1
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Dybdahl D, Roberson T, Rasor E, Kline L, Pershing M. Impact of a Hyperkalemia Protocol Tailored to Glucose Concentration and Renal Function on Insulin-Induced Hypoglycemia in Patients with Low Pretreatment Glucose. J Emerg Med 2024; 66:e421-e431. [PMID: 38462394 DOI: 10.1016/j.jemermed.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 03/12/2024]
Abstract
BACKGROUND Hyperkalemia is a common electrolyte abnormality that requires urgent treatment. Insulin is an effective treatment for hyperkalemia, but risk factors for developing insulin-induced hypoglycemia exist (e.g., low pretreatment glucose or renal impairment). OBJECTIVE This study evaluated the impact of a hyperkalemia protocol tailored to glucose concentration and renal function on insulin-induced hypoglycemia. METHODS This was a retrospective cohort study of emergency department patients with glucose ≤ 100 mg/dL treated with insulin for hyperkalemia. The primary outcome was incidence of hypoglycemia in patients treated prior to (July 1, 2018-June 30, 2019) vs. after (January 1, 2020-December 31, 2020) the protocol update, which individualized insulin and dextrose doses by glucose concentration and renal function. Secondary outcomes included change in potassium and protocol safety. We assessed factors associated with hypoglycemia using multiple logistic regression. RESULTS We included 202 total patients (preimplementation: 114, postimplementation: 88). Initial insulin dose was lower in the postimplementation group (p < 0.001). We found a nonsignificant reduction in hypoglycemia in the postimplementation group (42.1% vs. 30.7%, p = 0.10). Degree of potassium reduction was similar in patients who received insulin 5 units vs. 10 units (p = 0.72). Higher pretreatment glucose (log odds ratio [OR] -0.05, 95% confidence interval [CI] -0.08 to -0.02) and additional insulin administration (log OR -1.55, 95% CI -3.01 to -0.25) were associated with reduced risk of developing hypoglycemia. CONCLUSION A hyperkalemia protocol update was not associated with a significant reduction in hypoglycemia, and the incidence of hypoglycemia remained higher than anticipated. Future studies attempting to optimize treatment in this high-risk population are warranted.
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Affiliation(s)
- Daniel Dybdahl
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, Ohio
| | - Taylor Roberson
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, Ohio
| | - Emily Rasor
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, Ohio
| | - Laura Kline
- Department of Pharmacy, OhioHealth Riverside Methodist Hospital, Columbus, Ohio
| | - Michelle Pershing
- Department of Research, OhioHealth Research Institute, Columbus, Ohio
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2
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Weant KA, Gregory H. Acute Hyperkalemia Management in the Emergency Department. Adv Emerg Nurs J 2024; 46:12-24. [PMID: 38285416 DOI: 10.1097/tme.0000000000000504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Acute hyperkalemia is characterized by high concentrations of potassium in the blood that can potentially lead to life-threatening arrhythmias that require emergent treatment. Therapy involves the utilization of a constellation of different agents, all targeting different goals of care. The first, and most important step in the treatment of severe hyperkalemia with electrocardiographic (ECG) changes, is to stabilize the myocardium with calcium in order to resolve or mitigate the development of arrythmias. Next, it is vital to target the underlying etiology of any ECG changes by redistributing potassium from the extracellular space with the use of intravenous regular insulin and inhaled beta-2 agonists. Finally, the focus should shift to the elimination of excess potassium from the body through the use of intravenous furosemide, oral potassium-binding agents, or renal replacement therapy. Multiple nuances and controversies exist with these therapies, and it is important to have a robust understanding of the underlying support and recommendations for each of these agents to ensure optimal efficacy and minimize the potential for adverse effects and medication errors.
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Affiliation(s)
- Kyle A Weant
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia (Dr Weant); and Department of Pharmacy, University of North Carolina Health, Chapel Hill (Dr Gregory)
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3
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Pradhan J, Harding AM, Taylor SE, Lam Q. Implications of differences between point-of-care blood gas analyser and laboratory analyser potassium results on hyperkalaemia diagnosis & treatment. Intern Med J 2023; 53:2035-2041. [PMID: 36645311 DOI: 10.1111/imj.16020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 01/08/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND Hyperkalaemia is managed in the emergency department (ED) following measurement of potassium results by blood gas analysers (BGA) or laboratory analysers (LAB). AIMS To determine the prevalence of clinically significant differences between BGA and LAB potassium results and the impact on ED hyperkalaemia management. METHODS Retrospective analysis of time-matched ED BGA and LAB potassium samples from 2019 to 2020 (taken within 15 min, one or both results ≥6.0 mmol/L). Mean differences and 95% limits of agreement (LoA) were determined for pairs with one or both results ≥6.0 mmol/L and a separate 500 consecutive sample pairs. RESULTS Four hundred eighty-eight matched BGA and LAB samples met the inclusion criteria. Of these, 201 (41.2%) differed by ≤0.5 mmol/L, 169 (34.6%) included a haemolysed LAB sample, and 12 (2.5%) had an unreportable BGA sample. One hundred six (21.7%) pairs differed by >0.5 mmol/L, and 60/106 (57%) had normal LAB potassium results, but BGA indicated moderate/severe hyperkalaemia (two of these pairs received hyperkalaemia treatment). Of patients with a haemolysed LAB sample, or where pairs differed by >0.5 mmol, 48 were treated with insulin and five (10.4%) experienced hypoglycaemia. Mean differences and LoA for pairs with LAB results <6.0 mmol/L but BGA ≥6.0 mmol/L demonstrated unacceptable agreement, with 18 (25.7%) BGA results exceeding 8.0 mmol/L. CONCLUSIONS Potentially significant discordance may occur between BGA and LAB potassium results. Clinicians need to be aware of factors impacting both analytical methods' accuracy (such as poor venepuncture or sample handling, (K) EDTA interference) and undetectable haemolysis with BGA measurements. We recommend BGA hyperkalaemia be confirmed with LAB results using a non-haemolysed sample where time permits.
