Hypoglycemia in the Treatment of HyperKalemia

Hypoglycemia in the treatment of hyperkalemia in ESRD frequently happens! There ae growing in the body of literature to address this issue with different recommendations:

  1. administering 25 g of dextrose with insulin and 25 g of dextrose 1 h after insulin based on our result that hypoglycemia occurred 1–3 h after insulin with dextrose. Link to article
  2. The dextrose may be administered as 100 ml of 50% dextrose IVP or 50 ml of 50% dextrose IVPB, followed by 250 ml of
    D10 IVPB over 1 hour. Link to article

 

Argument for Low dose vs high dose Insulin induced hypoglycemia in the management of hyperkalemia

Link to weight based Insulin?

Link to No difference

Epinephrine, Is it still alive?!!!

It has been a very difficult time for Epi since last 5 years!

2011: Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial

2012: Prehospital Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest

2014: Is Epinephrine During Cardiac Arrest Associated With Worse Outcomes in Resuscitated Patients?

and now BMJ published in 2016: Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis.

This study shows that we are not compliant with ACLS guideline to give Epi in shockable rhythm. The guideline for shockable rhythm recommends 2min CPR then assessment of rhythm then continue CPR and first dose of EPI, but we give epi usually as soon as we insert the line. This approach will decreas odds of survival to hospital discharge , ROSC , and survival to hospital discharge with a good functional outcome.

 

Link to article

Amiodarone, Lidocaine, or Placebo in OHCA

Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest, which one is your choice? The 2015 update of ACLS is still recommending Amio in Vfib, VTach Cardiac arrest after Shock and Epi, But new study in NEJM proved that among 3026 patients who randomized to Amiodarone (974), Lidocaine (993), or Placebo (1059), there were no statistically significant rate of survival to hospital discharge or favorable neurologic outcome.

 

Link to article

Risk stratification in patients with Pulmonary Embolism

CHEST journal Published a systematic review and meta analysis regarding Risk Stratification of Patients With Acute Symptomatic Pulmonary Embolism Based on Presence or Absence of Lower Extremity DVT. In this review, in patients diagnosed with acute symptomatic PE, concomitant DVT was significantly associated with an increased risk of death within 30 days of PE diagnosis.

Link to article

Risk Stratification Rules:

  1. PESI: (Pulmonary Embolism Severity Index)
  2. Simplified PESI
  3. RIETE Score for Risk of Hemorrhage in PE Treatmen