A question for the group: Do you use insulin and glucose in the
management of severe hyperkalemia in congenital adrenal hyperplasia
(CAH) crisis? The Fleisher/Ludwig peds ER texts state that most
neonates with CAH tolerate K's of 10 remarkably well and that most of
the time, saline and steroids will resolve the hyperkalemia; and that
insulin is contraindicated because of the risk of causing hypoglycemia.
Someone responded in conference today that this was nonsense and that
you should treat very high K (and all high K with marked EKG changes or
arrhythmias) with insulin, as well as calcium, kayexelate, bicarb and
other means, as always. I have not been able to find case reports or
reviews that help weigh the risks of hypoglycemic seizures vs.
hyperkalemic arrhythmias for these babies. Can anyone comment, or point
me towards some literature? How would the presence of arrhythmias
affect your decision? (Our case patient had had a potassium of 10 and a
brief run of V-tach, for example, but then had a normal 12-lead despite
a repeat K of 10).
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