Insulin & Dextrose

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Insulin treats hyperkalemia by activating the skeletal muscle Na+-K+-ATPase which leads to intracellular potassium shift. Hypokalemic effect is greater with the combination of insulin and dextrose.treats hyperkalemia by activating the skeletal muscle Na+-K+-ATPase which leads to intracellular potassium shift. Hypokalemic effect is greater with the combination of insulin and dextrose.

Insulin-Dextrose

• Mechanism of Action: Shifts K+ intracellularly
• Dose: Intravenous, regular insulin 5-10 units, plus glucose 50%, 25g
• Pharmacokinetics:
  • Onset of Action: 15-60 mins
  • Duration of Effect: 4-6 hours
• Contraindications: Critically ill patients at increased risk for hyperglycemia
• Adverse Effects: Hypoglycemia – major side effect, hypokalemia, hypersensitivity
• Pearls: Unless patient is hyperglycemic because of underlying diabetes mellitus, concurrent administration of dextrose as bolus along with continuous infusion is required to prevent iatrogenic hypoglycemia; lowers serum K+ levels by ~1.5 mEq/L

Dextrose

• Pharmacokinetics:
  • Onset of Action: <5 mins
  • Duration of Effect: 0.5-2 hours

Pearls: D50W is equal to 2500 mOsm/L which could increase the risk of harm

When comparing D10W to D50W there was no statistically significant differences in median time to recovery (8 minutes), median post-treatment GCS, or # subjects experiencing a further hypoglycemic episodes.

• Extravasation Management from D50W
  • Immediately remove the IV line and the arm elevated
  • Cold compresses should be placed over the site of extravasation for 15 to 30 minutes and repeated every 4 hours while elevating the arm
  • Hyaluronidase injected subcutaneously 0.2 mL (150 U/1 mL) with a 25-gauge needle at 5 different sites along the leading edge of erythema.

Glucose Level	Dextrose Dose	Monitoring Parameters
>200 mg/dL	None	Hourly for 3 h
100–200 mg/dL	25 g D50 (50 mL) or 10-25g of D10W (100-250 ml)	Hourly for 3 h
<100 mg/dL	50 g D50 (100 mL) OR 25 g D50 (50 mL) with D10 infusion 250 mL/h for 1 h	Every 30 min for 1 h, then every hour for 3 h

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Overview of Evidence

Verdier M, DeMott JM, Peksa GD. A comparison of insulin doses for treatment of hyperkalaemia in intensive care unit patients with renal insufficiency. Aust Crit Care. 2021 Jun 21:S1036-7314(21)00070-9. doi: 10.1016/j.aucc.2021.05.004. Epub ahead of print. PMID: 34167889.

Design	• Single-center,  retrospective observational study • (n =174)
Intervention & Comparison	• 5 units vs 10 units IV regular  insulin in ICU patients
Outcome	• Hypoglycemia was more frequent with 10 units vs 5 units of  IV insulin (19.5 vs 9.2%, p=0.052)  • No difference in rates of severe hypoglycemia or change  in serum potassium

Moussavi K, Nguyen LT, Hua H, Fitter S. Comparison of IV Insulin Dosing Strategies for Hyperkalemia in the Emergency Department. Crit Care Explor. 2020 Apr 29;2(4):e0092. doi: 10.1097/CCE.0000000000000092. PMID: 32426734; PMCID: PMC7188424.https://pubmed.ncbi.nlm.nih.gov/32426734/

Design	• Retrospective,  observational study  • (n=700)
Intervention & Comparison	• <10 units vs 10 units IV regular insulin in ICU patients
Outcome	• Significantly lower frequency of hypoglycemia with lower  insulin doses (11.2 vs 17.6%, p=0.008) • Greater reduction in serum potassium with insulin doses  <10 units (mean reduction 0.94 vs 0.8, p=0.008)

Keeney KP, Calhoun C, Jennings L, Weeda ER, Weant KA. Assessment of intravenous insulin dosing strategies for the treatment of acute hyperkalemia in the emergency department. Am J Emerg Med. 2020 Jun;38(6):1082-1085. doi: 10.1016/j.ajem.2019.158374. Epub 2019 Jul 26. PMID: 31377014.

Design	• Single-centered retrospective observational study • (n=442)
Intervention & Comparison	• 5 units vs 10 units IV regular insulin in ED patients
Outcome	• Hypoglycemic events in patients with reduced eGFR  were higher in patients receiving 10 units of insulin (17.4 vs  7.9%, p=0.02) • Both high and low-dose insulin groups achieved similar potassium reductions from baseline. • Upon regression analysis, eGFR ≤45 mL/min/1.73 m2 and high dose insulin were both significantly associated with hypoglycemia