Insulin-induced Hypoglycemia after Implementing Hyperkalemia Protocol at Emergency Departments: An Updated Systematic Review
DOI:
https://doi.org/10.35516/jmj.v60i1.3263الكلمات المفتاحية:
Adult patients، Emergency Department، Glucose Level، Hyperkalemia، Insulin، Hypoglycemiaالملخص
Background: Addressing the critical gap in managing hyperkalemia in emergency settings, emphasizing the balance between effective potassium reduction and hypoglycemia prevention. The findings highlight the need for standardized protocols and further research to enhance patient safety and treatment efficacy. This review aims to determine the optimal intravenous insulin dose, the necessary dextrose administration, and the appropriate timing for glucose-level monitoring to prevent hypoglycemia in adults undergoing hyperkalemia treatment in emergency departments.
Methods: A systematic review was conducted following PRISMA guidelines. Full-text articles published in English between 2016 and 2024, were selected from MEDLINE (PubMed), Science Direct, CINAHL, Cochrane Database, and Google Scholar. The inclusion criteria comprised studies involving adult patients treated for hyperkalemia in emergency departments, focusing on insulin and dextrose administration protocols. The review was registered on PROSPERO (CRD42023399719). Data extraction and synthesis involved assessing study quality, insulin doses, dextrose administration, and timing of glucose monitoring.
Results: The review included 16 studies, with 11 patients involving renal disease. Hyperkalemia was defined by 12 studies (75%) as a potassium level exceeding 5 mmol/L. The prevalence of hypoglycemia ranged from 15-20%. There was variability in the initial glucose monitoring time post-insulin administration, with 10 studies (63%) opting for a 6-hour mark. The most reported insulin dose to prevent hypoglycemia was 5-10 units. Additionally, 50% of the studies recommended administering 25 g of dextrose (D50%) to prevent hypoglycemia.
Conclusions: Although optimized insulin therapy regimens have shown promise in reducing hypoglycemia risk, effective management of potassium levels remains a challenge. Future research must inform treatment guidelines and clinical practice, ensuring safer and more effective care for hyperkalemia patients.
المراجع
Emektar, E., Acute hyperkalemia in adults. Turk J Emerg Med, 2023. 23(2): p. 75-81.
Chandok, T., et al., Dynamic Changes of EKG by Severe Hyperkalemia: Transient Left Bundle Branch Block. Cureus, 2023. 15(3): p. e36124.
Lindner, G., et al., Acute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference. Eur J Emerg Med, 2020. 27(5): p. 329-337.
Verdier, M., J.M. DeMott, and G.D. Peksa, A comparison of insulin doses for treatment of hyperkalaemia in intensive care unit patients with renal insufficiency. Aust Crit Care, 2022. 35(3): p. 258-263.
Humphrey, T.J.L., et al., Clinical outcomes associated with the emergency treatment of hyperkalaemia with intravenous insulin-dextrose. Eur J Intern Med, 2022. 95: p. 87-92.
Lim, S.H., et al., Evaluation of Care Outcomes of Patients Receiving Hyperkalemia Treatment With Insulin in Acute Care Tertiary Hospital Emergency Department. J Emerg Nurs, 2023. 49(1): p. 99-108.
Kijprasert, W., et al., Predicting hypoglycemia after treatment of hyperkalemia with insulin and glucose (Glu-K60 score). BMC Emerg Med, 2022. 22(1): p. 179.
Chothia, M.Y., et al., Hypoglycaemia due to insulin therapy for the management of hyperkalaemia in hospitalised adults: A scoping review. PLoS One, 2022. 17(5): p. e0268395.
Wang, F., et al., Elevated Fasting Blood Glucose Level Increases the Risk of Cognitive Decline Among Older Adults with Diabetes Mellitus: The Shanghai Aging Study. J Alzheimers Dis, 2019. 67(4): p. 1255-1265.
Chaytor, N.S., et al., Clinically significant cognitive impairment in older adults with type 1 diabetes. J Diabetes Complications, 2019. 33(1): p. 91-97.
Moussavi, K., et al., Comparison of IV Insulin Dosing Strategies for Hyperkalemia in the Emergency Department. Crit Care Explor, 2020. 2(4): p. e0092.
Farina, N. and C. Anderson, Impact of dextrose dose on hypoglycemia development following treatment of hyperkalemia. Ther Adv Drug Saf, 2018. 9(6): p. 323-329.
Chaitman, M., D. Dixit, and M.B. Bridgeman, Potassium-Binding Agents for the Clinical Management of Hyperkalemia. P T, 2016. 41(1): p. 43-50.
Bach, Q.N., et al., Evaluation of Insulin Use and Hypoglycemia in Hospitalized Elderly Patients. Hosp Pharm, 2017. 52(11): p. 761-765.
Aljabri, A.M. and S.A. Alsulami, Frequency of serum blood glucose monitoring after hyperkalaemia treatment using insulin and dextrose. J Taibah Univ Med Sci, 2022. 17(1): p. 82-86.
Monsieurs, K.G., et al., European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation, 2015. 95: p. 1-80.
Dépret, F., et al., Management of hyperkalemia in the acutely ill patient. Ann Intensive Care, 2019. 9(1): p. 32.