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Affiliation(s)
- Jasmin Pradhan
- Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew M Harding
- Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
- Emergency Department, Austin Health, Heidelberg, Victoria, Australia
| | - Simone E Taylor
- Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
- Emergency Department, Austin Health, Heidelberg, Victoria, Australia
| | - Que Lam
- Pathology Department, St Vincent's Health, Melbourne, Victoria, Australia
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4
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Rafique Z, Budden J, Quinn CM, Duanmu Y, Safdar B, Bischof JJ, Driver BE, Herzog CA, Weir MR, Singer AJ, Boone S, Soto-Ruiz KM, Peacock WF. Patiromer utility as an adjunct treatment in patients needing urgent hyperkalaemia management (PLATINUM): design of a multicentre, randomised, double-blind, placebo-controlled, parallel-group study. BMJ Open 2023; 13:e071311. [PMID: 37308268 PMCID: PMC10277034 DOI: 10.1136/bmjopen-2022-071311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/11/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Hyperkalaemia is common, life-threatening and often requires emergency department (ED) management; however, no standardised ED treatment protocol exists. Common treatments transiently reducing serum potassium (K+) (including albuterol, glucose and insulin) may cause hypoglycaemia. We outline the design and rationale of the Patiromer Utility as an Adjunct Treatment in Patients Needing Urgent Hyperkalaemia Management (PLATINUM) study, which will be the largest ED randomised controlled hyperkalaemia trial ever performed, enabling assessment of a standardised approach to hyperkalaemia management, as well as establishing a new evaluation parameter (net clinical benefit) for acute hyperkalaemia treatment investigations. METHODS AND ANALYSIS PLATINUM is a Phase 4, multicentre, randomised, double-blind, placebo-controlled study in participants who present to the ED at approximately 30 US sites. Approximately 300 adult participants with hyperkalaemia (K+ ≥5.8 mEq/L) will be enrolled. Participants will be randomised 1:1 to receive glucose (25 g intravenously <15 min before insulin), insulin (5 units intravenous bolus) and aerosolised albuterol (10 mg over 30 min), followed by a single oral dose of either 25.2 g patiromer or placebo, with a second dose of patiromer (8.4 g) or placebo after 24 hours. The primary endpoint is net clinical benefit, defined as the mean change in the number of additional interventions less the mean change in serum K+, at hour 6. Secondary endpoints are net clinical benefit at hour 4, proportion of participants without additional K+-related medical interventions, number of additional K+-related interventions and proportion of participants with sustained K+ reduction (K+ ≤5.5 mEq/L). Safety endpoints are the incidence of adverse events, and severity of changes in serum K+ and magnesium. ETHICS AND DISSEMINATION A central Institutional Review Board (IRB) and Ethics Committee provided protocol approval (#20201569), with subsequent approval by local IRBs at each site, and participants will provide written consent. Primary results will be published in peer-reviewed manuscripts promptly following study completion. TRIAL REGISTRATION NUMBER NCT04443608.
