Insulin Dextrose For Hyperkalemia Protocol In Reputable Hospitals

Hyperkalemia is a life-threatening medical problem. IV Insulin with dextrose is commonly used to treat severe hyperkalemia in the emergency departments. In severe hyperkalemia, hemodialysis is usually required.

Hyperkalemia using insulin and dextrose infusion is one part of the treatment protocol. One should follow all the steps in the management of acute hyperkalemia.

The management of chronic hyperkalemia is primarily aimed at avoiding medications and foods that may cause hyperkalemia.

Potassium binders or potassium exchange resins are drugs used to remove potassium from the body. These include:

Kayexalate (Sodium Polystyrene Sulfonate)
Patiromer (Veltassa), and
Lokelma (Sodium Zirconium Cyclosilicate)

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What is Hyperkalemia?

Hyperkalemia is defined as serum potassium levels exceeding 5 mEq/L. It is then further classified as:

Mild (serum potassium of 5 mEq/L to 6 mEq/L)
Moderate (serum potassium of 6.1 mEq/L to 7 mEq/L)
Severe (serum potassium of 7.1 mEq/L and above)

Pseudohyperkalemia is a falsely elevated serum potassium levels. It is usually not associated with ECG changes.

Potassium levels can be falsely elevated when potassium is released from the cells while withdrawing blood.

It is common in the following conditions:

Hemolysis
Marked Leukocytosis
Marked thrombocytosis
Applying a tourniquet while taking a venous sample

How do you diagnose Hyperkalemia?

Hyperkalemia can be easily diagnosed by a simple laboratory test, requesting serum potassium levels or serum electrolytes.

Serum electrolytes are done to estimate serum sodium and serum potassium levels. Some laboratories also include serum calcium, serum bicarbonate, and serum phosphate in the complete serum electrolyte panel.

Hyperkalemia can be predicted by an electrocardiogram (ECG). However, ECG changes are more marked and specific in cases of severe hyperkalemia.

Sine wave formation as a result of hyperkalemia in a patient with CKDinsulin dextrose for hyperkalemia protocol — **Broad QRS complexes, flattened P waves, and developing Sine wave formation as a result of severe hyperkalemia in a patient with CKD**

In addition, an underlying cardiac disease may cause false-positive ECG changes. Furthermore, ECG changes may be missed in the early stages of hyperkalemia.

Here are the ECG findings in patients with different degrees of hyperkalemia:

Serum Potassium Level	ECG Changes
5.5 – 6.5	Tall tented T-waves
6.5 – 7.0	P waves flatten (may disappear) prolonged PR interval
7.0 – 9.0	Bradycardia AV block Junctional rhythm Ventricular escape rhythm Slow atrial fibrillation Conduction blocks Prolonged QRS interval
>9.0	Sine waves Ventricular fibrillation Pulse less electrical activity with bizarre wide complex rhythm

What medications are used to treat hyperkalemia?

The emergency management of hyperkalemia is different from the chronic management of hyperkalemia.

Most emergency management of hyperkalemia temporarily shifts the potassium from the extracellular space to the intracellular space.

Chronic management is aimed at lowering the total serum potassium levels and hence excreting the potassium from the body via the kidneys or the GI tract.

Drugs that are used to treat hyperkalemia are tabulated below:

1. Calcium Gluconate

Mechanism of Action:

Stabilizes cardiac cell membranes and prevents arrhythmias.

Onset and duration of action:

The onset of action is rapid, within 1 – 2 minutes. Duration of action lasts for about 30 minutes

How to administer?

10 ml of 10% calcium gluconate injection is generally given over 5 to 10 minutes.
If ECG changes persist, the dose is repeated.
To avoid the risk of hypercalcemia (as in patients on digitalis), it can be given in 100 ml 5% dextrose water over 30 minutes.
Cardiac monitoring is recommended when administering calcium intravenously.

2. Sodium Bicarbonate

Mechanism of Action:

Alkalinizes the blood, shifting potassium from the extracellular space into cells.

Onset and Duration of Action:

It has an onset of action between 30 to 60 minutes which lasts for 2 to 6 hours.

How to administer?

It is recommended in patients with metabolic acidosis (Bicarbonate of less than 22 mEq/L) and hyperkalemia.
It is given as 50 mEq/L to 150 mEq/L infusion mixed with dextrose water and administered as a slow intravenous infusion over 30 minutes to 3 hours.

3. Insulin and Dextrose:

Mechanism of Action:

Insulin causes potassium entry into cells. Dextrose is added to prevent insulin-induced hypoglycemia.

Onset and Duration of Action:

It has an onset of action of 10 to 20 minutes with effects lasting 2 to 6 hours. The peak effect is seen in one hour.

How to administer?

10 units of insulin are administered with 25 to 50 gm of glucose and administered over 30 minutes. 10 units of insulin is mixed with 50 to 100 ml of 50% glucose.
In patients with hyperglycemia, the amount of dextrose may be reduced to 5 to 10 gm (50 to 100 ml of 10% dextrose) or insulin may be given without dextrose.

