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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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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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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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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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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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Pearson SC, O'Connor K, Keller K, Hodge TJ, Nesbit R. Efficacy of standard- vs reduced-dose insulin for treatment of hyperkalemia: A quasi-experiment. Am J Health Syst Pharm 2021; 79:S13-S20. [PMID: 34597356 PMCID: PMC8500027 DOI: 10.1093/ajhp/zxab382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Hyperkalemia more commonly affects patients with a glomerular filtration rate of less than 60 mL/min. Using intravenous (IV) insulin to shift potassium intracellularly may cause hypoglycemia, requiring additional treatment or longer hospitalization. Literature on insulin dosing in this context is limited, with one previous study indicating that 5 units of IV insulin might be as effective and result in less hypoglycemia than the standard dose of 10 units of IV insulin. The hyperkalemia treatment pathway at our institution was revised in May 2018 to include a reduced-dose option (5 units of insulin) for patients with end-stage renal disease. This study aimed to compare the prevalence of hypoglycemia between patients who received standard-dose vs reduced-dose IV insulin. METHODS This single-center, retrospective, quasi-experimental study evaluated the impact of revision of the hyperkalemia treatment pathway by assessing rates of hypoglycemia during the 6 months before and after implementation of the revised pathway. The primary endpoint was prevalence of hypoglycemia, defined as a blood glucose level of less than or equal to 70 mg/dL. RESULTS There was no statistically significant difference in the occurrence of hypoglycemia when comparing the pre- and postimplementation groups (36 [17.7%] patients vs 34 [18.7%] patients; P = 0.7924). The postimplementation group had a statistically significant lower reduction in potassium levels after treatment than the preimplementation group (mean [interquartile range], -0.9 [-1.3, -0.5] mEq/L vs -0.6 [-1.2, -0.2] mEq/L; P = 0.0095). Baseline potassium levels were similar between the groups. CONCLUSION Administration of reduced-dose IV insulin for treatment of hyperkalemia was significantly less effective in lowering serum potassium levels and did not decrease prevalence of hypoglycemia. When accounting for potential confounders, the only variable that was associated with hypoglycemia was pretreatment glucose level.
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Affiliation(s)
| | - Kristin O'Connor
- The University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Kimberly Keller
- The University of Tennessee Medical Center, Knoxville, TN, USA
| | - T J Hodge
- The University of Tennessee Medical Center, Knoxville, TN, USA
| | - Ross Nesbit
- The University of Tennessee Medical Center, Knoxville, TN, USA
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Aljabri AM, Alsulami SA. Frequency of serum blood glucose monitoring after hyperkalaemia treatment using insulin and dextrose. J Taibah Univ Med Sci 2021; 17:82-86. [PMID: 35140569 PMCID: PMC8802856 DOI: 10.1016/j.jtumed.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/13/2021] [Accepted: 07/25/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives In patients with hyperkalaemia, dextrose is administered alongside insulin treatment to prevent hypoglycaemia. However, the incidence of hypoglycaemia in the first 6 hours following this regimen remains high, and frequent blood glucose monitoring is essential. This study evaluates the frequency of blood glucose monitoring following this insulin regimen. Methods This retrospective, multicentre study evaluated adult patients (≥18 years) who had been hospitalised for hyperkalaemia (K ≥ 5 mEq/mL) and managed using intravenous insulin and dextrose. We excluded patients if dextrose was not administered within 60 minutes of insulin therapy. The primary outcome was the frequency of serum blood glucose monitoring within 6 hours of the regimen. Secondary outcomes were the time between insulin treatment and follow-up measurements, and the incidence of hypoglycaemia (blood glucose <70 mg/dL). Results In total, 521 hyperkalaemia episodes were available for analysis; 192 (36.9%) had at least one reported follow-up measurement, 30 had at least two follow-up measurements (5.8%), and six had at least three follow-up measurements (1.2%). The median times of obtaining the first, second, and third blood glucose measurements were 3 h (interquartile range [IQR]: 1.7–4 h), 3.9 h (IQR: 3.2–5.1 h), and 4 h (IQR: 3.2–5.1 h), respectively. The incidence of hypoglycaemia among the episodes with follow-up was 4.8%. Conclusions The frequency of serum blood glucose monitoring following insulin therapy was low and inconsistent. This study emphasised the importance of adopting protocols incorporating more frequent blood glucose monitoring.
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Affiliation(s)
- Ahmed M. Aljabri
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, KSA
- Corresponding address: Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, KSA.