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Affiliation(s)
- Zubaid Rafique
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Youyou Duanmu
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Internal Medicine, Hennepin Healthcare/University of Minnesota, Minneapolis, Minnesota, USA
| | - Matthew R Weir
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Adam J Singer
- Department of Emergency Medicine, SUNY Stony Brook, Stony Brook, New York, USA
| | - Stephen Boone
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
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5
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Mattaliano G, Heberlein M, Cruz Benedetti I. Unanticipated hyperkalaemia and associated perioperative complications in three captive grey wolves (
Canis lupus
) undergoing general anaesthesia. VETERINARY RECORD CASE REPORTS 2023. [DOI: 10.1002/vrc2.597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Giorgio Mattaliano
- Department for Companion Animals and Horses Anaesthesiology and Perioperative Intensive‐Care Medicine, Vetmeduni Vienna Vienna Austria
| | | | - Inga‐Catalina Cruz Benedetti
- Department of Clinical Sciences, Faculty of Veterinary Medicine Université de Montréal Saint‐Hyacinthe Quebec Canada
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6
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Loubser J, Pinto Bronislawski L, Fonarov I, Casadesus D. Sine-wave electrocardiogram rhythm in a patient on haemodialysis presenting with severe weakness and hyperkalaemia. BMJ Case Rep 2023; 16:e255007. [PMID: 36898713 PMCID: PMC10008419 DOI: 10.1136/bcr-2023-255007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Affiliation(s)
- James Loubser
- Internal Medicine, Jackson Memorial Hospital, Miami, Florida, USA
- Internal Medicine, St George's University, Great River, New York, USA
| | - Luana Pinto Bronislawski
- Internal Medicine, Jackson Memorial Hospital, Miami, Florida, USA
- Internal Medicine, St George's University, Great River, New York, USA
| | - Ilya Fonarov
- Internal Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - Damian Casadesus
- Internal Medicine, Jackson Memorial Hospital, Miami, Florida, USA
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7
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Long DS, Kelly MA, Lim SH. Risk factors, prevention and treatment of hypoglycaemia after hyperkalaemia in adult patients using intravenous insulin: An integrative review. Int J Nurs Pract 2023; 29:e13080. [PMID: 35859317 DOI: 10.1111/ijn.13080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/02/2022] [Accepted: 06/27/2022] [Indexed: 02/04/2023]
Abstract
AIM An integrative review was conducted to synthesize published evidence on the prevention and treatment of hypoglycaemia and patient risk factors, in adult patients treated for hyperkalaemia with intravenous insulin and dextrose. METHODS This review followed the framework by Whittemore and Knafl. Papers included were limited to English language studies involving participants who were aged 18 years and above and admitted in the inpatient acute care and emergency departments. The literature search was performed using five electronic databases (CINAHL, Embase, PubMed, Proquest and Cochrane). RESULTS A total of 22 studies were included. Two main themes were derived-patient risk factors and prevention-intervention strategies. Five main patient risk factors were lower pretreatment blood glucose (<7 mmol/L), lower weight, renal insufficiencies, older age and nondiabetic. The four subthemes in the prevention-intervention strategies included (i) methods of administration and dosing of intravenous insulin and dextrose, (ii) frequency of blood glucose monitoring, (iii) education to healthcare professionals and (iv) rescue agents. CONCLUSIONS Standardized computerized order sets and integrated decision tool that can advise appropriate prescription of a higher volume of dextrose or lower insulin dose according to patient risk factors, regular monitoring and reinforced education may prevent and mitigate the risk of hypoglycaemia.
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Affiliation(s)
| | - Michelle A Kelly
- Clinical and Health Sciences, University of South Australia, Adelaide, Australia, Australia.,Clinical & Health Sciences, UniSA - East Campus, Adelaide, Australia.,Curtin School of Nursing, Curtin University, Perth, Australia
| | - Siew Hoon Lim
- Division of Nursing, Singapore General Hospital, Singapore
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8
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Evaluation of Care Outcomes of Patients Receiving Hyperkalemia Treatment With Insulin in Acute Care Tertiary Hospital Emergency Department. J Emerg Nurs 2023; 49:99-108. [PMID: 36266095 DOI: 10.1016/j.jen.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/04/2022] [Accepted: 09/14/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Treatment of hyperkalemia using intravenous insulin can result in severe hypoglycemia, but regular blood glucose monitoring is not standardized. This study aimed to (i) explore the demographics of adult patients receiving hyperkalemia treatment and (ii) identify the incidence rate of hypoglycemia and associated demographic or clinical characteristics. METHODS A descriptive design with prospective data collection was used. This study recruited 135 patients who received hyperkalemia treatment in the emergency department. Structured blood glucose monitoring was conducted at 1, 2, 4, and 6 hours after receiving intravenous insulin. Univariate analyses of association between demographic and clinical variables and hypoglycemia outcome were performed. RESULTS There were 31 hypoglycemic events, with 11.9%, 7.4%, 2.2%, and 1.5% occurring at the 1, 2, 4, and 6 hours after treatment. The logit regression showed no significantly increased risk of hypoglycemia in terms of the demographic and clinical variables. DISCUSSION The variation in blood glucose response observed in this study combined with the high incidences of hypolycaemia indicated the need for frequent and longer duration of monitoring for patients who were being treated for hyperkalaemia with IDT.
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9
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Kijprasert W, Tarudeeyathaworn N, Loketkrawee C, Pimpaporn T, Pattarasettaseranee P, Tangsuwanaruk T. Predicting hypoglycemia after treatment of hyperkalemia with insulin and glucose (Glu-K60 score). BMC Emerg Med 2022; 22:179. [DOI: 10.1186/s12873-022-00748-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Hyperkalemia can lead to fatal cardiac arrhythmias. Ten units of intravenous (IV) regular insulin with 25 g of glucose is the mainstay for treating hyperkalemia. However, the most important complication of this treatment is hypoglycemia. We aimed to develop a scoring model to predict hypoglycemia after the treatment of hyperkalemia.
Methods
A retrospective study was conducted at a university-based hospital between January 2013 and June 2021. We included the hyperkalemic patients (> 5.3 mmol/L) who were ≥ 18 years old and treated with 10 units of IV regular insulin with 25 g of glucose. Incomplete data on posttreatment blood glucose, pregnancy, and diabetes mellitus were excluded. Endpoint was posttreatment hypoglycemia (≤ 70 mg/dL or ≤ 3.9 mmol/L). Multivariable logistic regression was used to establish a full model and a subsequently reduced model using the backward elimination method. We demonstrated the model performance using the area under the receiver operating characteristic curve (AuROC), calibration plot, and Hosmer–Lemeshow goodness-of-fit test. Internal validation was done with a bootstrap sampling procedure with 1000 replicates. Model optimism was estimated.
