If 24-hour pharmacy service is not available, stock hyperkalemia treatment kits on patient care units in automated dispensing cabinets (ADCs). For the other 99% of the time, good old-fashioned IV insulin is the way to go. Efficacy of albuterol inhalation in treatment of hyperkalemia in premature neonates. Please enable it to take advantage of the complete set of features! Emergency Treatments. Hyperkalemia, or high serum levels of potassium above normal range, is an electrolyte imbalance that can cause serious and lethal cardiac arrhythmias. Hyperkalemia is a common clinical problem that is most often a result of impaired urinary potassium excretion due to acute or chronic kidney disease (CKD) and/or disorders or drugs that inhibit the renin-angiotensin-aldosterone system (RAAS). Acute hyperkalemia is a clinical emergency that requires immediate treatment with the agents discussed below (TABLE 1).IV Calcium: IV calcium is indicated when the serum potassium is >6.5 mEq/L regardless of whether ECG changes are present.6 Given their poor sensitivity and specificity, ECG changes should not be used as diagnostic criteria for treatment of hyperkalemia.7 The immediate goal of acute management in hyperkalemi… This was sometimes caused by an automatic default to the subcutaneous route for routine insulin pre- scribed outside of standard order sets that had been developed for IV insulin. [Continuous subcutaneous insulin infusion]. Some episodes of hypoglycemia have also been caused by administering only the insulin portion of the treatment and not the glucose component.2, Delays. Hyperkalemia is a life-threatening condition that requires prompt management in the ED. Acta Paediatr Taiwan;40:314–8. Some organizations use a rapid-acting insulin (i.e., insulin aspart, insulin lispro) rather than short-acting insulin (i.e., regular insulin) because it may decrease the incidence of hypoglycemia, given its shorter half-life.1, When treating hyperkalemia, the potential for errors and patient harm is significant due to the urgency of the treatment, the difficulty in measuring and administering bolus doses of IV insulin, and the risk of treatment-induced hypoglycemia. Treat at threshold. Lawes S, Gaunt M, Grissinger M. Treating hyperkalemia: avoiding additional harm when using insulin and dextrose. The pharmacy dispensed a 3 mL vial of U-100 regular insulin without clarification that only 0.1 mL would be needed for a 10 unit dose. regular insulin and 5 (6%) with subcutaneous regular insulin. Although hyperkalemia is a medical emergency, the administration of insulin, in most circumstances, can wait until a pharmacist prepares a stat dose. Most insulin syringes in hospitals have an attached needle appropriate for subcutaneous administration of medications. Insulin remains one of the cornerstones of early severe hyperkalemia management. Would you like email updates of new search results? If transfer to another unit is necessary, accomplish the handoff as soon as possible so treatment can begin. Treatment of type I diabetic with subcutaneous insulin resistance by a totally implantable insulin infusion device ("Infusaid"). Covariates included time and date of insulin administration; blood glucose levels before and at one, two, four, and six hours after insulin injection (if available); sex; weight; dose of insulin given for hyperkalemia treatment; creatinine; known diagnosis of diabetes; concomitant use of albuterol; and concomitant use of corticosteroids. Standard order sets. Hypoglycemia may occur up to 6 hours after dextrose and insulin administration, especially if the patient has renal dysfunction.1,5. Clipboard, Search History, and several other advanced features are temporarily unavailable. potential for errors and patient harm is significant due to the urgency of the treatment Other medications needed for hyperkalemia treatment can typically be obtained from a code cart or ADC but may be provided in the kit if necessary. When the procedure had been completed, a resident went to the pharmacy to request the medications needed for hyperkalemia treatment, including 10 units of regular insulin. BD and Monoject offer these syringes; for an example, click here. Insulin is used in the treatment of hyperkalemia Hyperkalemia is a condition in which the levels of potassium in the bloodstream are abnormally high. Hyperkalaemia can occur rapidly in patients who are treated with short acting insulin only. In a 2011 analysis, we found that human error (e.g., mental slips, lapses, forgetfulness) associated with insulin dose measurement and hyperkalemia treatment was a predominant cause of dosing errors.2. Am J Med. On two occasions during his hospital admissions he had a rapid onset of hyperkalaemia after short interruptions to this intravenous insulin infusion. Also, some hospitals may use insulin pens for subcutaneous insulin delivery, so newer nurses may be unfamiliar with drawing up insulin from a vial with an insulin syringe. Hyperkalemia is typically corrected with one or more intravenous (IV) doses of 50% dextrose and an IV bolus dose of 10 units of rapid-acting insulin or short- Insulin works via a complex process to temporarily shift potassium intracellularly. There are many causes for hyperkalemia, mostly related to kidney disease because this organ helps control the levels of potassium in the body, and to hormonal causes. J Emerg Med 2019; 57:36. Double check. However, at the crux of many of these errors is the lack of a luer-compatible insulin syringe without a needle that can be used to measure and administer IV insulin via needleless access devices and lines. [64945] Intravenous dosage (continuous infusion) Adults. 