing uid containers with additives such as KCl has
long been recognized and has been associated with
adverse drug reactions in human patients as well as companion animals.1,3,7,9,10,1318 Several studies have conrmed that non-rigid uid containers are most
susceptible to inadequate mixing of additives and have
investigated dierent techniques to ensure more adequate mixing.1,7,9,13,14,17 One time inversion of the infusion bag into a hanging position after additives were
added to the bag in a bottom up position have been
shown to provide adequate mixing when compared to
injecting additives to a exible bag already hanging in
the infusion position.7,9,14 Other experimental studies
have shown that adequate mixing can be achieved with
one or two double inversions of PVC containers held by
their ends.16 Studies on adequate mixing of magnesium
additives to non-rigid uid containers show that adequate mixing can be achieved with 3 inversions of the
bag and that inversing the bag 15 times provides no
additional advantage.19 Shaking of PVC containers has
been shown to provide less mixing of KCl than the double inversion technique and is not recommended, and
squeezing the bag after additives are injected in an infusion position has even been shown to pump the additives
from the dependent injection port into the infusion
chamber.9,16 No standardized mixing protocol was in
place at our facility at the time of this study and a
837
838
Footnotes
a
Acknowledgments
Funding: There was no funding source for this study.
Conict of Interest Declaration: Authors disclose no
conict of interest.
O-label Antimicrobial Declaration: Authors declare
no o-label use of antimicrobials.
References
1. Gong H Jr, King CY. Inadequate drug mixing: a potential
hazard in continuous intravenous administration. Heart Lung
J Crit Care 1983;12:528532.
2. Lawson DH. Adverse reactions to potassium chloride. Q
J Med 1974;43:433440.
3. Lawson DH. The clinical use of potassium supplements.
J Maine Med Assoc 1975;66:166169.
4. Anon. Mixing drugs with intravenous infusions. Drug Ther
Bull 1970;8:5356.
5. DiBartola SP, De Morais HA. Disorders of potassium:
hypokalemia and hyperkalemia. In: DiBartola SP, ed. Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice, 4th ed.
St. Louis: Elsevier Saunders; 2012:92119.
6. Feldman EC, Church DB. Electrolytes disorders: potassium
(hyper/hypokalemia). In: Ettinger SJ, Feldman EC, eds. Textbook
of Veterinary Internal Medicine, 7th ed. St. Louis: Elsevier Saunders; 2010:303307.
7. Lankton JW, Siler JN, Neigh JL. Letter: hyperkalemia after
administration of potassium from nonrigid parenteral-uid containers. Anesthesiology 1973;39:660661.
8. Shapiro S. Fatal drug reactions among medical inpatients. J
Am Med Assoc 1971;216:467.
9. Williams RH. Potassium overdosage: a potential hazard of
non-rigid parenteral uid containers. Br Med J 1973;1:714715.
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15. Deardor DL, Schmidt CN, Wiley RA. Eect of preparation techniques on mixing of additives in intravenous uids in
nonrigid containers. Hosp Pharm 1993;28:306, 309310, 312313.
16. Deardor DL, Schmidt CN. Mixing additives in plastic
LVPs. Am J Hosp Pharm 1980;37:1610, 1613.
17. Thompson WL, Feer TD. Incomplete mixing of drugs in
intravenous infusions. Crit Care Med 1980;8:603607.
18. Todd B. Intravenous drug hazards: interactions, adsorption,
and inadequate mixing. Geriatr Nurs 1988;9:20, 22.
19. Whang R, Papper S, Fryer A. Intravenous magnesium
potential hazard of inadequate mixing. J Am Coll Nutr 1983;2:97
100.
20. Donaldson TM, Mani V, Wheeler DW. Factors aecting
the concentration of electrolyte infusions prepared from stock
solutions. Postgrad Med J 2011;87:8388.