2026 Southeastern Residency Conference

Title: Insulin Treatment Strategies for Emergent Hyperkalemia  
Authors: Margaret Brown, Matthew Bamber, William Markle
FirstHealth Moore Regional Hospital Emergency Department – Pinehurst, NC

Background: Hyperkalemia is a medical emergency that can cause cardiac abnormalities and lead to cardiac arrest. Intravenous (IV) bolus insulin regular is a standard medication used to treat emergent hyperkalemia. Insulin shifts potassium and glucose intracellularly, which can lead to hypoglycemia. The objective of this study is to evaluate the rate of hypoglycemia between different doses of IV insulin regular in managing hyperkalemia.


Methods: This retrospective chart review study evaluated the rate of hypoglycemia in hyperkalemic (K > 5 mEq/L) patients treated with 10 or 5 units of IV insulin regular in FirstHealth Moore Regional Hospital Emergency Department between June 2024 and June 2025. The study included patients 18 years and older, with serum potassium > 5 mEq/L, and treatment initiation in the emergency department. Exclusion criteria included initial glucose < 70 mg/dL or > 180 mg/dL and receipt of in-patient dialysis. The primary outcome is the incidence of hypoglycemia (glucose <70 mg/dL). Secondary outcomes include amount of dextrose administered, in-hospital mortality, decrease in serum potassium from baseline, time from insulin administration to serum potassium < 5 mEq/L, time from serum potassium > 5 mEq/L to administration of IV insulin regular, number of patients who received multiple doses of insulin, mean number of doses of insulin received per patient, mean total units of insulin received per patient.


Results: A total of 81 patients were included, with 30 in the group receiving an initial bolus of 10 units IV insulin regular, and 51 patients receiving 5 units IV insulin regular. The primary outcome of the incidence of hypoglycemia found no statistically significant difference between the 10-units and 5-unit groups (5/30 vs 3/51; p=0.12). Only one secondary outcome was statistically significant: the mean number of insulin doses received between the 10-unit and 5-unit groups (1.1 vs 1.5; p = 0.03). Both the 10-unit and 5-unit group produced similar mean potassium reduction (1.58 vs 1.60 mEq/L; p = 0.44).


Conclusions: When comparing the incidence of hypoglycemia between a high and low dose IV insulin regular regimen to treat emergency hyperkalemia, there was no statistically significant difference between the groups. The small sample size may underestimate the true incidence of hypoglycemia. This study did not adjust for administration of concomitant hyperkalemia medications, which could change the overall decrease in serum potassium. Further studies are needed to evaluate the impact of underweight and obesity on hypoglycemia.