Treatment of Hyperkalemia With a Low-Dose Insulin Protocol Is Effective and Results in Reduced Hypoglycemia

Bairbre A McNicholas, Mai H Pham, Katrina Carli, Chang Huei Chen, Nancy Colobong-Smith, Arthur Eric Anderson, Hien Pham, Bairbre A McNicholas, Mai H Pham, Katrina Carli, Chang Huei Chen, Nancy Colobong-Smith, Arthur Eric Anderson, Hien Pham

Abstract

Introduction: Complications associated with insulin treatment for hyperkalemia are serious and common. We hypothesize that, in chronic kidney disease (CKD) and end-stage renal disease (ESRD), giving 5 units instead of 10 units of i.v. regular insulin may reduce the risk of causing hypoglycemia when treating hyperkalemia.

Methods: A retrospective quality improvement study on hyperkalemia management (K+ ≥ 6 mEq/l) from June 2013 through December 2013 was conducted at an urban emergency department center. Electronic medical records were reviewed, and data were extracted on presentation, management of hyperkalemia, incidence and timing of hypoglycemia, and whether treatment was ordered as a protocol through computerized physician order entry (CPOE). We evaluated whether an educational effort to encourage the use of a protocol through CPOE that suggests the use of 5 units might be beneficial for CKD/ESRD patients. A second audit of hyperkalemia management from July 2015 through January 2016 was conducted to assess the effects of intervention on hypoglycemia incidence.

Results: Treatments ordered using a protocol for hyperkalemia increased following the educational intervention (58 of 78 patients [74%] vs. 62 of 99 patients [62%]), and the number of CKD/ESRD patients prescribed 5 units of insulin as per protocol increased (30 of 32 patients [93%] vs. 32 of 43 [75%], P = .03). Associated with this, the incidence of hypoglycemia associated with insulin treatment was lower (7 of 63 patients [11%] vs. 22 of 76 patients [28%], P = .03), and there were no cases of severe hypoglycemia compared to the 3 cases before the intervention.

Conclusion: Education on the use of a protocol for hyperkalemia resulted in a reduction in the number of patients with severe hypoglycemia associated with insulin treatment.

Keywords: adverse events; computerized physician order entry; end-stage renal disease; hyperkalemia; hypoglycemia.

Figures

Figure 1
Figure 1
Flowchart outlining the audit cycle of the intervention. Presentation and management of all patients presenting with hyperkalemia to an emergency department (ED) over two 6-month periods before and after a quality intervention were investigated. Management of hyperkalemia was assessed based on the following: whether it was ordered by protocol using computerized physician order entry (CPOE); number of patients experiencing hypoglycemia (

Figure 2

Outline of management protocol for…

Figure 2

Outline of management protocol for hyperkalemia available for emergency department (ED) providers to…

Figure 2
Outline of management protocol for hyperkalemia available for emergency department (ED) providers to use as part of computerized provider order entry (CPOE) system. This is a summary of the comprehensive protocol for hyperkalemia management available through the CPOE stystem in the ED. The protocol stipulates monitoring of patients, including a facilitating telemetry order and potassium recheck. The protocol indicates a different treatment algorithm based on whether the patient had end-stage renal disease (ESRD) and whether hyperkalemia was emergent (K > 6.5 or K = 5.3−6.4 with electrocardiographic [ECG] changes). Treatment is stratified according to insulin and non−insulin-based therapy with information on the rationale for treatment. Blood glucose (BG) monitoring guidelines after insulin treatment are also provided, with a link to a hypoglycemia management protocol. amps, Ampules; CKD, chronic kidney disease; HD, hemodialysis; POC, point of care; Rx, prescription.
Figure 2
Figure 2
Outline of management protocol for hyperkalemia available for emergency department (ED) providers to use as part of computerized provider order entry (CPOE) system. This is a summary of the comprehensive protocol for hyperkalemia management available through the CPOE stystem in the ED. The protocol stipulates monitoring of patients, including a facilitating telemetry order and potassium recheck. The protocol indicates a different treatment algorithm based on whether the patient had end-stage renal disease (ESRD) and whether hyperkalemia was emergent (K > 6.5 or K = 5.3−6.4 with electrocardiographic [ECG] changes). Treatment is stratified according to insulin and non−insulin-based therapy with information on the rationale for treatment. Blood glucose (BG) monitoring guidelines after insulin treatment are also provided, with a link to a hypoglycemia management protocol. amps, Ampules; CKD, chronic kidney disease; HD, hemodialysis; POC, point of care; Rx, prescription.