Fenger, A.W., et al., Glycaemic control for patients with severe acute brain injury: Protocol for a systematic review. Acta Anaesthesiol Scand, 2023. 67(2): p. 240-247.
Hamed, A.E., et al., Managing diabetes and liver disease association. Arab J Gastroenterol, 2018. 19(4): p. 166-179.
Mortensen, E.M., et al., Association of hypoglycemia with mortality for subjects hospitalized with pneumonia. Am J Med Sci, 2010. 339(3): p. 239-43.
Ahee, P. and A.V. Crowe, The management of hyperkalaemia in the emergency department. J Accid Emerg Med, 2000. 17(3): p. 188-91.
Elliott, M.J., et al., Management of patients with acute hyperkalemia. CMAJ, 2010. 182(15): p. 1631-5.
Mahoney, B.A., et al., Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev, 2005. 2005(2): p. CD003235.
Harel, Z. and K.S. Kamel, Optimal Dose and Method of Administration of Intravenous Insulin in the Management of Emergency Hyperkalemia: A Systematic Review. PLoS One, 2016. 11(5): p. e0154963.
Liberati, A., et al., The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol, 2009. 62(10): p. e1-34.
Aljabri, A., et al., Blood glucose reduction in patients treated with insulin and dextrose for hyperkalaemia. Emerg Med J, 2020. 37(1): p. 31-35.
LaRue, H.A., G.D. Peksa, and S.C. Shah, A Comparison of Insulin Doses for the Treatment of Hyperkalemia in Patients with Renal Insufficiency. Pharmacotherapy, 2017. 37(12): p. 1516-1522.
Garcia, J., et al., Reduced Versus Conventional Dose Insulin for Hyperkalemia Treatment. J Pharm Pract, 2020. 33(3): p. 262-266.
Crnobrnja, L., et al., The Association of Insulin-dextrose Treatment with Hypoglycemia in Patients with Hyperkalemia. Sci Rep, 2020. 10(1): p. 22044.
McNicholas, B.A., et al., Treatment of Hyperkalemia With a Low-Dose Insulin Protocol Is Effective and Results in Reduced Hypoglycemia. Kidney Int Rep, 2018. 3(2): p. 328-336.
Brown, K., et al., Assessing the Impact of an Order Panel Utilizing Weight-Based Insulin and Standardized Monitoring of Blood Glucose for Patients With Hyperkalemia. Am J Med Qual, 2018. 33(6): p. 598-603.
Lui, V.H., Reducing iatrogenic hypoglycemia in hyperkalemic patients treated with insulin therapy with a modified hyperkalemia order set at The Queen’s Medical Center, in nursing. 2019, University of Hawai'i at Manoa: University of Hawai'i at Manoa. p. 32
Keeney, K.P., et al., Assessment of intravenous insulin dosing strategies for the treatment of acute hyperkalemia in the emergency department. Am J Emerg Med, 2020. 38(6): p. 1082-1085.
Coca, A., et al., Hypoglycemia following intravenous insulin plus glucose for hyperkalemia in patients with impaired renal function. PLoS One, 2017. 12(2): p. e0172961.
Jacob, B.C., et al., Hypoglycemia Associated With Insulin Use During Treatment of Hyperkalemia Among Emergency Department Patients. Hosp Pharm, 2019. 54(3): p. 197-202.
Wheeler, D.T., et al., Weight-based insulin dosing for acute hyperkalemia results in less hypoglycemia. J Hosp Med, 2016. 11(5): p. 355-7.
Pearson, S.C., et al., Efficacy of standard- vs reduced-dose insulin for treatment of hyperkalemia: A quasi-experiment. Am J Health Syst Pharm, 2022. 79(Suppl 1): p. S13-S20.
Scott, N.L., et al., Hypoglycemia as a complication of intravenous insulin to treat hyperkalemia in the emergency department. Am J Emerg Med, 2019. 37(2): p. 209-213.
Moussavi, K., et al., Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. J Emerg Med, 2019. 57(1): p. 36-42.
Pearson, I., et al., Emerging responses implemented to prevent and respond to violence against women and children in WHO European member states during the COVID-19 pandemic: a scoping review of online media reports. BMJ Open, 2021. 11(4): p. e045872.
Bilotta, F., et al., Insulin infusion therapy in critical care patients: regular insulin vs short-acting insulin. A prospective, crossover, randomized, multicenter blind study. J Crit Care, 2015. 30(2): p. 437.e1-6.
Zuern, A., et al., Effect of a Standardized Treatment Panel on Hypoglycemic Events in Hospitalized Acute Hyperkalemic Patients Treated With Intravenous Regular Insulin. Hosp Pharm, 2020. 55(4): p. 240-245.
Duranay, M., et al., Comparison of aminophylline and insulin infusions in treatment of hyperkalemia in patients with end-stage renal disease. Nephron, 1996. 73(1): p. 105.
Mahajan, S.K., M. Mangla, and K. Kishore, Comparison of aminophylline and insulin-dextrose infusions in acute therapy of hyperkalemia in end-stage renal disease patients. J Assoc Physicians India, 2001. 49: p. 1082-5.
Li, T. and A. Vijayan, Insulin for the treatment of hyperkalemia: a double-edged sword? Clin Kidney J, 2014. 7(3): p. 239-41.