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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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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: 302] [Impact Index Per Article: 100.7] [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] [Key Words] [MESH Headings] [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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12
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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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Yang I, Smalley S, Ahuja T, Merchan C, Smith SW, Papadopoulos J. Assessment of dextrose 50 bolus versus dextrose 10 infusion in the management of hyperkalemia in the ED. Am J Emerg Med 2020; 38:598-602. [PMID: 31837905 DOI: 10.1016/j.ajem.2019.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/24/2019] [Accepted: 09/20/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Hypoglycemia is a common adverse effect when intravenous (IV) insulin is administered for hyperkalemia. A prolonged infusion of dextrose 10% (D10) may mitigate hypoglycemia compared to dextrose 50% (D50) bolus. Our objective was to evaluate whether D10 infusion is a safe and effective alternative to D50 bolus for hypoglycemia prevention in hyperkalemic patients receiving IV insulin. METHODS We conducted a retrospective review of patients ≥ 18 years who presented to the emergency department (ED) with hyperkalemia (K+ > 5.5) and received IV insulin and D10 infusion or D50 bolus within 3 h. The primary endpoint was incidence of hypoglycemia, defined as blood glucose (BG) ≤ 70 mg/dL, in the 24 h following IV insulin administration for hyperkalemia. RESULTS A total of 134 patients were included; 72 in the D50 group and 62 in the D10 group. There was no difference in incidence of hypoglycemia between the D50 and D10 groups (16 [22%] vs. 16 [26%], p = 0.77). Symptomatic hypoglycemia, severe hypoglycemia, and hyperglycemia rates in the D50 and D10 groups were [5 (7%) vs. 2 (3%), p = 0.45], [5 (7%) vs. 1 (2%), p = 0.22], and [34 (47%) vs. 23 (37%), p = 0.31] respectively. Low initial BG was a predictor for developing hypoglycemia. CONCLUSIONS In our study, D10 infusions appeared to be at least as effective as D50 bolus in preventing hypoglycemia in hyperkalemic patients receiving IV insulin. In context of ongoing D50 injection shortages, D10 infusions should be a therapeutic strategy in this patient population.
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Affiliation(s)
- Irene Yang
- Department of Pharmacy, NYU Langone Health, 550 First Ave, New York, NY 10016, USA.
| | - Samantha Smalley
- Department of Pharmacy, NYU Langone Health, 550 First Ave, New York, NY 10016, USA.
| | - Tania Ahuja
- Department of Pharmacy, NYU Langone Health, 550 First Ave, New York, NY 10016, USA.
| | - Cristian Merchan
- Department of Pharmacy, NYU Langone Health, 550 First Ave, New York, NY 10016, USA.
| | - Silas W Smith
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, 550 First Ave, New York, NY 10016, USA.
| | - John Papadopoulos
- Department of Pharmacy, NYU Langone Health, 550 First Ave, New York, NY 10016, USA.
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14
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Tran AV, Rushakoff RJ, Prasad P, Murray SG, Monash B, Macmaster H. Decreasing Hypoglycemia following Insulin Administration for Inpatient Hyperkalemia. J Hosp Med 2020; 15:368-370. [PMID: 32039749 DOI: 10.12788/jhm.3357] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 11/10/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acute hyperkalemia (serum potassium ≥ 5.1 mEq/L) is often treated with a bolus of IV insulin. This treatment may result in iatrogenic hypoglycemia (glucose < 70 mg/dl). OBJECTIVES The aims of this study were to accurately determine the frequency of iatrogenic hypoglycemia following insulin treatment for hyperkalemia, and to develop an electronic health record (EHR) orderset to decrease the risk for iatrogenic hypoglycemia. DESIGN This study was an observational, prospective study. SETTING The setting for this study was a university hospital. PATIENTS All nonobstetric adult inpatients in all acute and intensive care units were eligible. INTERVENTION Implementation of a hyperkalemia orderset (Orderset 1.1) with glucose checks before and then one, two, four, and six hours after regular intravenous insulin administration. Based on the results from Orderset 1.1, Orderset 1.2 was developed and introduced to include weight-based dosing of insulin options, alerts identifying patients at higher risk of hypoglycemia, and tools to guide decision-making based on the preinsulin blood glucose level. MEASUREMENTS Patient demographics, weight, diabetes history, potassium level, renal function, and glucose levels were recorded before, and then glucose levels were measured again at one, two, four, and six hours after insulin was administered. RESULTS The iatrogenic hypoglycemia rate identified with mandatory glucose checks in Orderset 1.1 was 21%; 92% of these occurred within three hours posttreatment. Risk factors for hypoglycemia included decreased renal function (serum creatinine >2.5 mg/dl), a high dose of insulin (>0.14 units/kg), and re-treatment with blood glucose < 140 mg/dl. After the introduction of Orderset 1.2, the rate of iatrogenic hypoglycemia decreased to 10%. CONCLUSIONS The use of an EHR orderset for treating hyperkalemia may reduce the risk of iatrogenic hypoglycemia in patients receiving insulin while still adequately lowering their potassium.
