Assessing the Impact of an Order Panel Utilizing Weight-Based Insulin and Standardized Monitoring of Blood Glucose for Patients With Hyperkalemia

Abstract

Intravenous insulin with glucose is used in urgent treatment for hyperkalemia but has a significant risk of hypoglycemia. The authors developed an order panel within the electronic health record system that utilizes weight-based insulin dosing and standardized blood glucose monitoring to reduce hypoglycemia. As initial evaluation of this protocol, the authors retrospectively compared potassium and blood glucose lowering in patients treated with the weight-based (0.1 units/kg) insulin order panel (n = 195) with those given insulin based on provider judgment (n = 69). Serum potassium lowering did not differ between groups and there was no relationship between dose of insulin and amount of potassium lowering. There was a difference in hypoglycemia rates between groups ( P = .049), with fewer severe hypoglycemic events in the panel (2.56%) than in the non-panel group (10.14%). These data suggest weight-based insulin dosing is equally effective for lowering serum potassium and may lower risk of severe hypoglycemia.

Blood glucose reduction in patients treated with insulin and dextrose for hyperkalaemia

“…The recorded incidence of hypoglycaemia (22%), severe hypoglycaemia (6%) and the median time to detection of hypoglycaemia (108 min) in our study is consistent with previous reports 5 9–13 15–18. The increased prevalence of hypoglycaemia in our sample compared with other cohorts may reflect the exclusion of patients receiving therapies such as dextrose containing intravenous solutions and albuterol that are expected to be protective against the development of hypoglycaemia and were not adequately controlled in previous samples.…”

“…The first one was a small prospective pilot study in nine patients undergoing dialysis which found a similar mean blood glucose reduction of 29±8 mg/dL measured at one hour after the administration of 10 units of intravenous regular insulin plus 25 g intravenous dextrose 7. Another study that reported the change in blood glucose following insulin was recently published by Brown et al 13. It was a single-centre retrospective chart review study evaluating the lowering effect of a weight-based intravenous regular insulin order panel compared with fixed insulin dose, at provider discretion, on the potassium and blood glucose values up to 8 hours following insulin treatment for patients with hyperkalaemia.…”

“…A greater reduction in blood glucose levels occurred 5 hours after the regimen; however, few patients had their blood glucose checked at this time limiting the ability to assess the true change in blood glucose. To our knowledge, the only other study to report glucose changes over time identified mean blood glucose values obtained very early (0–20 min) which were initially >200 mg/dL followed by an apparent decline at 21–60 min which was sustained at >120 min 13. Farina and Anderson retrospectively evaluated the incidence of hypoglycaemia, severe hypoglycaemia and hyperglycaemia at approximately 60 and 240 min following either intravenous 50 g of dextrose or 25 g in addition to 10 units of intravenous insulin lispro to treat hyperkalaemia.…”

“…A small pilot study reported the extent to which blood glucose decreased with the regimen, and the mean blood glucose reduction was found to be 29±7.9 mg/dL but follow-up was limited to only one hour 7. A larger retrospective cohort study of patients receiving insulin dosed according to provider discretion or a weight-based protocol reported the change in blood glucose as a secondary outcome 13. Potential confounders including use of non-basal subcutaneous insulin within 8 hours were present in some patients.…”

Decreasing Hypoglycemia following Insulin Administration for Inpatient Hyperkalemia

“…4,7,9 To decrease the risk of iatrogenic hypoglycemia, we redesigned our hyperkalemia insulin orderset to address the strongest predictors of hypoglycemia (doses of regular insulin greater than 0.14 units/kg and preinsulin blood glucose less than 140 mg/dL). The main changes were weight-based insulin dosing (based on previously published data) 10 and adjustment of glu-cose administration based on the patient's glucose levels. 11 Following these changes, the rates of both hypoglycemia and severe hypoglycemia were statistically significantly reduced.…”