Results
Three hundred and eighty-five patients were included, with 97 posttreatment hypoglycemia (25.2%). The predictive model comprised the following three criteria: age > 60 years old, pretreatment blood glucose ≤ 100 mg/dL (≤ 5.6 mmol/L), and pretreatment potassium > 6 mmol/L. The AuROC of this model was 0.671 (95% confidence interval [CI] 0.608 to 0.735). The calibration plot demonstrated consistency with the original data. Hosmer–Lemeshow goodness-of-fit test showed no evidence of lack-of-fit (p 0.792); therefore, the model was also fit to the original data. Internal validation via bootstrap sampling showed a consistent AuROC of 0.670 (95% CI 0.660 to 0.670) with minimal model optimism. A high risk for posttreatment hypoglycemia was indicated if the patient met at least one of those criteria. Sensitivity and specificity were 95.9% and 14.9%, respectively.
Conclusion
High risk was indicated when at least one of the criteria was met: age > 60 years old, pretreatment blood glucose ≤ 100 mg/dL (≤ 5.6 mmol/L), and pretreatment potassium > 6 mmol/L. Blood glucose levels should frequently check in the high-risk group.
Trial registration
TCTR20210225002 (www.thaiclinicaltrials.org).
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10
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Pollack K, Manning KR, Balassone J, Bui C, Taylor DM, Taylor SE. Response to Re: Hyperkalaemia in the emergency department: Epidemiology, management and monitoring of treatment outcomes. Emerg Med Australas 2022; 34:844-845. [PMID: 35785520 DOI: 10.1111/1742-6723.14042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/27/2022]
Affiliation(s)
| | - Kiri R Manning
- Emergency Department, Middlemore Hospital, Auckland, New Zealand
| | | | - Calista Bui
- Pharmacy Department, Austin Health, Melbourne, Victoria, Australia
| | - David McD Taylor
- Emergency Department, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Simone E Taylor
- Pharmacy Department, Austin Health, Melbourne, Victoria, Australia
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11
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Chothia MY, Humphrey T, Schoonees A, Chikte UME, Davids MR. Hypoglycaemia due to insulin therapy for the management of hyperkalaemia in hospitalised adults: A scoping review. PLoS One 2022; 17:e0268395. [PMID: 35552566 PMCID: PMC9097985 DOI: 10.1371/journal.pone.0268395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/28/2022] [Indexed: 12/22/2022] Open
Abstract
Introduction Hyperkalaemia is a very common electrolyte disorder encountered in hospitalised patients. Although hypoglycaemia is a frequent complication of insulin therapy, it is often under-appreciated. We conducted a scoping review of this important complication, and of other adverse effects, of the treatment of hyperkalaemia in hospitalised adults to map existing research on this topic and to identify any knowledge gaps. Materials and methods We followed the PRISMA-ScR guidelines. Studies were eligible for inclusion if they reported on any adverse effects in hospitalised patients ≥18-years-old, with hyperkalaemia receiving treatment that included insulin. All eligible research from 1980 to 12 October 2021 were included. We searched Medline (PubMed), Embase (Ovid), the Cochrane Library, CINHAL, Africa-Wide Information, Web of Science Core Collection, LILACS and Epistemonikos. The protocol was prospectively registered with the Open Science Framework (https://osf.io/x8cs9). Results Sixty-two articles were included. The prevalence of hypoglycaemia by any definition was 17.2% (95% CI 16.6–17.8%). The median timing of hypoglycaemia was 124 minutes after insulin administration (IQR 102–168 minutes). There were no differences in the prevalence of hypoglycaemia when comparing insulin dose (<10 units vs. ≥10 units), rate of insulin administration (continuous vs. bolus), type of insulin (regular vs. short-acting) or timing of insulin administration relative to dextrose. However, lower insulin doses were associated with a reduced prevalence of severe hypoglycaemia (3.5% vs. 5.9%, P = 0.02). There was no difference regarding prevalence of hypoglycaemia by dextrose dose (≤25 g vs. >25 g); however, prevalence was lower when dextrose was administered as a continuous infusion compared with bolus administration (3.3% vs. 19.5%, P = 0.02). The most common predictor of hypoglycaemia was the pre-treatment serum glucose concentration (n = 13 studies), which ranged from < 5.6–7.8 mmol/L. Conclusion This is the first comprehensive review of the adverse effects following insulin therapy for hyperkalaemia. Hypoglycaemia remains a common adverse effect in hospitalised adults. Future randomised trials should focus on identifying the optimal regimen of insulin therapy to mitigate the risk of hypoglycaemia.
