Highly concentration electrolytes: A silent risk every nurse must recognize
Hemapriya.K.H1, Abinaya.G1, Akashmol. H1 Lavanya.M1, Muthulakshmi2, Deeparani Alagarsamy3
1Staff, Nurse, Nurse Residency Programme, Kauvery Hospital, Radial Road, Chennai
2Clinical Instructor, Kauvery Hospital, Radial Road, Chennai
3Deputy Nursing Superintendent & NRP course coordinator, Kauvery Hospital, Radial Road, Chennai
Introduction
Highly concentrated electrolytes are frequently used in clinical practice for correcting severe electrolyte imbalances, managing critical conditions, and supporting life-saving interventions. These electrolytes can be imbalanced, leading to high or low levels. High or low levels of electrolytes disrupt normal bodily functions and can lead to life-threatening complications. However, their administration carries significant risks including tissue injury, cardiac arrhythmias and metabolic disturbances.
We need to by, the guidelines to ensure the safe and effective administration of these solutions while minimizing complications.
Every nurse who handles IV therapy should understand what HCEs are, why they are dangerous, and how to handle them safely.
What are high concentrated electrolytes
Electrolytes such as Sodium chloride, potassium chloride (KCL), calcium gluconate, magnesium sulphate and sodium bicarbonate are essential for maintaining physiological homeostasis. High concentration solutions typically refer to those that exceed standard maintenance level. For example, potassium chloride concentrations greater than 20mEq/100 ml or calcium, preparations that can cause irritation. Undiluted electrolytes can cause sudden cardiac arrest, tissue necrosis, or death if not administered properly.
| Electrolyte | Concentration | Uses |
|---|---|---|
| Sodium chloride | 3% | Hyponatremia Increased Intracranial pressure |
| Potassium chloride | 15% | Hypokalaemia |
| Magnesium sulphate | 50% | Hypomagnesemia Eclampsia |
| Calcium gluconate | 10% | Hypocalcaemia Cardiac protection |
| Sodium bicarbonate | 8.4% | Metabolic acidosis |
Risks
- Medication errors: administering concentrated electrolytes undiluted can cause cardiac arrest, arrhythmia, or death.
- Wrong dose/ preparation: small calculation errors can lead to massive overdose
- Storage confusion: look-alike vials or ampules can lead to mix-ups.
Recommended guidelines for safe administration
Indication and prescription
High concentrated electrolytes should only be administered when prescribed by a licensed health care provider after evaluating the patient condition, laboratory findings and overall clinical picture. A clear indication on dosage rate of infusion and monitoring plan must be documented before starting the infusion.
Dilution guidelines
The INS emphasizes that highly concentrated electrolyte solutions should be diluted to safe concentration before administration
- Potassium Chloride
- Maximum concentration is 10-20 mEq/100ml (depending on patient condition and setting) always dilute and never administer as bolus or undiluted through peripheral lines.
- 1 ampule contains 10ml, 1 ml = 150mg, 10ml =1500mg
- Calcium Gluconate
- Administer slowly and dilute as required to avoid vein irritation or cardiac complication. Use central venous access for rapid infusion if needed.
- 1 ampule contains 10ml, 1ml = 50mg, 10ml = 1000mg (1g)
- Magnesium Sulphate
- Administer in diluted form with proper monitoring of deep tendon reflexes, respiratory status, signs of toxicity, hypotension, pulmonary oedema, bradycardia, arrhythmias, progressive muscle weakness, decreased urine output, headache at defied interval during administration.
- While discontinuation immediately disconnect the infusion, remove the container from the IV pole, and discard the infusion when discontinued.
- 1 ampule contains 2ml (50% Mgso4), 1ml = 500mg,
- 2ml = 1000mg (1g)
- Sodium Bicarbonate
- Only administer after confirming the need through blood gas analysis and metabolic panel results.
- ampule contains = 25ml, 1ml = 84mg, 25ml = 2100 mg
Routes of administration
Peripheral lines may be used for lower concentration but require strict monitoring for signs of infiltration and phlebitis. Central venous catheters are preferred for higher concentration or rapid infusion. Ensure correct catheter placement and patency before administering.
