UNCONTROLLED WHEN PRINTED
 Introduction
  • Insulin is a regulatory anabolic protein hormone that lowers blood glucose levels by binding to insulin receptors to increase glucose uptake, inhibit hepatic glucose output and promote glycogen production.
  • An additional use for insulin is in combination with a dextrose infusion to help lower potassium levels in hyperkalaemia. Insulin causes an intracellular shift of potassium by stimulating sodium influx; exchanging intracellular sodium for extracellular potassium through activation of the Na+ - K+ -ATPase transporter. IV insulin is believed to cause a dose-dependent decrease in serum potassium, with 10 units estimated to lower serum potassium by 0.6 to 1.2 mEq/L. When administered intravenously, the potassium shifting effects of insulin occur within 15 min of administration1.
  • High-dose insulin and glucose therapy is also an effective treatment for severe beta blocker and calcium channel-blocker poisoning, with studies showing greater efficacy in terms of haemodynamic stability than with conventional treatment2.
 Indications
  • Diabetic ketoacidosis (DKA)
  • Hyperosmolar hyperglycaemic syndrome (HSS)

In conjunction with glucose:

  • Hyperkalaemia
  • Severe beta-blocker and calcium channel-blocker toxicity
 Contraindications
  • Hypoglycaemia
 Precautions / Notes
  • Rapid correction of hyperglycaemia may contribute to cerebral oedema and electrolyte imbalances
  • Hypoglycaemia may occur if insulin dose is too high in relation to insulin requirement
  • Hypoglycaemia may occur during treatment of hyperkalaemia and beta-blocker and calcium channel-blocker toxicity despite concurrent infusion of glucose, and blood glucose should be monitored regularly
 Preparation
Preparation
 Management
 Weight-based Calculations
 
Clear
 kg 
Mode: 
Weight: 
Cefazolin for fractures/prophylaxis
Presentation: /mL
Calculated dose:  in

ASMA Approval required
Diabetic ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic Syndrome (HSS)
 Preparation
Mix 50 units (0.5ml) Actrapid with 49.5ml 0.9% sodium chloride in a 50ml syringe to achieve a final concentration of 1 unit/ml. Label syringe and administer via syringe driver.

Note: Management of DKA / HSS requires I-STAT

Adult

Blood Glucose Level (mmol/L) Infusion dose (50 units in 50ml)
5 or less 0 units/hour (ml/hr)
5.1 – 10 1 units/hour (ml/hr)
10.1 – 15 2 units/hour (ml/hr)
15.1 – 20 3 units/hour (ml/hr)
20.1 – 25 4 units/hour (ml/hr)
Greater than 25 5 units/hour (ml/hr)
Hyperkalaemia (K+ >6.5)
 Preparation
Mix 10 units (0.1ml) of Actrapid with 49.9ml of 50% glucose in a 50ml syringe to achieve a final concentration of 0.2 units/ml. Label syringe and administer via syringe driver
  • 10 units of Actrapid with 50ml of 50% glucose over 15 minutes
  • Repeat as necessary to lower K+ to < 6.5 mEq/L
Beta-blocker or Calcium channel-blocker Toxicity
 Preparation
Mix 50 units (0.5 ml) Actrapid with 49.5 ml 0.9% sodium chloride in a 50 ml syringe to achieve a final concentration of 1 unit/ml. Label syringe and administer via syringe driver.

This antidote is only administered to critically ill patients with:

  • Hypotension (SBP <90 mmHg) despite fluid challenge and atropine administration
  • Bradycardia < 60 unresponsive to atropine
  • 2nd or 3rd degree Conduction blocks
  • Commence therapy by administering 25 g glucose (50 ml of 50% solution)
  • Administer Actrapid 1 unit/kg as an IV bolus

If required:

  • Ongoing infusion of 25 g glucose (50 ml of 50% solution/hr) to maintain BSL 5.5-14 mmol/L)
  • Ongoing infusion of Actrapid 0.5 units/kg/hr IV

Infusion table for ongoing treatment of beta-blocker/calcium channel-blocker toxicity

Patient weight (kg) Infusion rate (0.5 units/kg/hr) (ml/h)
50 25 u/hr (25 ml/hr)
60 30 u/hr (30 ml/hr)
70 35 u/hr (35 ml/hr)
80 40 u/hr (40 ml/hr)
90 45 u/hr (45 ml/hr)
100 50 u/hr (50 ml/hr)
 Special Considerations
  • Monitor carefully for signs of hypoglycaemia every 20 minutes for the 1st hour in high-dose insulin therapy.
Presentation
  • Actrapid human insulin (rys) 1000IU in 10mL (100IU/mL) injection multidose vial
Actrapid
Settings
Current mode:
Extended Care:
Colour assist:

References

Moussavi K, Fitter S, Gabrielson SW et al. 2019. Management of hyperkalaemia with insulin and glucose: pearls for the emergency clinician. The Journal of emergency Medicine;57(1):36-42

Engebretsen KM, Kaczmarek KM, Morgan J & Holger JS. 2011. High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning. Clinical Toxicology:49:277-283

Queensland Ambulance Service DKA protocol.

Wyatt JP, Taylor RG, deWit K, Hotton EJ. 2020. Management of hyperkalaemia. In: Oxford Handbook of Emergency Medicine (5th ed). Oxford University Press.

Murray L, Little M, Pascu O, Hoggett K. 2015. high dose insulin therapy. In: Toxicology Handbook (3rd ed). Elsevier

Nickson CP, & Little M (2009). Early use of high-dose insulin euglycaemic therapy for verapamil toxicity. The Medical journal of Australia, 191 (6), 350-2


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