Back to Basics: Insulin in the ED (Part 2)


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 



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