Infusion rate and monitoring
Infusion rate should be individualised based on patient age, renal function and comorbidities. Continuous monitoring of vital signs, ECG and serum electrolyte levels is essential. Observe for adverse effects such as arrhythmias hypotension or neurological symptoms.
Risk management
Avoid rapid bolus administration unless in life threatening conditions and with cardiac monitoring. Use infusion pumps for precise delivery and to prevent accidental overdose. Educate nursing staff on recognizing signs of extravasation, infiltration and other complications.
Documentation
Document the electrolytes type concentration dilution method, infusion rate, patient response and any intervention in the medical record. Record adverse events promptly to ensure patient safety and quality improvements.
Nursing special considerations
Patient assessment
Evaluate renal function, cardiac status and current medications to avoid interactions or worsening electrolyte disturbances
Patient education
Explain the need for the infusion, possible side effects and the importance of reporting symptoms such as muscle weakness, numbness or chest pain immediately.
Team communication
Ensure effective coordination between prescriber, pharmacists and nursing staff to prevent errors.
Infusion protocols
- Verify physician order including indications and concentration and infusion rate
- Confirm patient identity and review recent lab values (serum electrolytes and renal function)
- Ensure venous access type is appropriate for the concentration
- Prepare infusion using correct dilution calculations
- Educate the patient and family on the purpose and potential side effects
Potassium chloride infusion protocol
- Use only after confirming hypokalaemia (typically < 3.0 mEq/L)
- Always dilute never give undiluted or as IV push or it is fatal when administered undiluted
- Start at 5 mEq/ hr for peripheral lines, maximum 20 mEq/hr for central lines
- Monitor ECG continuously if infusion rate >10 mEq/hr
- Check serum potassium every 2-4 hrs
- Stop infusion if arrhythmias or muscle weakness occur
Calcium Gluconate infusion protocol
- Confirm hypocalcaemia (<8.5 mg/dl) or life-threatening complications
- Administer 1g elemental calcium over 10-20mins
- Repeat only after lab values are checked
- Monitor ECG, heart rate and blood pressure before and during infusion
- Observe for infiltration stop immediately if pain or swelling develops
Magnesium Sulphate infusion protocol
- Confirm deficiency or condition like eclampsia
- Administer a test dose if needed
- Infuse at recommended rates while monitoring respiratory efforts and reflexes
- Monitor renal function reduce dose if impaired
- Stop if deep tendon reflexes are absent or respiratory depression occurs
Sodium Bicarbonate infusion protocol
- Use only in severe acidosis confirmed by ABG
- Avoid rapid administration and monitor PH closely
- Dilute as per recommendations to prevent local irritation
- Check calcium levels during infusion
- Document blood gas ranges after each adjustment
Hypertonic saline protocol
- Confirm indications (symptomatic hyponatremia)
- Correct sodium not more than 8-10 mEq/L in 24 hrs
- Use infusion pumps and central venous access
- Monitor neurological status, serum sodium and fluid balance
Phosphate infusion
- Confirm hypophosphatemia (<2.0 mEq/L) calculate replacement based on body weight severity
- Use central access for higher concentration
- Monitor calcium phosphate balance and renal output
Monitoring checklist
Recommended guidelines for close monitoring to capture the adverse drug reaction
- Vital signs monitoring before administration, during administration (every 15min for 1hr and followed by every 30mins for 1hr ) and after administration
- Double verification with senior staff nurse before administration
- Vigilant in implementing all rights of medication to prevent the near miss, medication errors and sentinel events.