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Affiliation(s)
- Mogamat-Yazied Chothia
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
| | - Toby Humphrey
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Anel Schoonees
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Usuf Mohamed Ebrahim Chikte
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mogamat Razeen Davids
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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12
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Pollack K, Manning KR, Balassone J, Bui C, Taylor DM, Taylor SE. Hyperkalaemia in the emergency department: Epidemiology, management and monitoring of treatment outcomes. Emerg Med Australas 2022; 34:751-757. [PMID: 35411698 DOI: 10.1111/1742-6723.13971] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To describe the epidemiology, treatment and monitoring of treatment outcomes of patients presenting to the ED with hyperkalaemia. METHODS We undertook a retrospective observational study in a mixed adult/paediatric ED over five 3-month periods. Consecutive patients were included if they had an initial serum or blood gas potassium ≥6.0 mmol/L. Patients were excluded if their principal diagnosis was diabetic ketoacidosis, their blood sample was haemolysed or the blood gas result was inconsistent with a subsequent serum potassium. Data were extracted from electronic medical records and two senior emergency registrars independently assessed available ECGs. Moderate and severe hyperkalaemia were potassium 6.0-6.4 and ≥6.5 mmol/L, respectively. RESULTS Overall, 392 patients were included (mean age 73.7 years, triage category 1 or 2 28.3%, admitted 91.3%). Three hundred and twenty-one (81.9%, 95% confidence interval [CI] 77.6-85.5%) patients took one or more medications that predispose to hyperkalaemia and 335 (85.5%, 95% CI 81.5-88.7%) had one or more predisposing comorbidities. Two hundred and seventy-one (69.1%, 95% CI 64.3-73.6%) patients had moderately severe and 121 (30.9%, 95% CI 26.4-35.7%) had severe hyperkalaemia. Two hundred and fifty-nine (66.1%, 95% CI 61.1-70.7%) patients were administered at least one medication in ED to lower the potassium concentration and 51 (13.0%, 95% CI 9.9-16.8%) were dialysed. One hundred and eighty-seven patients received intravenous insulin: 40 (21.4%) had documented biochemical hypoglycaemia, but 45 (24.1%) had no post-insulin blood glucose level documented. Hyperkalaemia-associated ECG changes were uncommon. CONCLUSION Most ED patients with hyperkalaemia have identifiable clinical and medication-related risk factors. Variations in care were widespread and monitoring for iatrogenic adverse events was suboptimal.
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Affiliation(s)
| | | | | | - Calista Bui
- Pharmacy Department, Austin Health, Melbourne, Victoria, Australia
| | - David McD Taylor
- Emergency Department, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Simone E Taylor
- Emergency Department, Austin Health, Melbourne, Victoria, Australia.,Pharmacy Department, Austin Health, Melbourne, Victoria, Australia
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13
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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; 35:258-263. [PMID: 34167889 DOI: 10.1016/j.aucc.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 04/26/2021] [Accepted: 05/09/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Hyperkalaemia is a complication in patients with chronic kidney disease or acute kidney injury and occurs frequently in the intensive care unit. One treatment approach includes intravenous (IV) insulin to shift potassium intracellularly. OBJECTIVES The primary outcome was hypoglycaemia (blood glucose <70 mg/dL) after insulin administration. Secondary outcomes included change in serum potassium levels and incidence of severe hypoglycaemia. METHODS This was a single-centre, retrospective study evaluating critically ill adult patients with chronic kidney disease stage III-V, end-stage renal disease, or acute kidney injury who received IV insulin for treatment of hyperkalaemia from March 2008 to September 2018. Patients were divided into two insulin-dosing regimen groups: 5 units or 10 units. RESULTS Of the 174 patients included, hypoglycaemia after insulin administration occurred in eight of 87 patients (9.2%) in the 5-unit group and 17 of 87 patients (19.5%) in the 10-unit group (p = 0.052). There was no difference in rates of severe hypoglycaemia or change in serum potassium levels. CONCLUSIONS In critically ill patients requiring treatment for hyperkalaemia, a lower dose of IV insulin does not result in lower statistically significant rates of hypoglycaemia. However, lower insulin doses provide a similar potassium-lowering effect and cause a meaningful decrease in hypoglycaemic episodes. Intensive care unit providers may consider 5 units of IV insulin over 10 units although further larger controlled studies are needed.
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Affiliation(s)
- Miranda Verdier
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Joshua M DeMott
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA; Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA; Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA.
