Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician

Background: Hyperkalemia is a common, potentially lethal clinical condition that accounts for a significant number of emergency department (ED) visits. Insulin and dextrose are frequently used to manage patients with hyperkalemia. Objective: This narrative review evaluates several myths concerning hyperkalemia treatment with insulin and dextrose in the ED and provides recommendations based on the current evidence. Discussion: Hyperkalemia is a life-threatening condition requiring emergent therapy. One of these therapies includes insulin with glucose. However, hypoglycemia after insulin use is a frequent complication during hyperkalemia management. The published literature suggests that low pretreatment glucose, no history of diabetes mellitus, female gender, abnormal renal function, and lower body weight increase the risk of hypoglycemia. Several strategies can reduce the risk of hypoglycemia with insulin therapy, which include using insulin 5 units or 0.1 units/kg instead of 10 units, administering dextrose 50 g instead of 25 g, or administering dextrose as a prolonged infusion instead of a rapid intravenous bolus. 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. Conclusion: Several myths surround hyperkalemia management with insulin and dextrose. This review evaluates the evidence concerning insulin and glucose for hyperkalemia and suggests several modifications to insulin and dextrose dosing to reduce the risk of hypoglycemia.