Before infusion
- Review recent lab values (electrolytes, kidney function and acid base status)
- Confirm diagnosis and indication for therapy
- Confirm diagnosis and indication for therapy
- Assess venous access suitability
- Prepare solutions using proper dilution methods
- Educate patient and family
During infusion
- Verify infusion pumps setting
- Monitor infusion rate continuously
- Check ECG for arrhythmias if potassium or calcium involved
- Monitor vital signs
- Assess infusion for redness, swelling or infection
- Repeat serum electrolytes at scheduled intervals
After infusion
- Document infusion details, lab values and patient details
- Report any adverse reactions immediately
- Educate patient on fo0llow up care and warning signs
Nursing Responsibility
| Electrolyte | Concentrations available | Target Concentration | Dilution | Final volume | Nurses Responsibility |
|---|---|---|---|---|---|
| Potassium Chloride (KCL) | 20% Solution (2 mEq/mL) | 10 mEq/100mL | 5 mL dilution in 0.9% NS or 5% Dextrose | 100 mL | Peripheral line: 5–10 mEq/hr; Central line: 10–20 mEq/hr; Central access + continuous ECG monitoring |
| Potassium Chloride (KCL) | 20% Solution (2 mEq/mL) | 20 mEq/100mL | 10 mL dilution in 0.9% NS or 5% Dextrose | 250 mL | Peripheral line: 5–10 mEq/hr; Central line: 10–20 mEq/hr; Central access + continuous ECG monitoring |
| Potassium Chloride (KCL) | 20% Solution (2 mEq/mL) | 30 mEq/100mL | 15 mL dilution in 0.9% NS or 5% Dextrose | 500 mL | Peripheral line: 5–10 mEq/hr; Central line: 10–20 mEq/hr; Central access + continuous ECG monitoring |
| Calcium Gluconate | 10% solution, 9 mg/mL Elemental Calcium | 1 g elemental calcium | 10 mL dilution in 0.9% NS or 5% Dextrose | 20 mL | Infuse slowly over 10–20 minutes; Repeat only if labs not improved |
| Calcium Gluconate | 10% solution, 9 mg/mL Elemental Calcium | 2 g elemental calcium | 20 mL dilution in 0.9% NS or 5% Dextrose | 100 mL | Infuse slowly over 10–20 minutes; Repeat only if labs not improved |
| Magnesium Sulphate | 20% solution (200 mg/mL or 8.12 mEq/mL) | 1 g/100 mL (10%) | 5 mL dilution in 0.9% NS or 5% Dextrose | 100 mL | Peripheral preferred at slow rate; Central line preferred; ICU/emergency use only |
| Magnesium Sulphate | 20% solution (200 mg/mL or 8.12 mEq/mL) | 2 g/100 mL (20%) | 10 mL dilution in 0.9% NS or 5% Dextrose | 100 mL | Peripheral preferred at slow rate; Central line preferred; ICU/emergency use only |
| Magnesium Sulphate | 20% solution (200 mg/mL or 8.12 mEq/mL) | 3 g/100 mL (30%) | 20 mL dilution in 0.9% NS or 5% Dextrose | 100 mL | Peripheral preferred at slow rate; Central line preferred; ICU/emergency use only |
| Sodium Bicarbonate | 8.4% Solution (1 mEq/mL) | 50 mEq/L | Diluted or undiluted (50 mL bottle) | 500 mL | Treat metabolic acidosis with caution; Avoid rapid correction |
| Sodium Bicarbonate | 8.4% Solution (1 mEq/mL) | 100 mEq/L | Diluted or undiluted (100 mL bottle) | 500 mL | Treat metabolic acidosis with caution; Avoid rapid correction |
| Hypertonic Solution | 3% or 5% Solution | As ordered | Undiluted | — | Use only for severe hyponatremia; Central access required |
| Phosphate Solution | 15 mmol/mL | 7 mmol/100 mL | 0.47 mL | 100 mL | Peripheral infusion possible; Central preferred; Monitor calcium–phosphate balance |
| Phosphate Solution | 15 mmol/mL | 15 mmol/100 mL | 1 mL | 100 mL | Peripheral infusion possible; Central preferred; Monitor calcium–phosphate balance |
| Phosphate Solution | 15 mmol/mL | 20 mmol/100 mL | 2 mL | 100 mL | Peripheral infusion possible; Central preferred; Monitor calcium–phosphate balance |
References
- Infusion nurses society(2024), infusion therapy standards of practice, retrieved from https://www.ins1.org./publication/infusion-therapy-standards-of-practice/
- Institute of safe medication practices(2022), practical strategies in pursuit of safety, retrieved from https://www.ismp.org
- Institute of safe medication practices (ISMP) Canada (2025), retrieved from https://www.ismp-canada.org
- World health organization (WHO), control of concentrated electrolyte solutions, retrieved from https://cdn.who.int