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14
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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Moussavi K, Garcia J, Tellez-Corrales E, Fitter S. Reduced alternative insulin dosing in hyperkalemia: A meta-analysis of effects on hypoglycemia and potassium reduction. Pharmacotherapy 2021; 41:598-607. [PMID: 33993515 DOI: 10.1002/phar.2596] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/01/2021] [Accepted: 04/18/2021] [Indexed: 11/08/2022]
Abstract
STUDY OBJECTIVE Recent studies have identified that reduced alternative intravenous insulin doses, such as 5 units or 0.1 units/kg, may reduce the risk of hypoglycemia compared to standard doses of 10 units in patients treated for hyperkalemia. However, some studies suggest that these alternative doses may reduce the ability to lower serum potassium. This study was performed to determine the impact of alternative insulin dosing on hypoglycemia and potassium reduction in patients with hyperkalemia. DESIGN Meta-analysis. DATA SOURCE PubMed/MEDLINE, CENTRAL, Ovid, and ClinicalTrials.gov were searched from inception through November 2020. PATIENTS Patients treated with standard (10 units) or alternative (<10 units) insulin dosing strategies for hyperkalemia. Only studies that evaluated hypoglycemia (serum glucose <70 mg/dl), severe hypoglycemia (serum glucose <50 mg/dl), and potassium reduction post-treatment were included in the meta-analysis. All articles were assessed for bias using the Cochrane Risk of Bias Assessment Tool and Newcastle-Ottawa scales for randomized prospective trials and retrospective trials, respectively. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Ten retrospective cohort studies (n = 3437) were included and had low- or moderate-risk of bias. Alternative insulin dosing strategies included 5 units, 0.1 units/kg, and <10 units. Alternative dosing had lower pooled odds of hypoglycemia (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.43-0.69, I2 = 8%) and severe hypoglycemia (OR 0.41, 95% CI 0.27-0.64, I2 = 0%). No difference in potassium reduction was detected (mean difference -0.02 mmol/L, 95% CI -0.11-0.07, I2 = 53%). CONCLUSIONS Alternative insulin dosing strategies for hyperkalemia management resulted in less hypoglycemia and severe hypoglycemia without compromising potassium reduction compared to standard dose. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Kayvan Moussavi
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Joshua Garcia
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Eglis Tellez-Corrales
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Scott Fitter
- Emergency Medicine, Loma Linda University Medical Center, Loma Linda, California, USA.,Loma Linda University School of Pharmacy, Loma Linda, California, USA
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 288] [Impact Index Per Article: 96.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Tee SA, Devine K, Potts A, Javaid U, Razvi S, Quinton R, Roberts G, Leech NJ. Iatrogenic hypoglycaemia following glucose-insulin infusions for the treatment of hyperkalaemia. Clin Endocrinol (Oxf) 2021; 94:176-182. [PMID: 32979855 DOI: 10.1111/cen.14343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/02/2020] [Accepted: 09/15/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To study the incidence of, and risk factors for, iatrogenic hypoglycaemia following GwI infusion in our institution. CONTEXT Hyperkalaemia is a life-threatening biochemical abnormality. Glucose-with-insulin (GwI) infusions form standard management, but risk iatrogenic hypoglycaemia (glucose ≤ 3.9 mmol/L). Recently updated UK guidelines include an additional glucose infusion in patients with pretreatment capillary blood glucose (CBG) < 7.0 mmol/L. DESIGN Retrospective analysis of outcomes for GwI infusions prescribed for hyperkalaemia from 1 January to 28 February 2019, extracted from the Newcastle upon Tyne Hospitals NHS Foundation Trust electronic platform (eRecord). PARTICIPANTS 132 patients received 228 GwI infusions for hyperkalaemia. MAIN OUTCOME MEASURES Incidence, severity and time to onset of hypoglycaemia. RESULTS Hypoglycaemia incidence was 11.8%. At least 1 hypoglycaemic episode occurred in 18.2% of patients with 6.8% having at least 1 episode of severe hypoglycaemia (< 3.0 mmol/L). Most episodes (77.8%) occurred within 3 h of treatment. Lower pretreatment CBG (5.9 mmol/L [4.1 mmol/L-11.2 mmol/L], versus 7.6 mmol/L [3.7 mmol/L-31.3 mmol/L], P = .000) was associated with hypoglycaemia risk. A diagnosis of type 2 diabetes and treatment for hyperkalaemia within the previous 24 h were negatively associated. CONCLUSIONS Within our inpatient population, around 1 in 8 GwI infusions delivered as treatment for hyperkalaemia resulted in iatrogenic hypoglycaemia. Higher pretreatment CBG and a diagnosis of type 2 diabetes were protective, irrespective of renal function. Our findings support the immediate change to current management, either with additional glucose infusions or by using glucose-only infusions in patients without diabetes. These approaches should be compared via a prospective randomized study.
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Affiliation(s)
- Su Ann Tee
- Department of Diabetes & Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Kerri Devine
- Department of Diabetes & Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Department of Diabetes & Endocrinology, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK
- Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
| | - Adam Potts
- Department of Diabetes & Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Usman Javaid
- Department of Diabetes & Endocrinology, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Salman Razvi
- Department of Diabetes & Endocrinology, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK
- Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
| | - Richard Quinton
- Department of Diabetes & Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
| | - Graham Roberts
- Diabetes Research Group, Swansea University, Swansea, UK
- Clinical Research Facility - Cork, University College Cork, Cork, Ireland
| | - Nicola J Leech
- Department of Diabetes & Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, UK
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Crnobrnja L, Metlapalli M, Jiang C, Govinna M, Lim AKH. The Association of Insulin-dextrose Treatment with Hypoglycemia in Patients with Hyperkalemia. Sci Rep 2020; 10:22044. [PMID: 33328554 PMCID: PMC7745028 DOI: 10.1038/s41598-020-79180-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022] Open
Abstract
Treatment of hyperkalemia with intravenous insulin-dextrose is associated with a risk of hypoglycemia. We aimed to determine the factors associated with hypoglycemia (glucose < 3.9 mmol/L, or < 70 mg/dL) and the critical time window with the highest incidence. In a retrospective cohort study in a tertiary hospital network, we included 421 adult patients with a serum potassium ≥ 6.0 mmol/L who received insulin-dextrose treatment. The mean age was 70 years with 62% male predominance. The prevalence of diabetes was 60%, and 70% had chronic kidney disease (eGFR < 60 ml/min/1.73 m2). The incidence of hypoglycemia was 21%. In a multivariable logistic regression model, the factors independently associated with hypoglycemia were: body mass index (per 5 kg/m2, OR 0.85, 95% CI: 0.69–0.99, P = 0.04), eGFR < 60 mL/min/1.73 m2 (OR 2.47, 95% CI: 1.32–4.63, P = 0.005), diabetes (OR 0.57, 95% CI 0.33–0.98, P = 0.043), pre-treatment blood glucose (OR 0.84, 95% CI: 0.77–0.91, P < 0.001), and treatment in the emergency department compared to other locations (OR 2.53, 95% CI: 1.49–4.31, P = 0.001). Hypoglycemia occurred most frequently between 60 and 150 min, with a peak at 90 min. Understanding the factors associated with hypoglycemia and the critical window of risk is essential for the development of preventive strategies.
