Is Lactated Ringer’s Solution Safe for Hyperkalemia Patients?

Is Lactated Ringer's Solution Safe for Hyperkalemia Patients?

Background

There are three primary fluids used for resuscitation, each contains varying amounts of potassium per liter (Table 1):

  • 0.9% Sodium Chloride (normal saline)
  • Lactated Ringer’s solution
  • Plasma-Lyte A

Additionally, these fluids contain markedly different amounts of other electrolytes, some of which directly influence their pH (Table 1).

SolutionNa*Cl*K*Ca*Lactate*Acetate*Osmolarity^pH
Sodium Chloride 0.9% (normal saline)1541543085.5
Lactated Ringer’s13010942.7282736.5
Plasma-Lyte A140985272947.4
Blood135-14596-1063.5-58.5-10.50-1NA275-2957.35-7.45

Table 1: Characteristics of IV fluids vs blood [1-3] (* = mEq/L; ^ = mOsmol/L); note: this is not an exhaustive list of fluid contents

A common question is if the balanced fluids containing potassium (Lactated Ringer’s and Plasma-Lyte A) are safe to use in hyperkalemia patients. The answer is YES! Despite containing potassium, these fluids will still decrease the serum potassium level of a hyperkalemic patient. This is because the potassium concentration in these fluids is lower relative to the patient’s serum potassium level and dramatically lower than the patient’s intracellular potassium concentration.

Evidence

A secondary analysis of the SMART trial did not find a difference in severe hyperkalemia (K ≥7 mEq/L) in hyperkalemic patients that received a balanced fluid (8.5%) vs those that received normal saline (14%) (p=0.24) [4]. The authors concluded that:

Our results suggest that the acid-base effects of isotonic crystalloids are more important for potassium homeostasis than the relatively small amount of potassium in these fluids.

A breakdown of the SMART Trial secondary analysis by Journal Feed summarizes other major findings and concludes, “It’s reasonable to choose LR to treat hyperkalemia over NS.” Lastly, Dr. Josh Farkas provides a succinct summary of this topic in a 2014 EMCrit/Pulmcrit post which is helpful in understanding the interplay between fluid balance and the different replacement options. Additionally, he discusses the potential for normal saline to cause a non-anion gap metabolic acidosis thereby leading to increased serum potassium levels.

Bottom Line

Balanced fluids (Lactated Ringer’s and Plasma-Lyte A) containing potassium can safely be used in patients with hyperkalemia. Given their more neutral pH, they may be preferred over normal saline in some patients.

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References

  1. Sodium Chloride Injection. Package Insert. Baxter Healthcare Corporation; 2013.
  2. Lactated Ringers Injection. Package Insert. Baxter Healthcare Corporation; 2019.
  3. Plasma-Lyte A Injection. Package Insert. Baxter Healthcare Corporation; 2019.
  4. Toporek, A. H., Semler, M. W., Self, W. H., Bernard, G. R., Wang, L., Siew, E. D., Stollings, J. L., Wanderer, J. P., Rice, T. W., Casey, J. D., & SMART Investigators and the Pragmatic Critical Care Research Group. (2021). Balanced crystalloids versus saline in critically ill adults with hyperkalemia or acute kidney injury: Secondary analysis of a clinical trial. American Journal of Respiratory and Critical Care Medicine. doi: 10.1164/rccm.202011-4122LE. PMID: 33503391.

 

ALiEM AIR Series | Environmental 2021 Module

This image has an empty alt attribute; its file name is AIR-logo-2016-transparent-SAEM-CORD-586x650.jpg

Welcome to the AIR Environmental Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to environmental emergencies in the Emergency Department. 6 blog posts within the past 12 months (as of January 2021) met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 3 AIR and 3 Honorable Mentions. We recommend programs give 3 hours (about 30 minutes per article) of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Interested in taking the environmental quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Environmental Emergencies