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Affiliation(s)
- Allen Vinh Tran
- School of Pharmacy, University of California, San Francisco, California
| | - Robert J Rushakoff
- Division of Endocrinology and Metabolism, University of California, San Francisco, California
| | - Priya Prasad
- Division of Hospital Medicine, University of California, San Francisco, California
| | - Sara G Murray
- Division of Hospital Medicine, University of California, San Francisco, California
| | - Bradley Monash
- Division of Hospital Medicine, University of California, San Francisco, California
| | - Heidemarie Macmaster
- Institute for Nursing Excellence, University of California, San Francisco, California, (currently at Lahey Health System, Burlington, Massachusetts
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15
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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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16
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Broz J, Urbanova J, Nunes M, Brabec M, Brunerova L. "Controversies in Management of Hyperkalemia:" Remarks on the Risk of Hyperglycemia. J Emerg Med 2019; 56:458-459. [PMID: 30979404 DOI: 10.1016/j.jemermed.2018.09.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/02/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Jan Broz
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jana Urbanova
- Second Department of Internal Medicine, Center for Research of Diabetes, Metabolism, and Nutrition, Third Faculty of Medicine, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Marisa Nunes
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marek Brabec
- Institute of Computer Science of the ASCR, Prague, Czech Republic
| | - Ludmila Brunerova
- Second Department of Internal Medicine, Center for Research of Diabetes, Metabolism, and Nutrition, Third Faculty of Medicine, Charles University, University Hospital Kralovske Vinohrady, Prague, Czech Republic
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17
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Risks of Hypoglycemia with Insulin Therapy for Hyperkalemia. J Emerg Med 2019; 56:459-460. [DOI: 10.1016/j.jemermed.2018.12.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 12/24/2018] [Indexed: 11/21/2022]
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18
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Dépret F, Peacock WF, Liu KD, Rafique Z, Rossignol P, Legrand M. Management of hyperkalemia in the acutely ill patient. Ann Intensive Care 2019; 9:32. [PMID: 30820692 PMCID: PMC6395464 DOI: 10.1186/s13613-019-0509-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/22/2019] [Indexed: 02/07/2023] Open
Abstract
Purpose To review the mechanisms of action, expected efficacy and side effects of strategies to control hyperkalemia in acutely ill patients. Methods We searched MEDLINE and EMBASE for relevant papers published in English between Jan 1, 1938, and July 1, 2018, in accordance with the PRISMA Statement using the following terms: “hyperkalemia,” “intensive care,” “acute kidney injury,” “acute kidney failure,” “hyperkalemia treatment,” “renal replacement therapy,” “dialysis,” “sodium bicarbonate,” “emergency,” “acute.” Reports from within the past 10 years were selected preferentially, together with highly relevant older publications. Results Hyperkalemia is a potentially life-threatening electrolyte abnormality and may cause cardiac electrophysiological disturbances in the acutely ill patient. Frequently used therapies for hyperkalemia may, however, also be associated with morbidity. Therapeutics may include the simultaneous administration of insulin and glucose (associated with frequent dysglycemic complications), β-2 agonists (associated with potential cardiac ischemia and arrhythmias), hypertonic sodium bicarbonate infusion in the acidotic patient (representing a large hypertonic sodium load) and renal replacement therapy (effective but invasive). Potassium-lowering drugs can cause rapid decrease in serum potassium level leading to cardiac hyperexcitability and rhythm disorders. Conclusions Treatment of hyperkalemia should not only focus on the ability of specific therapies to lower serum potassium level but also on their potential side effects. Tailoring treatment to the patient condition and situation may limit the risks. Electronic supplementary material The online version of this article (10.1186/s13613-019-0509-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- François Dépret
- GH St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, St-Louis Hospital, Assistance Publique-Hopitaux de Paris, Paris, France.,University Paris Diderot, Paris, France.,UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - W Frank Peacock
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kathleen D Liu
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Zubaid Rafique
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Rossignol
- F-CRIN INI-CRCT Network, Vandœuvre-lès-Nancy, France.,CHRU-Nancy, INSERM 1116, Université de Lorraine, CIC Plurithématique 1433, 54000, Nancy, France
| | - Matthieu Legrand
- GH St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, St-Louis Hospital, Assistance Publique-Hopitaux de Paris, Paris, France. .,University Paris Diderot, Paris, France. .,UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France. .,F-CRIN INI-CRCT Network, Vandœuvre-lès-Nancy, France.
