D50 Dosing for Hyperkalemia with IV Insulin
For a patient with hyperkalemia and a current glucose of 107 mg/dL receiving 10 units of IV insulin, administer 1 amp (50 mL) of D50W (25 grams of glucose), but strongly consider giving 2 amps (100 mL) of D50W (50 grams of glucose) to reduce hypoglycemia risk given the borderline glucose level. 1
Standard Protocol
The American Heart Association guideline establishes the baseline approach: 2
- 10 units of regular insulin IV with 25 grams of glucose (50 mL of D50W = 1 amp) over 15-30 minutes 2, 1
- This achieves approximately 0.8 mmol/L potassium reduction within 60 minutes 1
Critical Modification for Your Patient's Glucose Level
Your patient's glucose of 107 mg/dL places them at HIGH RISK for hypoglycemia. Multiple sources identify patients with pre-treatment glucose <110 mg/dL as a vulnerable population requiring additional dextrose: 1, 3, 4
- Consider administering 50 grams of glucose (2 amps of D50W = 100 mL) instead of the standard 25 grams 1, 3
- Research demonstrates that 50 grams significantly reduces hypoglycemia in patients with baseline glucose <110 mg/dL (your patient is at 107 mg/dL) 3
- The higher dextrose dose does NOT compromise potassium reduction efficacy 3
Alternative Approach: D10 Infusion
If D50W is in short supply or you want additional hypoglycemia protection: 5, 6
- Give 1 amp D50W (50 mL) as initial bolus with the insulin 2
- PLUS add 250 mL of D10W infused over 2 hours 6
- This dual approach reduced hypoglycemia rates from 20% to 6% in high-risk patients 6
Mandatory Monitoring
Hypoglycemia commonly occurs 60+ minutes after insulin administration and can persist for 4-6 hours: 1, 4
- Recheck glucose at 60 minutes post-insulin 1
- Continue hourly glucose monitoring for at least 4-6 hours 1, 4
- Recheck potassium as insulin effects wane and rebound hyperkalemia can occur 1
Common Pitfall to Avoid
Never give insulin without glucose in hyperkalemia treatment - this dramatically increases hypoglycemia risk 1. The insulin-to-glucose ratio should be 1 unit of insulin for every 2.5 grams of glucose at minimum 1, meaning 10 units requires at least 25 grams (1 amp D50W), but 50 grams (2 amps) is safer for your patient's glucose level.