Insulin Before Dextrose or Vice Versa?

[vmrose93]

Do we give dextrose before insulin or vice versa when treating hyperkalemia? I'm a baby nurse and I remember my preceptor telling me something like this but I forgot. Something about you could tank the patient if one is given before the other. Thanks!

[marienm, RN, CCRN]

I push the dextrose first just in case I lose the IV. If I gave the insulin first but then lost the IV, the patient's blood sugar would be decreasing fairly rapidly while I fumbled around getting supplies & trying for new access.  That's my rationale, anyway, though I don't think I've ever lost an IV at exactly the moment between the two.

[NRSKarenRN, BSN, RN]

Its been quite awhile since in hospital,  found these up to date resources. Worst start to a shift was when I was asked to work Renal floor for a month, code called end of hall as I answered phone with stat lab result: K+ = 7.3   and I had no idea of treating ESRD with Hyperkalemia as I was used to vented COPD's -- totally different world of labs and meds.

Learned to give in this order:

1. Calcium Gluconate: hypocalcemia may exacerbate the cardiac effects of hyperkalemia. Calcium chloride only if central line avoid extravasion and tissue necrosis

2. D50 Bolus or continuous infusion 10% dextrose infusion at 50-75 ml/hour is associated with less hypoglycemia than bolus dosing with D50.    Q 15-30 min blood sugar to monitor /treat hypoglycemia x 2 hours.  Glucose helps transport insulin into cells.

3. Insulin: will drive the potassium back into the cells, causes hypoglycemia

4.  Albuteral /beta-2 agonists: shifts potassium intracellularly

5. Sodium Bicarb IV in metabolic acidosis

6. Loop/Thiazide diuretic: increases potassium excretion

Treatment of Hyperkalemia With a Low-Dose Insulin Protocol Is Effective and Results in Reduced Hypoglycemia

Nursing Stat Pearls: Hyperkalemia

National Kidney Foundation:

Best Practices in Managing Kyperkalemia in Chronic Kidney Disease

American College Emergency Physicians:

Management Algorithm for Adults with Hyperkalemia

Medscape 2021:  Hyperkalemia practice essentials

Looking for others input + how their facility handles this emergency.

[marienm, RN, CCRN]

My facility does all the things you mentioned too, plus: kayexalate, get an EKG, possibly start emergent dialysis.  It's all depending on the patient, the etiology, and their K+ level.  But "1/2 amp of D50 plus IV insulin" is our typical treatment for a patient with K>5.8 but less than ~6.3 with no EKG changes.

[delrionurse]

For hyperkalemia, I give the insulin first due to the potential emergency (plus it's important to note how the patient looks ie. vomiting, weak, abd pain, EKG changes?) Then I give the dextrose. The insulin will help bring down the potassium level, before the dextrose. 

Also, dextrose is viscous and hard to push (if giving IV push). 

[DavidFR, BSN, MSN, RN]

Totally different approach here in France.

We give a bag of 250cc Glucose 30% with 10 units novorapide insulin added to the bag. Hence the glucose and the insulin are being administered together over 30 minutes.

We take a blood sugar after the start of the infusion, at the end, and then hourly for 3 hours. Check K+ 6 hours later.

The few times I've had to do this my experience has been that there is a slight peak in blood sugar at the end of the infusion, after which it normalises and stays normal. I've never had a hypo.  Potassium has usually normalised at the 6 hour post check. 

Even in patients who can take oral meds, I prefer this to Kayexalate which looks disgusting, and let's be honest, no patient has ever said "ooh that was lovely!" have they?!

[traumaRUs, MSN, APRN]

Nephrology APRN here: 

1. Calcium

2. Insulin and Glucose can be given at same time

3. Sodium bicarb 

4. Kayexalate (if you have it - shortage med)

[MaxAttack, BSN, RN]

Just for clarification because I see this done all the time in the hospital.

There is no role for sodium bicarb pushes here. It will not help and may potentially cause harm. It's outdated but just won't die (like most times we use bicarb pushes but that's another story). If it's going to be given it needs to be an infusion. The onset of action for kayexalate is 2-24 hours. It's fine for a gradual reduction but it will not help in an emergent/urgent situation. 

IBCC: Hyperkalemia

Treatment of Severe Hyperkalemia: Confronting 4 Fallacies

Updated Treatment Options in the Management of Hyperkalemia

Management of hyperkalemia in the acutely ill patient

 

For your initial question: the traditional teaching is dextrose first to prevent hypoglycemia. 

[delrionurse]

traumaRUs said:

Nephrology APRN here: 

1. Calcium

2. Insulin and Glucose can be given at same time

3. Sodium bicarb 

4. Kayexalate (if you have it - shortage med)

Calcium first if there are EKG changes, right? But if no EKG changes, insulin first?..Just a thought.

[chare]

delrionurse said:

Calcium first if there are EKG changes, right? But if no EKG changes, insulin first?..Just a thought.

Treatment of hypermalemia can be thought of in three phases: Stabilize the cardiac membrane, hide the  potassium, and excrete the potassium.  There is a mnemonic to help remember the steps: C BIGK DI

C - Calcium, either gluconate or chloride, in my experience calcium, is administered in the presence of ECG changes to stabilize the cardiac membrane; although some will administer based on an arbitrary serum level.

B - Beta 2 agonists (e. g., albuterol) or sodium bicarbonate move potassium into the cells.

IG - Insulin and glucose.  Glucose moving into the cell after insulin administration also facilitates movement of potassium into the cell.  If the glucose is high enough some providers might opt to hold on the glucose administration.  As for which to administer first, I'm not sure it matters which order, although @marienm, RN, CCRN's rationale for dextrose first makes sense.

K - Kayexcelate binds and excretes potassium through the gut.

DI - Diuretics or dialysis both excrete potassium as well.

[Lindseyjustine]

NRSKarenRN said:

Its been quite awhile since in hospital,  found these up to date resources. Worst start to a shift was when I was asked to work Renal floor for a month, code called end of hall as I answered phone with stat lab result: K+ = 7.3   and I had no idea of treating ESRD with Hyperkalemia as I was used to vented COPD's -- totally different world of labs and meds.

Learned to give in this order:

1. Calcium Gluconate: hypocalcemia may exacerbate the cardiac effects of hyperkalemia. Calcium chloride only if central line avoid extravasion and tissue necrosis

2. D50 Bolus or continuous infusion 10% dextrose infusion at 50-75 ml/hour is associated with less hypoglycemia than bolus dosing with D50.    Q 15-30 min blood sugar to monitor /treat hypoglycemia x 2 hours.  Glucose helps transport insulin into cells.

3. Insulin: will drive the potassium back into the cells, causes hypoglycemia

4.  Albuteral /beta-2 agonists: shifts potassium intracellularly

5. Sodium Bicarb IV in metabolic acidosis

6. Loop/Thiazide diuretic: increases potassium excretion

Treatment of Hyperkalemia With a Low-Dose Insulin Protocol Is Effective and Results in Reduced Hypoglycemia

Nursing Stat Pearls: Hyperkalemia

National Kidney Foundation:

Best Practices in Managing Kyperkalemia in Chronic Kidney Disease

American College Emergency Physicians:

Management Algorithm for Adults with Hyperkalemia

Medscape 2021:  Hyperkalemia practice essentials

Looking for others input + how their facility handles this emergency.

Thank you, I start my first term nursing program January 2024. This will be very helpful!