Neonatal Intensive Care Drug Manual

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Management of severe cardiotoxicity or cardiac arrest due to hyperkalaemia
Recommended dose [adult guideline]

Glucose:insulin ratio: A historical control study compared infusions with lower glucose:insulin ratio 3.3 g:1 unit [glucose 20%] versus a higher glucose:insulin ratio 5 g:1 unit [glucose 30%] for treatment of hyperkalaemia and reported reduced rates of moderate hyperglycaemia [77% to 21.7% (p = 0.001)] with a single infant in the lower arm having hypoglycaemia [6]. (LOE III-3, GOR C).

Management of severe cardiotoxicity or cardiac arrest due to hyperkalaemia: The Pediatric Advanced Life Support guidelines [7], Advanced Cardiac Life Support guidelines [8] and a simulation trial of medication preparation and delivery [9] support the following sequence of medications to treat hyperkalaemia during paediatric cardiac: First, calcium; second, sodium bicarbonate; and third, insulin with glucose. Recommended dose [adult guideline]: Glucose plus insulin: mix 25 g (50 mL of glucose 50%) glucose and 10 units regular insulin and give IV over 15 to 30 minutes. Glucose:insulin ratio = 2.5 g:1 unit.

Pharmacokinetics

Following IV administration, the observed half-life of insulin ranges from 5 to 15 minutes [Micromedex].

References

1. Thompson CD, Vital-Carona J, Faustino EV. The effect of tubing dwell time on insulin adsorption during intravenous insulin infusions. Diabetes Technol Ther. 2012;14:912-6.

2. Hewson M, Nawadra V, Oliver J, Odgers C, Plummer J, Simmer K. Insulin infusions in the neonatal unit: delivery variation due to adsorption. J Paediatr Child Health. 2000;36:216-20.

3. Vemgal P, Ohlsson A. Interventions for non-oliguric hyperkalaemia in preterm neonates. Cochrane Database Syst Rev. 2012:CD005257.

4. Hu PS, Su BH, Peng CT, Tsai CH. Glucose and insulin infusion versus kayexalate for the early treatment of non-oliguric hyperkalemia in very-low-birth-weight infants. Acta Paediatr Taiwan. 1999;40:314-8.

5. Malone TA. Glucose and insulin versus cation-exchange resin for the treatment of hyperkalemia in very low birth weight infants. J Pediatr. 1991;118:121-3.

6. Oschman A, Gansen A, Kilbride H, Sandritter T. Safety and efficacy of two potassium cocktail formulations for treatment of neonatal hyperkalemia. Ann Pharmacother. 2011;45:1371-7.

7. American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 12: Pediatric Advanced Life Support. ECCguidelines.heart.org.

8. American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 10: Special Circumstances of Resuscitation. ECCguidelines.heart.org.

9. Arnholt AM, Duval-Arnould JM, McNamara LM, Rosen MA, Singh K, Hunt EA. Comparatively Evaluating Medication Preparation Sequences for Treatment of Hyperkalemia in Pediatric Cardiac Arrest: A Prospective, Randomized, Simulation-Based Study. Pediatr Crit Care Med. 2015;16:e224-30.

10. Micromedex accessed 27^th July 2019.

Original version Date: 29/05/2017	Author: Neonatal Medicines Formulary Consensus Group
Current Version number: 1.1	Current Version Date: 12/08/2019
Risk Rating: Low	Due for Review: 12/08/2024
Approved by: DTC	Approval date: September 2019

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