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19
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Scott NL, Klein LR, Cales E, Driver BE. Hypoglycemia as a complication of intravenous insulin to treat hyperkalemia in the emergency department. Am J Emerg Med 2019; 37:209-213. [DOI: 10.1016/j.ajem.2018.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/27/2018] [Accepted: 05/09/2018] [Indexed: 10/16/2022] Open
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20
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Jacob BC, Peasah SK, Chan HL, Niculas D, Shogbon Nwaesei A. Hypoglycemia Associated With Insulin Use During Treatment of Hyperkalemia Among Emergency Department Patients. Hosp Pharm 2018; 54:197-202. [PMID: 31205332 DOI: 10.1177/0018578718779012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose: Hypoglycemia is a common adverse event associated with insulin during treatment of hyperkalemia in hospitalized patients; however, limited data exist regarding hypoglycemia incidence and appropriate dosing strategies for treatment of patients in the emergency department. The study objective was to determine the incidence of hypoglycemia associated with insulin use during treatment of hyperkalemia among patients seen in the emergency department. Methods: This was an Institutional Review Board (IRB)-approved retrospective, chart-review study. All adult patients who received intravenous regular insulin as a result of an order from the emergency department hyperkalemia order set were eligible for inclusion. The main clinical outcomes were incidence of hypoglycemia (blood glucose <70 mg/dL) and severe hypoglycemia (blood glucose <40 mg/dL). Blood glucose was checked within 24 hours of insulin administration. Results: A total of 172 patients were included. The incidence of hypoglycemia was 19.8% (n = 34) and the incidence of severe hypoglycemia was 5.2% (n = 9). Hypoglycemic patients had a significantly lower median blood glucose at baseline compared to those who did not develop hypoglycemia (83.5 [72.0-112.0] mg/dL vs 123.0 [96.0-167.0] mg/dL, P < .0001); however, no difference was noted between groups in the average insulin dose administered (0.11 ± 0.04 units/kg vs 0.12 ± 0.05 units/kg, P = .6175). Conclusion: There is a concerning risk of hypoglycemia associated with insulin use during treatment of hyperkalemia in the emergency department. Standard insulin doses may not be appropriate in some cases like patients with lower baseline blood glucose. Further research is warranted to develop safer hyperkalemia treatment protocols that mitigate this high risk of hypoglycemia associated with insulin use.
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Affiliation(s)
| | | | - Hannah L Chan
- University of Alabama at Birmingham Hospital, Birmingham, AL, USA
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21
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Palaka E, Leonard S, Buchanan-Hughes A, Bobrowska A, Langford B, Grandy S. Evidence in support of hyperkalaemia management strategies: A systematic literature review. Int J Clin Pract 2018; 72. [PMID: 29381246 DOI: 10.1111/ijcp.13052] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/06/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Hyperkalaemia is a potentially life-threatening condition that can be managed with pharmacological and non-pharmacological approaches. With the recent development of new hyperkalaemia treatments, new information on safe and effective management of hyperkalaemia has emerged. OBJECTIVES This systematic literature review (SLR) aimed to identify all relevant comparative and non-comparative clinical data on management of hyperkalaemia in adults. Our secondary aim was to assess the feasibility of quantitatively comparing randomised controlled trial (RCT) data on the novel treatment sodium zirconium cyclosilicate (ZS) and established pharmacological treatments for the non-emergency management of hyperkalaemia, such as the cation-exchangers sodium/calcium polystyrene sulphonate (SPS/CPS). METHODS MEDLINE, Embase and the Cochrane Library were searched on 3rd April 2017, with additional hand-searches of key congresses and previous SLRs. Articles were screened by two independent reviewers. Eligible records reported interventional or observational studies of pharmacological or non-pharmacological management of hyperkalaemia in adults. RESULTS Database searches identified 2,073 unique records. Two hundred and one publications were included, reporting 30 RCTs, 29 interventional non-RCTs and 43 observational studies. Interventions investigated in RCTs included ZS (3), SPS/CPS (3), patiromer (4) and combinations of temporising agents (6 RCTs). A robust and meaningful indirect treatment comparison between ZS and long-established cation-binding agents (SPS/CPS) was infeasible because of heterogeneity between studies (including time points and dosing) and small sample size in SPS/CPS studies. CONCLUSIONS Despite hyperkalaemia being associated with several chronic diseases, there is a paucity of high-quality randomised evidence on long-established treatment options (SPS and CPS) and a limited evidence base for hyperkalaemia management with these agents.