References

    1. Pfortmüller C.A., Leichtle A.B., Fiedler G.M. Hyperkalemia in the emergency department: etiology, symptoms and outcome of a life threatening electrolyte disorder. Eur J Intern Med. 2013;24:e59–e60.
    1. Fischer K.F., Lees J.A., Newman J.H. Hypoglycemia in hospitalized patients. Causes and outcomes. N Engl J Med. 1986;315:1245–1250.
    1. National Institute of Diabetes and Digestive and Kidney Diseases. US Renal Data System, 2006 Annual Data Report. Bethesda, MD: 2006.
    1. Conway R., Creagh D., Byrne D.G. Serum potassium levels as an outcome determinant in acute medical admissions. Clin Med (Lond) 2015;15:239–243.
    1. Phillips B.M., Milner S., Zouwail S. Severe hyperkalemia: demographics and outcome. Clin Kidney J. 2014;7:127–133.
    1. An J.N., Lee J.P., Jeon H.J. Severe hyperkalemia requiring hospitalization: predictors of mortality. Crit Care. 2012;16:R225.
    1. Wang C.H., Huang C.H., Chang W.T. The effects of calcium and sodium bicarbonate on severe hyperkalemia during cardiopulmonary resuscitation: a retrospective cohort study of adult in-hospital cardiac arrest. Resuscitation. 2016;98:105–111.
    1. Kovesdy C.P. Management of hyperkalemia in chronic kidney disease. Nat Rev Nephrol. 2014;10:653–662.
    1. Sterns R.H., Grieff M., Bernstein P.L. Treatment of hyperkalemia: something old, something new. Kidney Int. 2016;89:546–554.
    1. Gutzwiller J.P., Schneditz D., Huber A.R. Increasing blood flow increases kt/V(urea) and potassium removal but fails to improve phosphate removal. Clin Nephrol. 2003;59:130–136.
    1. Ellison D.H., Terker A.S., Gamba G. Potassium and its discontents: new insight, new treatments. J Am Soc Nephrol. 2016;27:981–989.
    1. Blumberg A., Weidmann P., Shaw S., Gnädinger M. Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure. Am J Med. 1988;85:507–512.
    1. Schafers S., Naunheim R., Vijayan A., Tobin G. Incidence of hypoglycemia following insulin-based acute stabilization of hyperkalemia treatment. J Hosp Med. 2012;7:239–242.
    1. 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;7:248–250.
    1. Iglesias P., Díez J.J. Insulin therapy in renal disease. Diabetes Obes Metab. 2008;10:811–823.
    1. Nguyen T.Q., Maalouf N.M., Sakhee K., Moe O.W. Comparison of insulin action on glucose versus potassium uptake in humans. Clin J Am Soc Nephrol. 2011;6:1533–1539.
    1. Coca A., Valencia A.L., Bustamante J. Hypoglycemia following intravenous insulin plus glucose for hyperkalemia in patients with impaired renal function. PLoS One. 2017;12:e0172961.
    1. Janjua H.S., Mahan J.D., Patel H.P. Continuous infusion of a standard combination solution in the management of hyperkalemia. Nephrol Dial Transplant. 2011;26:2503–2508.
    1. Allon M., Copkney C. Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients. Kidney Int. 1990;38:869–872.
    1. Wheeler D.T., Schafers S.J., Horwedel T.A. Weight-based insulin dosing for acute hyperkalemia results in less hypoglycemia. J Hosp Med. 2016;11:355–357.
    1. Rajendran R., Rayman G. Serious harm from inpatient hypoglycemia: a survey of hospitals in the UK. Diabet Med. 2014;31:1218–1221.
    1. Syed S., Wang D., Goulard D. Computer order entry systems in the emergency department significantly reduce the time to medication delivery for high acuity patients. Int J Emerg Med. 2013;6:20.
    1. Maslove D.M., Rizk N., Lowe H.J. Computerized physician order entry in the critical care environment: a review of current literature. J Intensive Care Med. 2011;26:165–171.
    1. Stone W.M., Smith B.E., Shaft J.D. Impact of a computerized physician order-entry system. J Am Coll Surg. 2009;208:960–967. [discussion 967–969]
    1. Chin H.L., Wallace P. Embedding guidelines into direct physician order entry: simple methods, powerful results. Proc AMIA Symp. 1999:221–225.
    1. Seaquist E.R., Anderson J., Childs B. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care. 2013;36:1384–1395.
    1. Chothia M.Y., Halperin M.L., Rensburg M.A. Bolus administration of intravenous glucose in the treatment of hyperkalemia: a randomized controlled trial. Nephron Physiol. 2014;126:1–8.
    1. Kim H.J. Combined effect of bicarbonate and insulin with glucose in acute therapy of hyperkalemia in end-stage renal disease patients. Nephron. 1996;72:476–482.
    1. Pierce D.A., Russell G., Pirkle J.L. Incidence of hypoglycemia in patients with low eGFR treated with insulin and dextrose for hyperkalemia. Ann Pharmacother. 2015;49:1322–1326.
    1. Harel Z., Kamel K.S. Optimal dose and method of administration of intravenous insulin in the management of emergency hyperkalemia: a systematic review. PLoS One. 2016;11:e0154963.
    1. Conte G., Dal Canton A., Imperatore P. Acute increase in plasma osmolality as a cause of hyperkalemia in patients with renal failure. Kidney Int. 1990;38:301–307.
    1. Palmer B.F. Regulation of potassium homeostasis. Clin J Am Soc Nephrol. 2015;10:1050–1060.
    1. Packham D.K., Rasmussen H.S., Lavin P.T. Sodium zirconium cyclosilicate in hyperkalemia. N Engl J Med. 2015;372:222–231.
    1. Kalantar-Zadeh K., Ikizler T.A., Block G. Malnutrition-inflammation complex syndrome in dialysis patients: causes and consequences. Am J Kidney Dis. 2003;42:864–881.
    1. Patterson C.C., Dahlquist G., Harjutsalo V. Early mortality in EURODIAB population-based cohorts of type 1 diabetes diagnosed in childhood since 1989. Diabetologia. 2007;50:2439–2442.
    1. Skrivarhaug T., Bangstad H.J., Stene L.C. Long-term mortality in a nationwide cohort of childhood-onset type 1 diabetic patients in Norway. Diabetologia. 2006;49:298–305.
    1. Gerstein H.C., Miller M.E., Byington R.P. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358:2545–2559.
    1. Cryer P.E. Death during intensive glycemic therapy of diabetes: mechanisms and implications. Am J Med. 2011;124:993–996.
    1. Di Lullo L., Rivera R., Barbera V. Sudden cardiac death and chronic kidney disease: from pathophysiology to treatment strategies. Int J Cardiol. 2016;217:16–27.
    1. Acker C.G., Johnson J.P., Palevsky P.M., 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;158:917–924.

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