Drop the potassium not the sugar!

Hyperkalemia is a common electrolyte abnormality found in the ED. Treatment involves calcium replacement (to stabilize cardiac myocytes), dextrose/insulin, albuterol, and sodium bicarbonate (if acidotic).

Many patients with hyperkalemia also have chronic or acute renal dysfunction, noted by elevated SCr values. Since insulin is eliminated by the kidneys unchanged from its initial form, it has a much longer duration of action in patients with kidney impairment. Also, it's thought that higher glucose concentrations (i.e. D50) use can induce more insulin secretion from pancreatic beta cells. Both greatly increase the risk for insulin induced hypoglycemia.

To prevent this, consider giving regular insulin 5 units IV (vs 10 units IV) and dosing 50 g of dextrose for those with initial sugars < 100 mg/dL. Also consider 1-2 hour CBG checks for 5-6 hours in these patients as well as hypoglycemia protocol initiation should you drop the sugar.