4. Albuterol (Salbutamol):

Mechanism of Action:

Stimulates beta-2 adrenergic receptors on cell membranes, promoting potassium uptake by cells.

Onset and duration of action:

It has a rapid onset of action of 3 – 5 minutes. The effect lasts for 1 to 4 hours.

How to administer?

Albuterol is administered in a dose of 10 to 20 mg via a nebulizer.
It can cause tremors and tachycardia and may not be effective in patients taking a beta-blocker.
Albuterol efficacy is enhanced when given with insulin and dextrose compared to when given alone.

5. Lasix (Furosemide):

Mechanism of action:

It causes the excretion of potassium from the renal tubules.

Onset and duration of action:

It has an onset of action of 5 to 30 minutes. The duration of action lasts for about 2 to 6 hours.

How to administer?

It is administered as an IV injection in a dose of 40 to 80 mg with simultaneous saline infusion.

6. Sodium Polystyrene Sulfonate (Kayexalate):

Mechanism of Action:

Exchanges sodium ions for potassium ions in the gastrointestinal tract, leading to potassium elimination.

Onset and duration of action:

It has an onset of action of 2 to 6 hours and the effect lasts for about 4 to 6 hours.

How to administer?

It is given in a dose of 15 – 30 gm of the resin in a powdered form, mixed with a laxative such as lactulose, and administered 4 times a day.

7. Lokelma (Sodium Zirconium Cyclosilicate):

Mechanism of Action:

Exchanges sodium and hydrogen ions for potassium ions in the gastrointestinal tract, leading to potassium elimination.

Onset and duration of action:

It has an onset of action of about one hour

How to administer?

It is given initially in a dose of 10 gm three times a day for 48 hours followed by a maintenance dose.
It is mixed with 45 ml of water and taken orally.

8. Veltassa (Patiromer):

Mechanism of Action:

It exchanges calcium for potassium in the distal colon where potassium levels are the highest, resulting in the excretion of potassium from the body.

Onset and duration of action:

It has an onset of action of about 7 hours and a duration of action of 24 hours.

How to administer?

It is given as oral suspension in a dose of 8.4 to 25.2 mg orally once daily.

Lastly, if all the above medications fail to lower the serum potassium or in cases of severe hyperkalemia, hemodialysis is the most effective modality to treat hyperkalemia.

How is Hyperkalemia treated with IV insulin and dextrose infusion?

IV insulin and dextrose infusion is one of the most commonly used treatments for hyperkalemia in the emergency department.

Insulin causes the influx of potassium from the extracellular space to the intracellular space. However, because insulin infusion can result in severe hypoglycemia, it is used with dextrose infusion.

Dextrose infusions commonly used are 50 ml of 50% dextrose water. Regular insulin is added to the dextrose infusion and infused slowly over 30 minutes.

In patients at risk of hypoglycemia such as those with kidney disease or liver disease, it is better to add 10 units of insulin to 100 ml of 50% dextrose and administered over 30 minutes.

Some patients such as those with diabetes and kidney disease have high sugars along with hyperkalemia.

These patients may be given insulin with 50 to 100 ml of 10% dextrose or 5% dextrose to avoid severe hyperglycemia and ketoacidosis.

What are the different protocols for treating hyperkalemia with insulin?

Medscape Insulin Dextrose Infusion Protocol for Hyperkalemia

10 units of regular insulin added to 50 ml of 50% dextrose water.

County Durhan and Darlington NHS Foundation Trust Insulin Dextrose for Hyperkalemia Protocol

- Mix 10 units of Actrapid insulin with 250 mL of 10% dextrose and administer over 10 minutes.
- Please be aware that the smallest available 10% glucose bag is 500 mL, so you should discard half of it, leaving you with 250 mL for administration.
OR
- Add 10 units of Actrapid to 50mL of Glucose 50% and give IV via a large peripheral vein over 15 to 30 minutes

Royal Children’s Hospital Insulin Dextrose for Hyperkalemia Protocol

Initial Treatment:
- Dextrose 10%: 5 mL/kg IV bolus (if no hyponatremia)
- Insulin short action: 0.1 U/kg IV bolus (max 10 units)
Then followed by infusion of insulin/glucose:
- Dextrose 10% IV at maintenance with 0.9% sodium chloride (normal saline)
- Insulin short action infusion: 0.1 U/kg/h IV

The Royal Hospital for Women Insulin Dextrose for Hyperkalemia Protocol

Short-acting insulin (ACTRAPID) 10 units IV bolus PLUS glucose 50% 50Ml IV over 5 minutes via a CENTRAL line

Add 10 units of short-acting insulin (ACTRAPID) to 50ml of glucose 50% and infuse over 30 minutes via a PERIPHERAL line.

Measure blood glucose levels every 30 minutes for two hours. If the blood glucose levels are stable, measure it every 60 minutes for four hours.