SiteArticleAuthorDateLabel
EMDocsMammalian Bites: ED Presentations, Evaluation, and ManagementErin Rizzo, MD and Jaryd Zummer, MDOctober 12, 2020AIR
EMDocsToxCard: Riot Control AgentsElissabeth Hagler, MD and Kathryn Kopec, DOJune 23, 2020AIR
EMOttawaHypothermia: Keeping your cool when it gets coldMark McKinney, MDMarch 5, 2020AIR
EMDocs[email protected]: Heat StrokeSofia Rodriguez, DOAugust 29, 2020HM
EMDocsToxCard: Caustic Eye InjuriesElizabeth Olson, MD and Christine Murphy, MDFebruary 4, 2020HM
EMDocs[email protected]: HypothermiaMcKenna Furgurson, MDDecember 19, 2020HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

ACMT Toxicology Visual Pearls – In “Spore” Taste

puffball mushroom spore

A 15-year-old male presents symptomatic several hours after inhaling spores of this mushroom as a home remedy for epistaxis. What is the presentation and pathophysiology of the toxic syndrome associated with this mushroom?

For a video of this mushroom in action: https://youtu.be/G_DXTlvvsco

  1. Dyspnea and cough from hypersensitivity alveolitis
  2. Flushing, nausea and vomiting from acetaldehyde accumulation
  3. Nausea, vomiting and hepatoxicity from RNA synthetase inhibition
  4. Seizures from reduced GABA production in the central nervous system

(more…)

By |2021-04-10T10:23:37-07:00Apr 7, 2021|ACMT Visual Pearls, Tox & Medications|

EMRad: Can’t Miss Pediatric Elbow Injuries

 

Have you ever been working a shift at 3 am and wondered, “Am I missing something? I’ll just splint and instruct the patient to follow up with their PCP in 1 week.” This can be a reasonable approach, especially if you’re concerned there could be a fracture. But we can do better. Enter the “Can’t Miss” series: a series organized by body part that will help identify common and catastrophic injuries. This list is not meant to be a comprehensive review of each body part, but rather to highlight and improve your sensitivity for these potentially catastrophic injuries. We reviewed the approach to the pediatric elbow previously. Now, the “Can’t Miss” pediatric elbow injuries. (more…)

By |2021-04-10T10:24:46-07:00Apr 5, 2021|EMRad, Orthopedic, Pediatrics, Radiology, Trauma|

SplintER Series: Kitty Nibble: A Case of the Sausage Finger

 

A 30-year-old female presents with left second finger pain with overlying erythema, warmth, and swelling the day after her cat bit her finger. She cannot fully extend the finger, it is tender and she has pain when it is passively extended. Her hand appears as shown above (Figure 1. Case courtesy of Kristina Kyle, MD).

 

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SplintER Series: A Case of Hip Pain

humeral shaft fracture xray

Figure 1. Image prompt: AP view of the pelvis and left hip. Authors’ own images.

A 70-year-old male presents with left hip pain and inability to ambulate after a mechanical trip and fall. Examination demonstrates that the left lower extremity is shortened, abducted and externally rotated. Hip and pelvis x-rays are obtained (Figure 1).

 

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ALiEM AIR Series | Gastroenterology 2020 Module

This image has an empty alt attribute; its file name is AIR-logo-2016-transparent-SAEM-CORD-586x650.jpg

Welcome to the AIR Gastroenterology Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to gastroenterology in the Emergency Department. 6 blog posts within the past 12 months (as of November 2020) met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 1 AIR and 5 Honorable Mentions. We recommend programs give 3 hours (about 30 minutes per article) of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Interested in taking the gastroenterology quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Gastroenterology Emergencies

SiteArticleAuthorDateLabel
EMCrit: IBCCHypertriglyceridemic PancreatitisJosh Farkas, MD28 August 2020AIR
EMCrit: IBCCNausea, emesis, and antiemeticsJosh Farkas, MD17 Aug 2020HM
ALiEMUnlocking the MIC-keyMarc Cassone, DO and Natalie Senter, MD24 Aug 2020HM
RebelEMHALT-IT: TXA for GI bleedsSalim Rezaie, MD27 Jun 2020HM
EMDocsImproving the ED Diagnosis of Mesenteric IschemiaAngela Cai, MD and Ian DeSouza, MD14 Sep 2020HM
EMDocsNon-Obstetric Abdominal Pain in the Pregnant PatientMarina Boushra, MD25 Nov 2019HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

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