Insulin and Glucose Infusion Rate for Hyperkalemia

Standard Treatment Protocol

The American Heart Association guidelines specify administering 10 units of regular insulin as an intravenous bolus (or infused over 15-30 minutes) combined with 25-50 grams of glucose for severe hyperkalemia with cardiotoxicity or cardiac arrest 1, 2
Administer IV over 15 to 30 minutes, with a ratio of 1 unit of insulin for every 4 grams of glucose, as recommended by the American Heart Association and supported by the American Academy of Pediatrics 1, 2

Abnormal renal function is a risk factor for hypoglycemia, according to the American Heart Association 1
No history of diabetes mellitus is a risk factor for hypoglycemia, as noted by the American Diabetes Association 3

The American Heart Association and the American Academy of Pediatrics recommend not using insulin and glucose as a continuous "drip" for hyperkalemia treatment, but rather as a one-time bolus or short infusion 1, 2

The American College of Cardiology recommends monitoring glucose every 15 minutes initially during dextrose titration in patients with severe hyperkalemia 4
The American Diabetes Association suggests that insulin therapy should be delayed until potassium is restored to ≥3.3 mEq/L, and once hyperkalemia resolves, 20-30 mEq potassium should be added to each liter of IV fluid 5, 6

The American Diabetes Association recommends not administering insulin if serum potassium is < 3.3 mEq/L until potassium is restored to safe levels, as insulin worsens hypokalemia by driving potassium into cells, risking life-threatening cardiac arrhythmias, respiratory muscle paralysis, and death 7
Hypokalaemia occurs in approximately 50% of DKA cases during treatment, and severe hypokalaemia (< 2.5 mEq/L) is associated with increased inpatient mortality, according to The Lancet Diabetes and Endocrinology 8