PART 1: Fluid selection for resuscitation of hypovolemic, hyperkalemic renal failure
Introduction with a case
Start with isotonic sodium bicarbonate
Complete the volume resuscitation with lactated ringers
PART 2: pH-guided resuscitation
- Isotonic bicarbonate (D5W with 3 amps bicarb per liter) is a good choice for initial resuscitation of a renal failure patient with acidosis and hyperkalemia, as it may improve both.
- Normal saline has been proven to worsen hyperkalemia in renal failure and should be avoided in these patients. Contrary to prevailing mythology, LR is safe in hyperkalemic renal failure.
- The only potential contraindications to LR are elevated intracranial pressure or profound liver failure.4 LR is a reasonable choice of resuscitation fluid for most patients.
- Large-volume crystalloid resuscitation represents a unique opportunity to correct certain acid-base disorders using pH-guided resuscitation.
- Fluids are some of the resuscitationist’s best drugs: correct choice and dosage matter.
(6) I just learned that ampules of bicarbonate may be available in different sizes. The ampules which I am referring to here are 50ml of bicarbonate in a concentration of 8.4% by weight, which is equal to 1 mEq/ml. Adding three of these ampules (150cc of 8.4% bicarbonate) to a liter of D5W creates 1,150 ml of fluid with a concentration of bicarbonate of 130 mEq/L, which is close to isotonic. When ordering a “liter” of this solution, the patient actually receives 1,150 ml of fluid containing 150 mEq of sodium bicarbonate.