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Kidney Week

Abstract: TH-PO368

Minimizing Hypoglycemia Associated with Insulin Use for the Treatment of Hyperkalemia in the Inpatient Setting

Session Information

Category: Fluid, Electrolytes, and Acid-Base Disorders

  • 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

  • Batwara, Ruchika, Icahn School of Medicine at Mount Sinai, New York, New York, United States
  • Twomey Brenner, Ciaran A., King's College London, London, United Kingdom
  • Shapiro, Janet M., Icahn School of Medicine at Mount Sinai, New York, New York, United States
Background


Insulin use for hyperkalemia has been linked to hypoglycemia, especially with the commonly used 10 Units of Regular Insulin. However, studies have shown that a lower insulin dose of 5 units is just as effective in reducing potassium levels, with fewer incidences of hypoglycemia. Our Quality Improvement Project aims to establish a standardized Insulin protocol for hyperkalemia treatment across our Health System.

Methods

We searched our hospital's Electronic Health Record database to assess uses of the inbuilt "Hyperkalemia Order Set" within 30 days before and after the intervention. Our analysis considered lab data, Insulin usage, and finger stick glucose (FSG) after Insulin administration. The intervention involved: (A) educating the providers and (B) modifying the Hyperkalemia Order Set to default to 5 Units of Insulin, with up to 10 Units allowed at the provider's discretion. An alert was included with the Insulin order, reminding the provider to adjust the dose for renal impairment.

Results

During the 30-day observation phase, 48 orders were identified for intravenous (IV) Regular Insulin (with IV Dextrose 25 grams, per protocol) in patients with a mean pre-treatment serum potassium of 6.0 Meq/L. Among these orders, 69% prescribed 10 Units of Insulin while 31% prescribed 5-8 units of Insulin. We found 6 documented cases of hypoglycemia (FSG < 60) accounting for 12.5% of all orders. These patients were more likely to have received a higher dose of Insulin (mean Insulin dose = 10.2 Units) and have impaired renal function.
In the post-intervention analysis, 37 orders were identified for IV Regular Insulin over a 30-day period. The mean pre-treatment potassium level was 6.5 Meq/L. Of these orders, 15.7% prescribed 10 Units of Insulin while the remaining 84.3% prescribed 5 units of insulin or less. Notably, three cases of severe hyperkalemia (mean potassium = 7.3 Meq/L) were successfully treated stepwise with 5 Units of Insulin followed by an additional 5 units given after repeating the potassium and glucose level. No cases of hypoglycemia were identified in the post-intervention phase.

Conclusion

Institutions need to have consistent protocols in place for managing hyperkalemia. Lower doses of insulin can effectively treat hyperkalemia while minimizing the risk of hypoglycemia.