Acute Crit Care.  2024 Nov;39(4):499-506. 10.4266/acc.2024.00661.

Incidence of hypoglycemia in hyperkalemia patients after treatment with insulin and dextrose in the emergency department of a tertiary care hospital in India: a prospective observational study

• Chaurasia V
• Jamshed N
• Aggrawal P
• Bhoi S
• Ekka M
• Sinha TP
• Kumar A
• Mishra PR
• Das AK

• KMID: 2563538
• DOI: http://doi.org/10.4266/acc.2024.00661

Abstract

Background
Hypoglycemia is a serious, often overlooked complication of treating hyperkalemia with insulin and dextrose. If not recognized and managed, it can increase morbidity and mortality. This study aimed to estimate the incidence of hypoglycemia in hyperkalemic patients treated with 10 units of intravenous insulin, 50 ml of 50% dextrose, 10 ml of 10% calcium gluconate, and salbutamol nebulization. Additionally, the timing of hypoglycemia onset and its associated factors were studied.
Methods
This prospective observational study included hyperkalemic patients (serum potassium >5.5 mmol/L) who visited the emergency department between January 26, 2020, and August 26, 2021. The primary outcome was hypoglycemia (blood glucose <70 mg/dl) within 3 hours of receiving the standard treatment. Glucose levels were measured hourly for 3 hours. Univariate and multivariate logistic regression identified factors associated with hypoglycemia.
Results
Of 100 patients, 69% were male, and the median age was 46 years (IQR, 30–60 years). Hypoglycemia occurred in 44%, and 10% developed severe hypoglycemia (blood glucose <54 mg/dl). The median time for hypoglycemia onset was 2 hours (IQR, 1–2 hours). Low pretreatment blood glucose (<100 mg/dl) was significantly associated with hypoglycemia, according to both univariate and multivariate analyses.
Conclusions
The study found a higher incidence of hypoglycemia in hyperkalemia treatment than reported in retrospective studies, suggesting the need for standardized management protocols with integrated glucose monitoring.

Keyword

dextrose; hyperglycemia; insulin; hyperkalemia; hypoglycemia

Figure

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  Figure 1. Flow of the patients in the study. ED: emergency department.

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  Figure 2. Comorbidity profile of study participants (n=100).

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  Figure 3. Development of hypoglycaemia in study participants (n=100).

Reference

1. Long B, Warix JR, Koyfman A. Controversies in management of hyperkalemia. J Emerg Med. 2018; 55:192–205.

2. Kline JA, Weisberg LS. Acid-base, electrolyte, and metabolic abnormalities. In : Parrillo JE, Dellinger RP, editors. Critical care medicine: principles of diagnosis and management in the adult. Elsevier;2008. p. 1203–43.

3. Mount DB. Disorders of potassium balance. In: Yu AS, Chertow GM, Luyckx V, Marsden A, Skorecki K, Taal MW, editors. Brenner and Rector's the kidney. Elsevier; 2008. p. 547-87.

4. Brown RS. Potassium homeostasis and clinical implications. Am J Med. 1984; 77(5A):3–10.

5. Fischer KF, Lees JA, Newman JH. Hypoglycemia in hospitalized patients: causes and outcomes. N Engl J Med. 1986; 315:1245–50.

6. Gerich JE, Meyer C, Woerle HJ, Stumvoll M. Renal gluconeogenesis: its importance in human glucose homeostasis. Diabetes Care. 2001; 24:382–91.

7. McNicholas BA, Pham MH, Carli K, Chen CH, Colobong-Smith N, Anderson AE, et al. Treatment of hyperkalemia with a low-dose insulin protocol is effective and results in reduced hypoglycemia. Kidney Int Rep. 2017; 3:328–36.

8. Truhlář A, Deakin CD, Soar J, Khalifa GE, Alfonzo A, Bierens JJ, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015; 95:148–201.

9. Tee SA, Devine K, Potts A, Javaid U, Razvi S, Quinton R, et al. Iatrogenic hypoglycaemia following glucose-insulin infusions for the treatment of hyperkalaemia. Clin Endocrinol (Oxf). 2021; 94:176–82.

10. Acker CG, Johnson JP, Palevsky PM, Greenberg A. Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med. 1998; 158:917–24.

11. Brown DR, Brown CC, Delay TA, Hayes GL, Campbell RC. Incidence of hypoglycemia in patients with renal dysfunction treated for hyperkalemia with regular insulin: a single center, retrospective cohort study. Int Arch Clin Pharmacol. 2019; 5:018.

12. Fisch C. Relation of electrolyte disturbances to cardiac arrhythmias. Circulation. 1973; 47:408–19.

13. Schafers S, Naunheim R, Vijayan A, Tobin G. Incidence of hypoglycemia following insulin-based acute stabilization of hyperkalemia treatment. J Hosp Med. 2012; 7:239–42.

14. 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; 37:209–13.

15. 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. 2019; 54:197–202.

16. Boughton CK, Dixon D, Goble E, Burridge A, Cox A, Noble-Bell G, et al. Preventing hypoglycemia following treatment of hyperkalemia in hospitalized patients. J Hosp Med. 2019; 14:284–7.

17. 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. 2020; 37:31–5.

18. Harel Z, Kamel KS. Optimal dose and method of administration of intravenous insulin in the management of emergency hyperkalemia: a systematic review. PLoS One. 2016; 11:e0154963.

19. LaRue HA, Peksa GD, Shah SC. A comparison of insulin doses for the treatment of hyperkalemia in patients with renal insufficiency. Pharmacotherapy. 2017; 37:1516–22.

20. Apel J, Reutrakul S, Baldwin D. Hypoglycemia in the treatment of hyperkalemia with insulin in patients with end-stage renal disease. Clin Kidney J. 2014; 7:248–50.