Hypoglycemia as a complication of intravenous insulin to treat hyperkalemia in the emergency department

Scott, Nathaniel L.; Klein, Lauren R.; Cales, Ellen K.

doi:10.1016/j.ajem.2018.05.016

Cited by 29 publications

(35 citation statements)

References 22 publications

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“…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.…”

Section: Discussionsupporting

confidence: 89%

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

et al. 2019

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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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Section: Discussionsupporting

confidence: 89%

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

et al. 2019

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“…These risk factors have been reported in previous studies, although inconsistently. Pretreatment CBG is an important predictor of hypoglycemia following treatment for hyperkalemia and has been observed in patients in the emergency department 12 and in patients with renal impairment. 6,7 In the present study, lower body weight was observed in patients with hypoglycemia compared with those without hypoglycemia.…”

Section: Discussionmentioning

confidence: 99%

Preventing Hypoglycemia Following Treatment of Hyperkalemia in Hospitalized Patients

Boughton

Dixon

Goble

et al. 2019

Journal of Hospital Medicine

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H yperkalemia is common in hospitalized patients, with an estimated prevalence of 1%-10%. 1,2 Hyperkalemia can lead to life-threatening cardiac arrhythmias. The risk of arrhythmias increases with serum potassium values >6.5 mmol/L, and hyperkalemia is associated with increased in-hospital mortality. 3 Treatment for hyperkalemia is indicated by a combination of the absolute serum potassium level, the rate of change of potassium level, and the presence of electrocardiogram abnormalities.Intravenous insulin stimulates the sodium/potassium-ATP pump, leading to intracellular uptake of potassium. Recommendations vary regarding the optimal dosing of insulin and dextrose for the treatment of hyperkalemia. 4 Hypoglycemia is a common complication following treatment of hyperkalemia with insulin/dextrose. The reported incidence in hospitalized patients ranges from 6% to 75% depending on the population studied, the doses of insulin/ dextrose administered, and the definition of hypoglycemia. [5][6][7][8] Hypoglycemia itself is associated with increased morbidity and mortality in hospitalized patients. 9 The aims of this study were to describe the incidence of hypoglycemia following hyperkalemia treatment with intra-venous insulin/dextrose in inpatients in a large (900-bed) UK teaching hospital and to determine the risk factors predisposing to hypoglycemia.

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“…Renal insufficiency leads to decreased insulin clearance, which increases the risk of hypoglycemia 9. A recent study demonstrated that 17% of ED patients who receive insulin for hyperkalemia develop hypoglycemia within three hours 10. The risk of hypoglycemia may be mitigated by administering smaller doses of insulin, larger doses of dextrose, or by more careful monitoring after insulin administration 10.…”

Section: Discussionmentioning

confidence: 99%

“…A recent study demonstrated that 17% of ED patients who receive insulin for hyperkalemia develop hypoglycemia within three hours 10. The risk of hypoglycemia may be mitigated by administering smaller doses of insulin, larger doses of dextrose, or by more careful monitoring after insulin administration 10. With close monitoring even massive doses of insulin can be administered safely, as they are used to treat calcium-channel blocker and beta-blocker poisoning 11.…”

Section: Discussionmentioning

confidence: 99%

Incidence and Causes of Iatrogenic Hypoglycemia in the Emergency Department

Chittineni

Halverson

Cole

et al. 2019

WestJEM

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IntroductionHypoglycemia 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.MethodsWe 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.ResultsWe 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.ConclusionIn 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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Hypoglycemia as a complication of intravenous insulin to treat hyperkalemia in the emergency department

Cited by 29 publications

References 22 publications

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

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

Preventing Hypoglycemia Following Treatment of Hyperkalemia in Hospitalized Patients

Incidence and Causes of Iatrogenic Hypoglycemia in the Emergency Department

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