Is there another medication besides lidocaine (local anesthetic) that can act as a buffer to alleviate the burning sensation associated with intravenous (IV) potassium administration?

Alternatives to Lidocaine for Reducing IV Potassium-Associated Burning

Procaine is the best alternative to lidocaine for reducing the burning sensation associated with intravenous potassium administration, though ketamine can also be effective when combined with other analgesics.

Medication Options for IV Potassium Pain Management

Procaine

• Procaine hydrochloride (1%) can be used as an alternative to lidocaine for reducing local irritation from potassium infusions 1
• The FDA potassium label specifically mentions procaine as a treatment option when perivascular infiltration occurs
• Procaine has a lower incidence of transient neurologic symptoms compared to lidocaine (6% vs 31%) 2
• Can be infiltrated locally in the affected area if extravasation occurs

Ketamine

• Titrated intravenous ketamine can be effectively combined with other analgesics to treat severe pain 3
• Particularly useful for burn-induced pain and can limit opioid consumption
• Recommended by anesthesia guidelines for multimodal analgesia approaches

Sodium Bicarbonate (Buffer)

• Buffering local anesthetics with sodium bicarbonate (combining 2 mL of sodium bicarbonate with 18 mL of 1% anesthetic) can decrease the burning sensation during injection 3
• While primarily used with lidocaine, this buffering principle may be applied to procaine as well

Implementation Algorithm

1. First-line approach:

   • Dilute potassium to appropriate concentration
   • Administer through a large vein at a controlled rate
   • Consider procaine 1% for local infiltration if signs of irritation develop

2. For severe pain during infusion:

   • Consider low-dose ketamine (0.1-0.3 mg/kg IV) as an adjunct
   • Titrate based on validated pain assessment scales 3

3. If extravasation occurs:

   • Stop infusion immediately
   • Local infiltration with procaine hydrochloride 1% (hyaluronidase may be added) 1
   • Apply local heat to the affected area

Important Considerations and Precautions

• Monitoring: All patients receiving IV potassium should be monitored for signs of irritation and pain at the infusion site
• Contraindications: Avoid procaine in patients with true procaine allergy, active infections at injection site, or severe cardiac disease 4
• Adverse effects: Watch for signs of systemic toxicity including perioral numbness, facial tingling, light-headedness, and tinnitus 4, 5
• Rate of administration: Always administer potassium slowly to minimize vascular irritation regardless of buffer used

Potential Pitfalls

• Procaine may result in lower quality anesthesia compared to lidocaine in some applications 2
• Ketamine may cause psychomimetic effects at higher doses
• Even at therapeutic doses, local anesthetics can cause systemic toxicity in sensitive individuals 5
• Non-pharmacological approaches (such as application of heat) should be considered as adjuncts, not replacements for medication 1

Proper administration technique and appropriate dilution of potassium remain the most important factors in preventing infusion pain, with procaine or ketamine serving as effective adjuncts when needed.