2004 Sep 1;117(5):291-6. doi: 10.1016/j.amjmed.2004.05.010. Carefully evaluate whether luer-compatible needleless insulin syringes are needed in certain patient care units (e.g., critical care, emergency department). Horsham, PA 19044. Management of hyperkalemia is outlined in Table 2. Umpierrez GE, Latif K, Stoever J, Cuervo R, Park L, Freire AX, E Kitabchi A. Insulin remains one of the cornerstones of early severe hyperkalemia management. Hypoglycemia and ketoacidosis with insulin pump therapy in children and adolescents. These reminders should also appear on the medication administration record. Apel J, Reutrakul S, Baldwin D. Hypoglycemia in the treatment of hyperkalemia with insulin in patients with end-stage renal disease. Although the effects of hyperkalemia can be detected on an EKG as peaked T waves, a prolonged PR-interval, and a widened QRS-interval,1 an EKG is a poor indicator of hyperkalemia severity; thus, patients with hyperkalemia who meet criteria for treatment based on their potassium level should be treated without delay even in the absence of EKG changes, because even benign changes can quickly progress to lethal arrhythmias.3, Wrong route. On the day of the procedure, her potassium level was 5.9 mmol/L, and she was treated with KAYEXALATE (sodium polystyrene sulfonate). J Pediatr. Ensure adequate monitoring of glucose levels and signs and symptoms of hypoglycemia during treatment, even if dextrose is being administered, and for several hours after insulin administration. Luer-compatible insulin syringes. Insulin, beta-2 agonists, and bicarbonate accelerate the movement of potassium into muscle cells, and these agents are widely used to treat “severe” hyperkalemia. The patient was transferred to an intensive care unit (ICU) and able to tolerate meals with carbohydrates to provide a more physiological delivery of glucose. Insulin mechanism of action in hyperkalemia14,15 Insulin causes an intracellular shift of potassium by stimulating Na + -H + antiporters, promoting sodium influx. Usually this is ordered as 10 units of regular insulin IV and 1 … Also acts to minimise the hypoglycaemic effect of insulin. J Am Soc Nephrol 1995; 6:1134. In the protocols, also specify the insulin type, dose, and route of administration, and how to flush the IV line or access site, if necessary, to ensure the small volume of insulin has been fully administered; the concomitant dextrose concentration, volume, and route of administration; and specific doses and administration for all other pharmacological interventions (e.g., sodium bicarbonate, calcium chloride/gluconate, furosemide). Most dosing errors have involved measuring insulin doses in mL instead of units (e.g., 10 mL instead of 10 units), misreading the measurement markings on syringes, and not understanding the differences between insulin syringes and other parenteral syringes. Management of severe hyperkalemia Lawrence S. Weisberg, MD H yperkalemia is common in hospitalized patients, and may be associated with ad-verse clinical outcomes (1, 2). A 2017 analysis of almost 200 adverse events associated with hyperkalemia treatment showed that delayed treatment and administration of insulin by the wrong route or the wrong dose (mostly overdoses) were the most common types of errors.1 The analysis also showed that, despite the administration of dextrose, hypoglycemia was still a relatively common occurrence often linked to the variability in dextrose and insulin dosing, the type of insulin used, duration of the dextrose and insulin infusion, the sequence of administering the dextrose and insulin, and patient factors such as renal dysfunction. glucose/insulin. Nebulized albuterol is effective at moving potassium inside cells, but the necessary dose of 20 mg is not practical to give. Most delays have occurred because treatment was postponed until patients were transferred to another unit, or there were no immediate signs of changes on a patient’s electrocardiogram (EKG). IV insulin infusion uses a simple algorithm to maintain glycemic control over a wide range of insulin requirements. Though insulin certainly lowers plasma potassium concentrations, we often underestimate the hypoglycemic potential of a 10 unit IV insulin dose in this setting. Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. ©2021 Institute for Safe Medication Practices. If the syringes are made available in certain units, separate their storage from other insulin and parenteral syringes (e.g., stock only in code carts, away from other syringes) so they are less likely to be inadvertently mixed up, and ensure they are not automatically removed from stock due to low use. The two routes have drastic differences in pharmacokinetics as shown below (Table 3): Don’t assume that all practitioners are knowledgeable and skilled with measuring doses and administering IV insulin. Insulin should be given IV when treating hyperkalemia to promote consistent bioavailability.1,4, Dosing errors. Though insulin certainly lowers plasma potassium concentrations, we often underestimate the hypoglycemic potential of a 10 unit IV insulin dose in this setting. One of the most common treatment options is the administration of insulin and glucose to help shift potassium into the cell temporarily. Another event appeared in recent literature involving a medical resident working in interventional radiology (IR) who gave the wrong dose of insulin to a hemodialysis patient with hyperkalemia.3 The hospitalized patient was scheduled for replacement of her dialysis access in IR. These medications include: IV insulin and glucose; IV … Some dosing errors have occurred because practitioners failed to recognize that the U-100 strength of insulin equates to 100 units in each mL, and they were either practicing outside of their scope of practice or had never been taught to administer insulin IV.2,3 Providing the required insulin in vials rather than the exact dose, particularly without directions for measuring the dose, has also contributed to errors. National Library of Medicine Consider intravenous salbutamol 500micrograms slowly over 20min. Hyperglycemia was defined as glucose >180 mg/dL. More than a quarter (28.8%) of reports mentioned hypoglycemia after treatment with insulin for hyperkalemia. The way to do that is glucose and insulin. The patient was treated with a 10% dextrose infusion along with 4 bolus doses of 50% dextrose in the first 30 minutes, and then dialysis. May be ineffective if used alone in 12-40% of patients. The nurse calculated that she would need 0.1 mL of the insulin for the 10 unit dose, and a nurse manager verified the calculation. In one study of the use of 10 units regular insulin with 25 g dextrose for the treatment of hyperkalemia in patients with ESRD, 9 of 12 (75%) of the patients had a blood glucose <3.1 mmol/L (55 mg/dL) 1 h … HHS is much less common than DKA (2,3). Treatment should only be prescribed using a standard order set that is automatically populated with the correct dose and route of administration for the required medications, including insulin. Clearly define the scope of practice for practitioners that allows or disallows IV insulin administration, and restrict insulin preparation and/or administration to those who have demonstrated competency. COVID-19 is an emerging, rapidly evolving situation. The kits should contain 50% dextrose injection along with a 3 mL vial of rapid- or short-acting insulin (to lessen the potential amount of insulin a patient could receive in error), a luer-compatible insulin syringe, a removable needle or transfer device to withdraw the insulin from the vial to the syringe, a label for the syringe (to apply after preparation but before administration), a vial or syringe of a compatible flush solution, alcohol swabs, and directions for preparing and administering the dose. Due to the risk of inadvertent use for subcutaneous insulin doses that could then be accidentally administered IV, limiting use of these syringes for pharmacy-dispensed insulin doses or in hyperkalemia kits is preferred. While subcutaneous insulin does appear to be a safe and effective alternative to continuous IV insulin in the management of DKA, its benefit is much less apparent. Have pharmacy prepare, label, and dispense IV insulin doses in a ready-to-use form, either in a luer-compatible insulin syringe that can connect to a needleless system, or diluted in a small minibag. Recently, salbutamol has been advocated as equivalent to insulin and glucose with the advantage of nebulisation as an option. In these cases, the prescriber did not use the hyperkalemia order set to prescribe the insulin, or no such order set existed. Campbell IW, Kritz H, Najemnik C, Hagmueller G, Irsigler K. Pediatr Diabetes. Insulin was used in 76 patients (76%), of whom 71 (94%) were treated with i.v. Moussavi K, Fitter S, Gabrielson SW, et al. However, IV administration of regular insulin is a go-to agent for hyperkalemia and DKA. Insulin and glucose is the current standard acute treatment. We report a case of a previously stable Type 1 insulin-dependent diabetic who developed diabetic ketoacidosis with marked hyperkalaemia after starting continuous