Case 3: When to correct hyperkalemia before surgery?

Preoperative Care of Patients with Kidney Disease
Author: V. Dimov, M.D.

A 42-year-old male with diabetes type 1 (DM1), hypertension (HTN) and chronic kidney disease (CKD) with creatinine (Cr) 3.0 mg/dL is here for preoperative evaluation for back surgery. His potassium is 5.8 mEq/L.

Do you need to correct the potassium?

No recommendations exist for safe preoperative potassium values. One old study (1974) suggested avoiding general anesthesia in CKD and potassium level higher than 5.5 mEq/L.

Other studies showed no increase in arrhythmias among patients with preoperative potassium more than 5.5 mEq/L. This may be due to tolerance to chronically elevated potassium. Preoperative hyperkalemia is seen in 19-38% in CKD or ESRD.


No recommendation exists for a safe serum potassium level before surgery. A potassium level of less than 5.5 mEq/L is generally advisable.

It is important to review the type of intraoperative fluid with the anesthesiology and surgical teams. The most commonly used intravenous fluid during surgery in patients without renal impairement is "lactated Ringers" which contains potassium. In order to avoid hyperkalemia, the preferred solution in dialysis patients is isotonic saline.


Preoperative Care of Patients with Kidney Disease. Mahesh Krishnan, M.D., M.P.H. Am Fam Physician 2002;66:1471-6.
Perioperative Management of the Patient With Chronic Renal Failure. Kenneth E Otah, MD, MSc, Moro O Salifu, MD, MPH, Eseroghene Otah, MD., last accessed 3/7/06,
Among patients with AMI, the lowest mortality was observed with potassium levels between 3.5 and 4.5 mEq/L. JAMA, 2012.
Image source: Greg Robson, Creative Commons license.



Published: 05/30/2006
Updated: 10/19/2011

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