Gloucestershire Hospitals NHS Foundation Trust Insulin Dextrose for Hyperkalemia Protocol

Give 10 Units of Actrapid in 25 g Glucose (50ml 50% dextrose, 125ml 20% dextrose, or 250ml 10% dextrose over 15mins).

If pre-treatment blood glucose is < 7.0mmol/l (126 mg/dl), start 10% dextrose @ 50ml/hr for 5 hrs post initial infusion

Queensland Health Clinical Excellence Queensland Insulin Dextrose for Hyperkalemia Protocol

Option 1: Insulin and 50% glucose are given concurrently via the same IV line as two separate infusions

Requirements:

Insulin Actrapid 100 units per 1 mL
50% glucose concentration (0.5 grams per 1 mL)

Dosage:

Begin the insulin infusion at a rate of 0.05–0.2 units per kilogram per hour.
Initiate the 50% glucose infusion at a rate of 0.5 grams per kilogram per hour (equivalent to 1 mL per kilogram per hour).

How to prepare:

Draw up 25 units per kilogram of insulin and dilute to a total volume of 50 mL using 0.9% sodium chloride. This results in a concentration of 0.05 units per kilogram in 0.1 mL (single strength).
Draw up 30 mL of 50% glucose.

How to administer?

Before starting the infusions, administer a bolus of each infusion simultaneously:
- Insulin: 0.1 unit per kilogram over 3 minutes.
- 50% glucose: 1 gram per kilogram (equivalent to 2 mL per kilogram) over 5 minutes.
Subsequently, begin the continuous infusions of insulin and 50% glucose concurrently.

Option 2: Insulin and 25% glucose are given in one syringe as one infusion

Requirements:

Insulin Actrapid 100 units per 1 mL
50% glucose concentration equivalent to 0.5 grams per 1 mL

Dosage:

Adjust dosages based on serum potassium and blood glucose levels.

Preparation:

Draw up 25 mL of 50% glucose and dilute it to a total volume of 50 mL with 0.9% sodium chloride. This results in a concentration of 25% glucose.
Draw up 7.5 units per kilogram of insulin, and note the volume in mL.
From the 25% glucose solution, withdraw the same volume as obtained when drawing up 7.5 units per kilogram of insulin.
Add the 7.5 units per kilogram of insulin to the 25% glucose solution, resulting in a total volume of 50 mL.
The concentration of insulin is now 0.15 units per kilogram per mL.

How to administer?

Initiate the infusion at a rate of 1 mL per hour (equivalent to 0.15 units per kilogram per hour).

GUH Insulin Dextrose for Hyperkalemia Protocol

Dextrose and Insulin are administered according to blood glucose:

Blood Glucose: < 5mmol/L (90 mg/dl):

Do not give insulin
Give 50 ml of 50% glucose IV over 10 minutes

Blood Glucose: 5 – 14 mmol/L (90 mg/dl – 252 mg/dl):

Give 50 ml of 50% glucose IV over 10 minutes, followed immediately by 5 units of NovoRapid Insulin IV (if eGFR < 30ml/min/1.73m2) or 10 units of NovoRapid Insulin IV (if eGFR is more than 30ml/min/1.73m2)

Blood Glucose: >14 mmol/L (> 252 mg/dl):

Do not give insulin
5 units of NovoRapid Insulin IV (if eGFR < 30ml/min/1.73m2) or 10 units of NovoRapid Insulin IV (if eGFR is more than 30ml/min/1.73m2)

Note: Administer IV insulin by adding it to 10ml of 0.9% NaCl, mix it, and administer it as an IV push.

Canberra Hospital and Health Services Insulin Dextrose for Hyperkalemia Protocol

Treat with glucose 50% 50mL over 15 minutes together with regular insulin (e.g. Actrapid) 10 units intravenously.

What are the risks of treating hyperkalemia with intravenous insulin?

The most commonly encountered risk is hypoglycemia. Non-diabetic individuals and elderly patients especially those who have kidney impairment are highly at risk of developing hypoglycemia.

Blood sugars should be frequently monitored in these patients and treated with oral and/ or IV glucose depending on the severity of the condition.

Some patients, especially those with uncontrolled diabetes may develop hyperglycemia. Inadequate insulin and concentrated glucose infusion can result in hyperglycemia in these patients.

Insulin can be added separately in the form of subcutaneous injection, IM, or IV injection. Short-acting or rapidly-acting insulins are commonly used.

How to treat hypoglycemia after Insulin Dextrose Infusion?

Bedside glucose monitoring is recommended during the insulin dextrose infusion and up to 4 hours after the infusion has been completed.

If hypoglycemia develops during the infusion, insulin infusion is stopped or the rate of insulin infusion is reduced to half in cases of mild hypoglycemia.

Such patients may require 50 to 100 gm of glucose along with insulin, administered as 100 ml to 200 ml of 50% dextrose with 10 units of insulin. Alternatively, the dose of insulin may be reduced to 6 units.

According to some of the hospital’s recommendations, insulin should not be given if the blood glucose is less than 90 mg/dl (5 mmol/L)