subcutaneous insulin infusion for neuropathy. Conclusion: Several myths surround hyperkalemia management with insulin and dextrose. Unable to load your collection due to an error, Unable to load your delegates due to an error. Hyperkalemia is a serious, potentially lethal electrolyte disturbance that requires medical treatment without delay if it is severe enough to cause disturbances in cardiac conduction. This has resulted in several unsafe practices, including: 1) distribution of hyperkalemia treatment kits that, instead of insulin syringes without a needle, contain a tuberculin syringe and vial of rapid- or short-acting insulin; 2) calculating the volume of insulin needed for each dose so a luer-compatible (non-insulin) syringe can be used for administration, which has resulted in calculation and measurement errors; and 3) measuring doses in an insulin syringe, and then transferring the dose to a parenteral syringe for IV administration, which can lead to dose inaccuracies and infection control breaches. Institute for Safe Medication Practices In other cases, the IV insulin was mistakenly administered subcutaneously, perhaps because it was a more familiar route of administration. For example, just this month, we learned about an error in which a nurse correctly calculated the volume needed for a 10 unit dose of insulin lispro, but accidentally measured out 20 units of insulin using a 10 mL non-insulin syringe. High dose nebulized albuterol. He had little prior experience measuring and preparing insulin doses since medication administration of this type was not within his scope of practice. 2002 ;141:16–20. Treatment with subcutaneous insulin lispro has been shown to be an effective alternative to the use of intravenous regular insulin in the treatment of mild and moderate DKA; however, patients with severe DKA should be managed with intravenous insulin infusion in the ICU. Subcutaneous regular human insulin: 0.1 unit/kg subcutaneously every 1 to 2 hours; when blood glucose is less than 250 mg/dL (14 mmol/L), give glucose-containing fluids orally and reduce insulin to 0.05 unit/kg subcutaneously as needed to keep blood glucose around 200 mg/dL (11 mmol/L) until resolution of DKA. Reduction of severe hypoglycemic events in type I (insulin dependent) diabetic patients using continuous subcutaneous insulin infusion. Though insulin certainly lowers plasma potassium concentrations, we often underestimate the hypoglycemic potential of a 10 unit IV insulin dose in this setting. But hyperkalemia can affect your heart and other parts of your body, so it’s important to treat it. Glucose and insulin infusion versus kayexalate for the early treatment of non-oliguric hyperkalemia in very-low-birth-weight infants. Hyperkalemia is a potentially life-threatening metabolic problem caused by inability of the kidneys to excrete potassium, impairment of the mechanisms that … Also, some hospitals are only using insulin pens, which are likewise an inappropriate device to measure and administer IV insulin doses via a needleless system. Some insulin wrong route errors have occurred during order entry when IV insulin was prescribed by the subcutaneous route. The patient’s blood glucose was monitored, and she experienced no adverse effects. Allon M. Hyperkalemia in end-stage renal disease: mechanisms and management. Glucose and potassium levels stabilized, and the patient was transferred out of the ICU within 2 days. Establish standard hyperkalemia protocols that specify the threshold for treatment based on severity (e.g., potassium level above which to act), the corresponding pharmacological and clinical interventions, and monitoring parameters to gauge the patient’s response to the treatment. Volume deficit was repaired with 10-ml/kg aliquots of 0.9% sodium chloride. Its prevalence and clinical impact in critically ill patients are unknown. Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis. FOIA Treatment protocols. Careers. Education. This was sometimes caused by an automatic default to the subcutaneous route for routine insulin prescribed outside of standard order sets that had been developed for IV insulin. But the first syringe marking was actually 0.2 mL. Hewitt DB, Barnard C, Bilimoria KY. Insulin dosing error in a patient with severe hyperkalemia. 5: Singh BS, Sadiq HF, Noguchi A, Keenan WJ. This site needs JavaScript to work properly. Hyperkalemia treatment with intravenous insulin has been associated with hypoglycemia. The error was quickly discovered when a clinical nurse specialist asked the nurse, who had just completed orientation, to demonstrate how she had measured the insulin dose in a 10 mL syringe. INTRODUCTION. Kes P. Hyperkalemia: a potentially lethal clinical condition. Therefore, βAR agonists are used in the treatment of patients with hyperkalemia. Bethesda, MD 20894, Copyright Insulin works via a complex process to temporarily shift potassium intracellularly. 