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Going Bananas: Patient Considerations with Insulin/Dextrose for Acute Hyperkalemia - #MEDSHED

Updated: Jul 24, 2023

MEDSHED, a medication/intervention-focused short article that contributes towards a broader, clinical toolbank for various disease states. Stay tuned -

 


MEDSHED Topic: Insulin regular 10 units for severe hyperkalemia isn't a one-size fits-all dosing. It can induce hypoglycemia when used without consideration of patient-specific parameters.

  • Acute hyperkalemia is a common electrolyte abnormality that can potentially be life-threatening, if not recognized and treated appropriately.

  • Treatment consists of stabilizing the myocardium, transiently shifting potassium into the cell, and elimination of potassium.



AHA Treatment Recommendations

  • Stabilize myocardium

    • Calcium chloride (10%): 500 to 1000 mg (5 to 10 mL) IV over 2 to 5 minutes

  • Transiently shift potassium intracellularly

    • Sodium bicarbonate: 50 mEq IV over 5 minutes

    • Glucose plus insulin: mix 25 g (50 mL of D50) glucose and 10 U regular insulin and give IV over 15 to 30 minutes

    • Nebulized albuterol: 10 to 20 mg nebulized over 15 minutes

  • Elimination of potassium

    • Furosemide 40 to 80 mg IV

    • Potassium binder

    • Hemodialysis

Insulin/Dextrose

Insulin Regular Pharmacokinetics

Mechanism in hyperkalemia

Binds to insulin receptor

Activates Na-K-ATPase

Extra- to intracellular K+ shift

Onset

< 15 minutes

Excretion

Urinary

Duration

2 - 6 hours

Half-life

0.5 - 1 hr (prolonged in renal impairment)

  • It is important to note that the duration of insulin is prolonged in the setting of renal insufficiency.

  • Insulin regular IV 10 units lowers serum potassium greater than reduced doses with a higher incidence of hypoglycemia

  • Reduced doses are associated with less hypoglycemia without increasing cardiovascular events

  • Insulin regular 10 units IV is still preferred in acute life-threatening hyperkalemia and severely elevated serum potassium. It may also be appropriate for larger patients

Risk Factors for Hypoglycemia

Low BMI

Low initial BG

Elderly

Insulin naive

Renal impairment

No history of diabetes mellitus


Reduce insulin dose and/or increase dextrose with more than 1 risk

  • 0.1 units/kg (up to 10 units) or 5 units IV

  • 1 amp D50W: 25 gm; 1 D10W 250mL bag: 25 gm

  • Consider 50gm total whenever BG around 100 mg/dL


Additional Thoughts

  • Be mindful of endogenous insulin release when giving 50gm. May be beneficial to give second dose as D10W infused over several hours.

  • Blood glucose checks should be taken at 30 minutes, then q 1 hour from administration until clinically appropriate.

  • Development of powerplans that auto-orders blood glucose checks and solid education can reduce overall hypoglycemic events.


Short recap

Insulin regular 10 units IV may not be appropriate for all patients. Based on smaller scale trials, reduced doses are associated with less hypoglycemia without increasing cardiovascular events. Consider reduced doses of insulin and/or increased dextrose in patients at high risk for hypoglycemia.


Thank you for taking the time. MEDSHED series will be related to another upcoming project and will go more in detail! Stay tuned!



References

  1. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Part 2: Adult basic life support. Circulation. 2005;112:IV-121–IV-125

  2. Insulin Regular. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL

  3. Moussavi et al. Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. Crit Car Explor. 2020 Apr 29;2(4):e0092.

  4. Moussavi et al. Comparison of IV Insulin Dosing Strategies for Hyperkalemia in the Emergency Department. Crit Car Explor. 2020 Apr 29;2(4):e0092.

  5. Garcia et al. Reduced Versus Conventional Dose Insulin for Hyperkalemia Treatment. J Pharm Prac. 2020 Jun;33(3):262-266.

  6. Apel et al. Hypoglycemia in the treatment of hyperkalemia with insulin in patients with end-stage renal disease. Clin Kidney J. 2014;0:1–3

  7. Farina N, Anderson S. Impact of dextrose dose on hypoglycemia development following treatment of hyperkalemia. Ther Adv Drug Saf. 2018 Jun;9(6):323-329.





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