Hyperkalemia and order of meds

Specialties Emergency

Published

Okay, your patient's K+ is 7.2, and he is in ARF. You have orders to give him calcium chloride, sodium bicarb, insulin and D50. What order do you give these meds in? I always put the calcium in a 50 cc ns bag and run it over 5 minutes, then give D50, then insulin IV, then the bicarb. I always thought you wanted to calm the heart and protect it from the high K first, then take care of the K. Another nurse is saying to give the insulin, then the D50, then the calcium chloride, then the bicarb. What do you do? Thanks for any replies:)

Specializes in CCT.
I just read you should give insulin then glucose. Insulin transports K across the cell wall...then glucose is given to prevent hypoglycemia 2ndary to insulin. The dextrose will decrease the action of insulin on K so give dextrose last

Is there anyone who's not giving them darn near simultaneously?

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Specializes in Med Surg, ER, OR.

We give them essentially back to back. I never want to start pushing insulin unless I know I have a good enough IV for a round of d50! Necrotizing and hate not knowing I have a good IV here!

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Specializes in Emergency, Critical Care Transport.

I just remember "B-DIK" or "C-BDIK" (oh say it out loud and you won't forget it).

Calcium, bicarb, dextrose, insulin, kayexalate. C-BDIK.

:D

Say it 3 times fast and try not to laugh.

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I have never heard this acronym before and I have to say I will never forget it now!!!

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I have to say... I have never heard this acronym before, and I will never forget it now!!!

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Specializes in ED.

Had one with 7.7, HR in 30-40's, a P wave once every 7-8 beats. Gave Ca, then HCO3, D50, insulin, kayex, then for her first dialysis. Her only complaint was I wouldn't let her eat. EKG never changed.

It sucked chasing her K on Thanksgiving.

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I know this post is really old, but here's my 2 cents from the icu perspective. (From a trauma I major university hospital).

In an emergent situation, give calcium first, followed by d50/regular insulin: usually 1amp to 10 units. IV insulin has an onset of minutes whereas glucose has an onset of

Its been said in here to give glucose first in case you lose access... This is false sense of security : "Do not give glucose alone as hyperosmolarity can shift potassium out of cells."(reference 3) And you could end up with a higher K than when you started, which is bad for the heart, the body's life organ. While giving insulin IV alone has its downside, so does the faster onset d50. If in doubt about access because you only have one 22g that has been in for days, I would mix the regular insulin in the d50 and give TOGETHER.

as far as the mechanism, there are mixed comments in here.the correct answer is this:

in a normal patient, k+ is intracellular and Na+ is extracellular. When the serum k+ is elevated, it is because there is an increased amount of K+ outside of the cell. This can be caused from CRF or ARF, burns, crush injuries, or even the use of too much potassium salts (cardiac patients on a low Na+ diet).

Insulin isn't to prevent the patients blood sugar from elevating or d50 from falling, both incorrect conclusions. The correct answer is insulin moves glucose into the cell, which then draws in the potassium. The insulin hormone binds to an insulin receptor on the cell membrane which allows the cell to be open for glucose to enter. (When insulin is low, glu can't enter the cell, which gives you high serum blood sugar). The cell needs glucose (carbon) for ATP which attaches to the Na/K pump on the incide if the cell and allows the 3 sodium to exit and 2 potassium to enter the cell.

To show th validity of this post, here are a few resources

1. http://www.eric.vcu.edu/home/resources/consults/Hyperkalemia.pdf

2. http://www.austincc.edu/apreview/EmphasisItems/Glucose_regulation.html

3. http://www.eric.vcu.edu/home/resources/consults/Hyperkalemia.pdf

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Specializes in SICU / Transport / Hyperbaric.

This was supposed to be in response to above post. don't know how it was added to the bottom of previous. Sorry.

Beta2 agonists (Albuterol) also may be beneficial for lowering the potassium level. Activation of B2 receptors stimulates formation of cyclic AMP which activates the Na-K ATPase pump driving K back into the cells.

Also keep in mind that if patient is on digitalis and digoxin toxicity is suspected in addition to hyperkalemia, DO NOT give calcium, you may have to give magnesium sulfate 2grams over about 5 minutes for arrhythmias.

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Specializes in Emergency.

I think the take home point should be that the calcium is the critical med, it's the one that provides the temporary protection to the heart for the increased extracellular K+. Once it is given, you have time to move the K+.

Also, both Dex and insulin can be given without an IV, it's more difficult to get them into high enough concentrations to move the K+ into the cells without an IV, but it can be done, so the concern about giving one without the other and having the IV fail is not really a concern.

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Specializes in Trauma/ER, Pysch, Pedi, Free Standing ER, L&D, ICU.
I know this post is really old, but here's my 2 cents from the icu perspective. (From a trauma I major university hospital).

In an emergent situation, give calcium first, followed by d50/regular insulin: usually 1amp to 10 units. IV insulin has an onset of minutes whereas glucose has an onset of

Its been said in here to give glucose first in case you lose access... This is false sense of security : "Do not give glucose alone as hyperosmolarity can shift potassium out of cells."(reference 3) And you could end up with a higher K than when you started, which is bad for the heart, the body's life organ. While giving insulin IV alone has its downside, so does the faster onset d50. If in doubt about access because you only have one 22g that has been in for days, I would mix the regular insulin in the d50 and give TOGETHER.

as far as the mechanism, there are mixed comments in here.the correct answer is this:

in a normal patient, k+ is intracellular and Na+ is extracellular. When the serum k+ is elevated, it is because there is an increased amount of K+ outside of the cell. This can be caused from CRF or ARF, burns, crush injuries, or even the use of too much potassium salts (cardiac patients on a low Na+ diet).

Insulin isn't to prevent the patients blood sugar from elevating or d50 from falling, both incorrect conclusions. The correct answer is insulin moves glucose into the cell, which then draws in the potassium. The insulin hormone binds to an insulin receptor on the cell membrane which allows the cell to be open for glucose to enter. (When insulin is low, glu can't enter the cell, which gives you high serum blood sugar). The cell needs glucose (carbon) for ATP which attaches to the Na/K pump on the incide if the cell and allows the 3 sodium to exit and 2 potassium to enter the cell.

To show th validity of this post, here are a few resources

1. http://www.eric.vcu.edu/home/resources/consults/Hyperkalemia.pdf

2. Glucose Regulation

3. http://www.eric.vcu.edu/home/resources/consults/Hyperkalemia.pdf

WAIT... were you in my ER just the other day? LOL I only say that because I had to teach my preceptee the BDIK pneumonic but make sure to watch the monitor & assess the patient to determine the right order. My advanced patho made sure I'll never forget the glucose-K relationship because I remember asking her the same exact question as the original poster's. I have given Magnesium instead of Calcium before due to possible dig toxicity.

And on the comment regarding giving Kayex just before they go up the floor?... I wish. Sux when no room in ICU & it's an ED hold day =( Upside is great learning opportunity for the new GN I was precepting

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