200 Lakeside Drive, Suite 200 Because insulin may have a duration of action that exceeds dextrose, patients receiving insulin for hyperkalemia should be monitored for hypoglycemia hourly for at least 4-6 h after administration. Of the 132 charts randomly selected for review, … The idea of trating hyperkalemia (remember, that's high K+ in the blood) is to move it out of the blood and back on the other side of the cell membranes where most of the body's K+ belongs. REFERENCES. A physician prescribed treatment that included calcium gluconate 1 g IV, insulin lispro 10 units IV, and dextrose 50% IV. A total of 198 events involving insulin and dextrose for treating hyperkalemia were identified by analysts in reports submitted to the Pennsylvania Patient Safety Authority between January 1, 2005, and December 31, 2016. This single‐center, retrospective study compared the effects on hypoglycemia between weight‐based insulin dosing (0.1 U/kg of body weight up to a maximum of 10 U) compared to standard flat doses of 10 U among patients weighing less than 95 kg. The nurse manager did not verify the dose in the syringe prior to administration. when IV insulin was prescribed by the subcutaneous route. When the dosing error was identified, a rapid response team was called. Either way, it is prudent to check a fingerstick 1 hour after giving IV insulin+dextrose to treat hyperkalemia. Despite dextrose with insulin, hypoglycemia is a recognized complication of this treatment. A repeat potassium level was drawn, and the result, 6.9 mmol/L, was reported to IR during the procedure. h −1; CIRI group). If the insulin dose is to be administered IV push via a syringe, include on the order set a reminder to use a luer-compatible insulin syringe without a needle, and to flush the line or access site if necessary to ensure the small volume of insulin has been fully administered. Require an independent double check of all IV insulin doses to confirm the patient and the insulin type, concentration, dose, amount in the syringe, route of administration, and indication prior to administration. Its use will likely remain relegated to situations where an insulin drip is simply not possible. Several recent insulin errors during hyperkalemia treatment have been reported to ISMP or have appeared in the literature. Create standard order sets for hyperkalemia treatment and require their use. 8600 Rockville Pike Prevention and treatment information (HHS). Using a 10 mL syringe, she drew the insulin lispro into the syringe up to the first gradation mark, believing this represented 0.1 mL. Treatment of hyperkalemia with insulin and dextrose, without implementing clear protocols and error-reduction strategies, can lead to hypoglycemia and other patient harm. In all, 20 patients (26%) received 10 units, 1 (1.3%) patient received 8 units, and 55 patients (72.3%) received 5 units of regular insulin. 2006 Aug;7 Suppl 4:32-8. doi: 10.1111/j.1399-543X.2006.00169.x. Do not delay treatment of hyperkalemia based on the absence of symptoms or EKG changes once an established severity threshold for treatment has been reached. Risk factors for DKA include new diagnosis of diabetes mellitus, insulin omission, infection, myocardial infarction (MI), abdominal crisis, trauma and, possibly, continuous subcutaneous insulin infusion (CSII) therapy, thyrotoxicosis, cocaine, atypical antipsychotics and, possibly, interferon. Eichner HL, Selam JL, Holleman CB, Worcester BR, Turner DS, Charles MA. Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment, Medication Safety Officers Society (MSOS). Abstract We report a case of a previously stable Type 1 insulin-dependent diabetic who developed diabetic ketoacidosis with marked hyperkalaemia after starting continuous subcutaneous insulin infusion for neuropathy. Privacy, Help 20 mg is 4 to 8 times the usual dose for asthma. Accessibility The resident mistakenly administered the entire vial of insulin (300 units) instead of 10 units. Subcutaneous route of administration is a mainstay for insulin. Increased intracellular sodium concentrations trigger the activation of the Na + -K + ATPase transporter, which exchanges intracellular sodium for extracellular potassium. Regular insulin is a short-acting insulin that may be administered by subcutaneous, intramuscular or intravenous injection.2 When delivered intravenously, the onset of its hypoglycemic action is immediate.3 However, when regular insulin is given by the subcutaneous route, the onset of hypoglycemic action Although hyperkalemia treatment guidelines in the literature vary,1 many organizations begin treatment with the administration of one or more intravenous (IV) bolus doses of 50% dextrose and an IV bolus dose of 10 units of insulin. The goal of this study is to evaluate the utility of weight-based subcutaneous terbutaline dosing to reduce plasma potassium concentrations in a group of subjects with chronic …
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