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22
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McNicholas BA, Pham MH, Carli K, Chen CH, Colobong-Smith N, Anderson AE, Pham H. Treatment of Hyperkalemia With a Low-Dose Insulin Protocol Is Effective and Results in Reduced Hypoglycemia. Kidney Int Rep 2017; 3:328-336. [PMID: 29725636 PMCID: PMC5932119 DOI: 10.1016/j.ekir.2017.10.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/13/2017] [Accepted: 10/16/2017] [Indexed: 12/26/2022] Open
Abstract
Introduction Complications associated with insulin treatment for hyperkalemia are serious and common. We hypothesize that, in chronic kidney disease (CKD) and end-stage renal disease (ESRD), giving 5 units instead of 10 units of i.v. regular insulin may reduce the risk of causing hypoglycemia when treating hyperkalemia. Methods A retrospective quality improvement study on hyperkalemia management (K+ ≥ 6 mEq/l) from June 2013 through December 2013 was conducted at an urban emergency department center. Electronic medical records were reviewed, and data were extracted on presentation, management of hyperkalemia, incidence and timing of hypoglycemia, and whether treatment was ordered as a protocol through computerized physician order entry (CPOE). We evaluated whether an educational effort to encourage the use of a protocol through CPOE that suggests the use of 5 units might be beneficial for CKD/ESRD patients. A second audit of hyperkalemia management from July 2015 through January 2016 was conducted to assess the effects of intervention on hypoglycemia incidence. Results Treatments ordered using a protocol for hyperkalemia increased following the educational intervention (58 of 78 patients [74%] vs. 62 of 99 patients [62%]), and the number of CKD/ESRD patients prescribed 5 units of insulin as per protocol increased (30 of 32 patients [93%] vs. 32 of 43 [75%], P = .03). Associated with this, the incidence of hypoglycemia associated with insulin treatment was lower (7 of 63 patients [11%] vs. 22 of 76 patients [28%], P = .03), and there were no cases of severe hypoglycemia compared to the 3 cases before the intervention. Conclusion Education on the use of a protocol for hyperkalemia resulted in a reduction in the number of patients with severe hypoglycemia associated with insulin treatment.
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Affiliation(s)
- Bairbre A. McNicholas
- Division of Nephrology, University of Washington, Seattle, Washington, USA
- Department of Intensive Care Medicine, Saolta Hospital Groups, Galway University Hospitals, Newcastle Road, Galway, Ireland
- Correspondence: Bairbre McNicholas, Department of Intensive Care Medicine, Saolta Hospital Groups, Galway University Hospital, Newcastle Road, Galway, H91 YR71, Ireland.
| | - Mai H. Pham
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Katrina Carli
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Chang Huei Chen
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | | | | | - Hien Pham
- Division of Nephrology, University of Washington, Seattle, Washington, USA
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Cruz P, Blackburn MC, Tobin GS. A Systematic Approach for the Prevention and Reduction of Hypoglycemia in Hospitalized Patients. Curr Diab Rep 2017; 17:117. [PMID: 28980145 DOI: 10.1007/s11892-017-0934-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Hypoglycemia and severe hypoglycemia (SH) in the inpatient setting are associated with poor outcomes. This review is designed to highlight approaches to predict and prevent inpatient hypoglycemia that has been successfully implemented focusing on developing overlapping policies and procedures that allow safe glycemic management to occur at all levels of the institution. RECENT FINDINGS Standardizing point-of-care (POC) testing, nursing protocols, meal delivery, and formulary restriction are useful tools to prevent hypoglycemia. Informatics and real-time alert processes are highly effective tools to reduce hypoglycemia but require a significant investment in time and infrastructure as well as clear policies on how alerts are acted upon. Computerized dosing support technology and continuous glucose monitoring (CGM) technology are an emerging area of investigation showing promising results. Inpatient hypoglycemia is often predictable and preventable and requires institutional support to deliver targeted and safe diabetes care. This requires each institution to do periodic reassessment of policies and technologies. Future research needs to focus on the cost/benefits of interventions including studies of automated dosing algorithms as well as CGM in higher-risk patient populations.
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Affiliation(s)
- Paulina Cruz
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, Campus Box 8127, 660 South Euclid Avenue, St. Louis, MO, 63110-1093, USA
| | - Mary Clare Blackburn
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, Campus Box 8127, 660 South Euclid Avenue, St. Louis, MO, 63110-1093, USA
| | - Garry S Tobin
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, Campus Box 8127, 660 South Euclid Avenue, St. Louis, MO, 63110-1093, USA.
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