Insulin and Glucose Infusion Rate for Hyperkalemia
For hyperkalemia treatment, administer 10 units of regular insulin as an intravenous bolus (or infused over 15-30 minutes) combined with 25-50 grams of glucose (50 mL of D50 or equivalent), not as a continuous drip. 1, 2
Standard Treatment Protocol
The American Heart Association guidelines specify the following regimen for severe hyperkalemia with cardiotoxicity or cardiac arrest 1:
- Mix 25 g glucose (50 mL of D50) with 10 units regular insulin
- Administer IV over 15 to 30 minutes 1
- The ratio is 1 unit of insulin for every 4 grams of glucose 1
Alternative Dosing for Severe Cases
For patients with severe hyperkalemia (K+ >6.5 mmol/L) or marked ECG changes, consider 2:
- 20 units of regular insulin as a continuous IV infusion over 60 minutes
- Must be accompanied by 60 grams of glucose to prevent hypoglycemia 2
- This higher dose shows similar potassium reduction to standard 10-unit dosing (0.79 vs 0.78 mmol/L decrease at 60 minutes, p=0.98) 2
Reduced Dose Considerations
For patients at high risk of hypoglycemia, a reduced dose may be considered 3, 4:
- 5 units of regular insulin with 50 grams of glucose
- However, this is less effective when baseline K+ >6 mmol/L (0.238 mmol/L less reduction, p=0.018) 3
- Consider using 0.1 units/kg dosing as an alternative 4
Critical Safety Points
Hypoglycemia Risk Factors
Monitor closely if the patient has 5, 4:
- Age >60 years
- Pretreatment glucose ≤100 mg/dL (≤5.6 mmol/L)
- Pretreatment potassium >6 mmol/L
- Female gender
- Abnormal renal function
- Lower body weight
- No history of diabetes mellitus
Monitoring Requirements
- Check blood glucose hourly for at least 4-6 hours after insulin administration 4
- Insulin's duration of action exceeds that of dextrose, creating ongoing hypoglycemia risk 4
- Overall hypoglycemia incidence is approximately 6-25% with standard dosing 2, 5, 6
Common Pitfalls to Avoid
Do not use this as a continuous "drip" in the traditional sense - this is a one-time bolus or short infusion, not an ongoing infusion like insulin used for DKA 1. The evidence provided about DKA insulin infusions (0.1 U/kg/h) 1 addresses a completely different clinical scenario and should not be applied to acute hyperkalemia management.
Ensure adequate glucose administration - using 50 grams instead of 25 grams with 10 units of insulin reduces hypoglycemia risk 4, and 60 grams must be given with 20 units 2.
Do not assume diabetes protects against hypoglycemia - patients without diabetes actually have higher hypoglycemia risk 4.