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Affiliation(s)
- Ljiljana Crnobrnja
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Manogna Metlapalli
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Cathy Jiang
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Mauli Govinna
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Andy K H Lim
- Department of General Medicine, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia. .,Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia.
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Intravenous insulin for the management of non-emergent hyperglycemia in the emergency department. Am J Emerg Med 2020; 45:335-339. [PMID: 33041132 DOI: 10.1016/j.ajem.2020.08.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE There is currently no consensus regarding the necessity of emergency department (ED) glucose reduction to manage hyperglycemia in patients presenting without a hyperglycemic emergency. Known consequences of intravenous (IV) insulin administration include hypoglycemia, hypokalemia, and increased ED length of stay. The primary objective of this study was to assess the impact of IV regular insulin on glucose reduction and ED length of stay in patients presenting to the ED with non-emergent hyperglycemia. Secondary objectives included the characterization of potential adverse events. METHODS This was a retrospective, observational study of patients ≥18 years who received IV regular insulin and were discharged from the ED at a large academic Trauma Center. Univariate and multivariable regression analyses were utilized to determine if an association existed between IV insulin administration and blood glucose as well as ED length of stay. RESULTS A total of 405 patients were included in the analysis. An insulin dose >5 units was associated with a greater reduction in blood glucose (difference = 37.4 mg/dL; p < .001) but no difference in ED length of stay relative to ≤5 units. Furthermore, 7.9% of patients developed hypokalemia and 0.4% developed hypoglycemia. CONCLUSION The use of >5 units of IV regular insulin for the management of isolated hyperglycemia in the ED was associated with a modest reduction in blood glucose and no difference in ED length of stay compared with those that received ≤5 units. However, use of IV insulin for this purpose resulted in a 7.9% occurrence of hypokalemia.
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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; 38:1082-1085. [DOI: 10.1016/j.ajem.2019.158374] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/15/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022] Open
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21
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Moussavi K, Nguyen LT, Hua H, Fitter S. Comparison of IV Insulin Dosing Strategies for Hyperkalemia in the Emergency Department. Crit Care Explor 2020; 2:e0092. [PMID: 32426734 PMCID: PMC7188424 DOI: 10.1097/cce.0000000000000092] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The objectives of this study were to evaluate the safety and efficacy of insulin dosing of less than 10 units versus 10 units in patients receiving hyperkalemia treatment. DESIGN Retrospective single-center study. SETTING Emergency department at a large academic medical center in the United States. PATIENTS Seven hundred adults treated for hyperkalemia with IV regular insulin between April 1, 2013, and September 27, 2018. INTERVENTIONS Patients that received less than 10 units of insulin were compared to those that received 10 units of insulin. MEASUREMENTS AND MAIN RESULTS Patients treated with less than 10 units had significantly lower frequency of hypoglycemia (11.2% vs 17.6%; p = 0.008). Reduction in serum potassium was significantly more modest in size in patients treated with less than 10 units (mean reduction 0.94 ± 0.71 mMol/L) compared with patients treated with 10 units (mean reduction 1.11 ± 0.8 mMol/L; p = 0.008). There were no statistically significant differences between groups in time to hypoglycemia, nadir serum glucose, severe hypoglycemia (<40 mg/dL), dextrose requirements, use of concurrent agents for hyperkalemia, need for repeat insulin dosing, length of stay, or mortality. CONCLUSIONS Patients treated for hyperkalemia with insulin doses less than 10 units had reduced frequency of hypoglycemia; however, potassium reduction post treatment was more modest in these patients. These findings suggest providers choosing to administer 10 units IV insulin should ensure patients have adequate monitoring for hypoglycemia.
