Decreasing Incidence of Postinsulin Hypoglycemia for Hyperkalemia Treatment

Acute hyperkalemia (K = 5.1 mEq/L) treatment may include a 10 unit bolus of IV insulin regular. Nationally, this treatment results in a 20% rate of hypoglycemia and a 7% rate of severe hypoglycemia. At UCSF, after introduction of a updated hyperkalemia orderset (Revision a) that standardized blood glucose (BG) POCT pre-insulin administration and post-insulin administration (1, 2, 4, and 6 hours post-insulin), we found 21% of treatments resulted in hypoglycemia (<70 mg/dl) with 92% of these occurring <3 hours of insulin administration. After analysis for independent hypoglycemia risk factors, we further revised the hyperkalemia order set(Revision b) to: 1) weight-based insulin dosing 2) If pre-insulin BG < 50 mg/dL, then add an additional dextrose 50% (50 mL) IV once one-hour post-insulin administration 3) If pre-insulin BG >300 mg/dL, then remove dextrose 50% (50 mL) with insulin administration. There was a significant reduction in both hypoglycemia and severe hypoglycemia following implementation of the Revision b hyperkalemia orderset (Table).

In conclusion, we believe that an EMR hyperkalemia order set can help significantly reduce hypoglycemia events with predefined times for glucose monitoring, weight-based insulin dosing, standard glucose administration guidelines and prompts to warn providers of risks for hypoglycemia. This data supports optimization of glycemic control into the AHA hyperkalemia guidelines.