giving D50 for hyperkalemia

[NurseT88]

What is the standard way to give D50 for hyperkalemia? I'm not asking route, but the parenteral manual indicates IV direct is for emergency use only. Would you direct push the D50 for a potassium of 6.2? Or would you run an infusion? And if the option is to run an infusion - do you use a syringe pump? Or transfer the D50 into a minibag?

[ixchel]

Oooh, baby baybee, baby baybee...

Damn it.

[Swellz]

I've only ever pushed it, then given the insulin.

[chare]

We give an amp of D50 pushed over 17 minutes. We'll give the 10 units of Regular IV push if they've been having high blood sugars or have diabetes. Current recommendations are that if they have normal blood sugars and aren't critically ill, allow them to make their own insulin to cover the dextrose.

Could you provide a source for this?

All that I've been able to find still indicates insulin and glucose together. Thanks.

[whichone'spink, BSN, RN]

It's hard to push all that sludge but it's best just to push it. It ends up being over 5 minutes anyway.

[Blondenurse83]

We use that on my unit, and it is pushed along with the insulin. It is difficult to push due to the consistency of the D50 so it usually takes awhile (5 minutes to push).

[suanna]

D50 has always made me nervous. I had an experience of pushing it about 30 years ago, and the patient ended up hemolyzing in the vein, resulting in a compartment syndrome-faciotomy-leach trerapy- eventual amputation. D50 is very hyperosmotic. I don't know why it dosen't cause a hemolytic reaction every time it is given. That said- I'd push it slowly through an infusing IV at a brisk rate.

[AJJKRN]

I've only ever pushed it. Usually its 10 units of IV Novolog push and a half amp (half of one of those huge syringes) of D50 in a non diabetic patient.

Did you mean 10 units of Regular insulin IVP? It drives me a bit nuts when others here nit pick me and are rude/mean about it so I promise I'm not trying to be either, I just wanted to clarify. If my memory serves me right, only Regular insulin can be given through an IV route...right?

[chare]

Did you mean 10 units of Regular insulin IVP?...If my memory serves me right, only Regular insulin can be given through an IV route...right?

Novolog can be given IV.

[AJJKRN]

Novolog can be given IV.

See, tis why I clarify. Looks like the FDA tweaked Novolog routes in 2013 but when I graduated it was beat into our heads that only regular insulin could be given IV. This is a good reason why I've slightly been addicted to this site for so many years because of the wealth of knowledge, questions, and real life experiences. Just doesn't compare to all the journal reading and CE's I do to try and stay current.

[Dogen]

Could you provide a source for this?

All that I've been able to find still indicates insulin and glucose together. Thanks.

Since the insulin is what's lowering the K+, giving D50 without insulin seems pointless... some guidelines suggest not giving dextrose if CBG is high (see UpToDate below), but none I've seen recommend not giving insulin.

The guideline is insulin and D50. Some guidelines say give calcium IV to everyone, others say only to patients with ECGs changes beyond peaked Ts. Some say kayexalate for everyone, some say it's a low priority. But they all say insulin (usually 10 units of regular) with 25g of D50 (or 25g dextrose as D5 given as a drip).

UpToDate says:

Insulin administration lowers the serum potassium concentration by driving potassium into the cells, primarily by enhancing the activity of the Na-K-ATPase pump in skeletal muscle. Glucose is usually given with insulin to prevent the development of hypoglycemia. However, insulin should be given alone if the serum glucose is ≥250 mg/dL (13.9 mmol/L). The serum glucose should be measured one hour after the administration of insulin.One commonly used regimen for administering insulin and glucose is 10 units of regular insulin in 500 mL of 10 percent dextrose, given over 60 minutes. Another regimen consists of a bolus injection of 10 units of regular insulin, followed immediately by 50 mL of 50 percent dextrose (25 g of glucose). This regimen may provide a greater reduction in serum potassium since the potassium-lowering effect is greater at the higher insulin concentrations attained with bolus therapy. However, hypoglycemia occurs in up to 75 percent of patients treated with the bolus regimen, typically about one hour after the infusion. To avoid this complication, we recommend subsequent infusion of 10 percent dextrose at 50 to 75 mL/hour and close monitoring of blood glucose levels.

The administration of glucose without insulin is not recommended since the release of endogenous insulin can be variable and the attained insulin levels are generally lower with a glucose infusion alone. Furthermore, in susceptible patients (primarily diabetic patients with hyporeninemic hypoaldosteronism), hypertonic glucose in the absence of insulin may acutely increase the serum potassium concentration by raising the plasma osmolality, which promotes water and potassium movement out of the cells.

Bad Request

Medscape: Medscape Access

Hyperkalemia - American Family Physician

[NurseOnAMotorcycle, ASN, RN]

In our emergency dept I give IV insulin on a regular basis with the exception of any long acting insulins. I wish they would do it on the floors and save the pt another poke with another needle.

[misslindzee]

Is nobody else pushing sodium bicarb with it? We always did an amp of d50, 10 units regular insulin, and an amp of bicarb. We pushed it as fast as we could, but you can only go so fast with those amps..