Insulin in the ED (Part 2): Indications & Dosing

By: Rachel Rafeq, PharmD & Karen O'Brien, DO

Dosing for hyperkalemia

-       10 units of regular insulin IV  why 10 units? Because 10 units decreases K⁺ by 0.6-1.2 mEq/L

-       Be careful of renal failure and making patient hypoglycemic!

o   Give dextrose especially if glucose level <250 prior to giving insulin  an amp (25g) of D50 = overloading body for about 1 hour then get rebound hypoglycemia; also it’s not one size fits all, so D10 or D20 infusion may be better (and you don’t have to draw that viscous stuff up for 5 minutes straight!) 

o   Renal failure (or if they’re female or non-diabetics)? Give 5 units! 

-       Regular insulin lasts in body ~4-6 hours, so check finger sticks hourly for at least 4 hours 

Dosing for DKA/HHNK  be mindful of potassium; usually protocolized by your hospital

-       Aim for K of 4 to be on the safe side

-       Dose: regular insulin 0.1 units/kg/hr infusion 

Dosing for CCB/BB OD

-       10-FOLD INCREASE IN DOSE (compared to DKA dose)! 1unit/kg/hr with max of 10 units/kg/hr

-       Start on dextrose infusion

-       Can do concentrated drip (e.g., 16 units/1 mL) rather than a standard drop of 1 unit/mL to avoid volume overload

Dosing for hyperglycemia

-       Does hyperglycemia at discharge matter? Lots of patients can be managed outpatient

-       Unclear if short term (acute) management of hyperglycemia is beneficial

-       If asymptomatic, probably not worth an admission

-       Two studies looking at target glucose prior to ED discharge

o   >350 mg/dL blood glucose level, do you have to treat? Found that it did not decrease any events over 7 day course of follow up and there were 4/50 patients who had hypoglycemic events after treatment

o   So risk may outweight benefit if asymptomatic 

References

Hirsch IB, Juneja R, Beals JM, Antalis CJ, Wright EE. The Evolution of Insulin and How it Informs Therapy and Treatment Choices. Endocr Rev. 2020;41(5):733-755. doi:10.1210/endrev/bnaa015

Lexicomp Online, Pediatric and Neonatal Lexi-Drugs Online, Hudson, Ohio: UpToDate, Inc.; 2013; April 15, 2013

LaRue HA, Peksa GD, Shah SC. A Comparison of Insulin Doses for the Treatment of Hyperkalemia in Patients with Renal Insufficiency. Pharmacotherapy. 2017;37(12):1516-1522. doi:10.1002/phar.2038

Moussavi K, Nguyen LT, Hua H, Fitter S. Comparison of IV Insulin Dosing Strategies for Hyperkalemia in the Emergency Department. Crit Care Explor. 2020;2(4):e0092. Published 2020 Apr 29. doi:10.1097/CCE.0000000000000092

Laskey D, Vadlapatla R, Hart K. Stability of high-dose insulin in normal saline bags for treatment of calcium channel blocker and beta blocker overdose. Clin Toxicol (Phila). 2016;54(9):829-832. doi:10.1080/15563650.2016.1209766 

Moussavi K, Fitter S, Gabrielson SW, Koyfman A, Long B. Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. J Emerg Med. 2019;57(1):36-42. doi:10.1016/j.jemermed.2019.03.043

Driver BE, Klein LR, Cole JB, Prekker ME, Fagerstrom ET, Miner JR. Comparison of two glycemic discharge goals in ED patients with hyperglycemia, a randomized trial. Am J Emerg Med. 2019;37(7):1295-1300. doi:10.1016/j.ajem.2018.09.053

Driver BE, Olives TD, Bischof JE, Salmen MR, Miner JR. Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. Ann Emerg Med. 2016;68(6):697-705.e3. doi:10.1016/j.annemergmed.2016.04.057

Munoz C, Villanueva G, Fogg L, et al. Impact of a subcutaneous insulin protocol in the emergency department: Rush Emergency Department Hyperglycemia Intervention (REDHI). J Emerg Med. 2011;40(5):493-498. doi:10.1016/j.jemermed.2008.03.017