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Affiliation(s)
- Kayvan Moussavi
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA
| | - Lani T Nguyen
- Department of Pharmacy, Loma Linda University Medical Center, Loma Linda, CA
| | - Henry Hua
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA
| | - Scott Fitter
- Emergency Department, Department of Pharmacy, Loma Linda University Medical Center, Loma Linda, CA
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA
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Aljabri A, Perona S, Alshibani M, Khobrani M, Jarrell D, Patanwala AE. Blood glucose reduction in patients treated with insulin and dextrose for hyperkalaemia. Emerg Med J 2019; 37:31-35. [DOI: 10.1136/emermed-2019-208744] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/14/2019] [Accepted: 10/03/2019] [Indexed: 11/04/2022]
Abstract
BackgroundDextrose is commonly administered with insulin during the management of hyperkalaemia to avoid hypoglycaemia. Previous research has evaluated the incidence of hypoglycaemia; however, none have reported the extent of blood glucose reduction after this regimen. The aim of this study was to better characterise the changes in blood glucose and to identify patients who may have an increased response to insulin.MethodsThis was a multicentre retrospective study evaluating adult patients who received a regimen of 10 units of intravenous regular insulin plus 25 g of intravenous dextrose to manage hyperkalaemia between January 2014 and September 2016. The primary outcome was to evaluate the extent of blood glucose reduction (milligram per decilitre) up to 6 hours following the above regimen. Secondary outcomes included incidence of hypoglycaemia (blood glucose <70 mg/dL) and severe hypoglycaemia (blood glucose <40 mg/dL), and predictors of the extent of blood glucose reduction.ResultsA total of 90 patients were included. The median blood glucose change over 6 hours was −24 mg/dL (IQR −53 to 6 mg/dL). Hypoglycaemia developed in 20 patients (22.2%, 95% CI 14.1% to 32.2%) and five patients (5.6%, 95% CI 1.8% to 12.5%) had severe hypoglycaemia. Patients who developed hypoglycaemia had a median baseline blood glucose of 110 mg/dL (IQR 80 to 127 mg/dL), which decreased to a median value of 52 mg/dL (IQR 40 to 60 mg/dL). Higher baseline blood glucose was significantly associated with greater blood glucose reduction (coefficient −0.36, 95% CI −0.55 to −0.18, p<0.001).ConclusionsThe extent of blood glucose reduction is variable and hypoglycaemia is common. The high incidence of hypoglycaemia highlights the importance of frequent blood glucose monitoring.
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Chittineni C, Driver BE, Halverson M, Cole JB, Prekker ME, Pandey V, Lai T, Harrington J, Zhao S, Klein LR. Incidence and Causes of Iatrogenic Hypoglycemia in the Emergency Department. West J Emerg Med 2019; 20:833-837. [PMID: 31539342 PMCID: PMC6754198 DOI: 10.5811/westjem.2019.7.42996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 07/14/2019] [Indexed: 11/14/2022] Open
Abstract
Introduction Hypoglycemia is frequently encountered in the emergency department (ED) and has potential for serious morbidity. The incidence and causes of iatrogenic hypoglycemia are not known. We aim to describe how often the cause of ED hypoglycemia is iatrogenic and to identify its specific causes. Methods We included adult patients with a chief complaint or ED diagnosis of hypoglycemia, or an ED glucose value of ≤70 milligrams per deciliter (mg/dL) between 2009–2014. Two independent abstractors each reviewed charts of patients with an initial glucose ≤ 50 mg/dL, or initial glucose ≥ 70 mg/dL with a subsequent glucose ≤ 50 mg/dL, to determine if the hypoglycemia was caused by iatrogenesis. The data analysis was descriptive. Results We reviewed the charts of 591 patients meeting inclusion criteria. Of these 591 patients, 99 (17%; 95% confidence interval, 14–20%) were classified as iatrogenic. Of these 99 patients, 61 (61%) cases of hypoglycemia were caused by insulin administration and 38 (38%) were caused by unrecognized malnutrition. Of the 61 patients with iatrogenic hypoglycemia after ED insulin administration, 45 and 15 patients received insulin for hyperkalemia and uncomplicated hyperglycemia, respectively. One patient received insulin for diabetic ketoacidosis. Conclusion In ED patients with hypoglycemia, iatrogenic causes are relatively common. The most frequent cause was insulin administration for hyperkalemia and uncomplicated hyperglycemia. Additionally, patients at risk of hypoglycemia in the absence of insulin, including those with alcohol intoxication or poor nutritional status, should be monitored closely in the ED.
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Affiliation(s)
- Chaitanya Chittineni
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota.,University of Minnesota School of Medicine, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Brian E Driver
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Matthew Halverson
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Jon B Cole
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Matthew E Prekker
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Vidhu Pandey
- University of Minnesota School of Medicine, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Tarissa Lai
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Justin Harrington
- Mercy Medical Center-North Iowa, Department of Emergency Medicine, Mason City, Iowa
| | - Sean Zhao
- Aventura Hospital and Medical Center, Department of Emergency Medicine, Miami, Florida
| | - Lauren R Klein
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
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Moussavi K, Fitter S, Gabrielson SW, Koyfman A, Long B. Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. J Emerg Med 2019; 57:36-42. [DOI: 10.1016/j.jemermed.2019.03.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/16/2019] [Accepted: 03/31/2019] [Indexed: 12/13/2022]
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25
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Avoid Insulin-Related Adverse Events When Treating Hyperkalemia: Could Impaired Awareness of Hypoglycemia Play a Role? J Emerg Nurs 2018; 44:549. [PMID: 30415729 DOI: 10.1016/j.jen.2018.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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