Insulin Therapy in Divided Doses Coupled With Blood Transfusion Versus Large Bolus Doses in Patients at High Risk for Hyperkalemia During Liver Transplantation

Objective: To assess the effectiveness of an insulin regimen in divided doses designed to target risk factors of hyperkalemia in patients undergoing liver transplantation. Design: Retrospective comparison of the divided insulin dose regimen with a conventional large-bolus insulin method during liver transplantation. Setting: University-based, academic, tertiary center. Participants: Adult patients whose baseline potassium levels were ≥4.0 mmol/L and received insulin therapy during liver transplantation at the authors' medical center between January 2004 and April 2007. Interventions: Insulin was administered either in divided doses (1-2 units) for each unit of red blood cells transfused or in a large-bolus in patients at high risk for hyperkalemia during liver transplantation. Measurements and Main Results: Among 717 patients who underwent liver transplantation, 50 patients received insulin in divided doses, and 101 patients received a large-bolus of insulin. Perioperative characteristics were comparable except for higher insulin doses in the large-bolus group. The divided insulin regimen was associated with significantly lower mean potassium levels within 2 hours before reperfusion of the graft compared with the conventional group (p < 0.005). The mean glucose levels in the divided group were significantly lower in both the pre- and postreperfusion periods than in the conventional group (p < 0.05 to <0.001). Conclusions: The divided insulin dose regimen that specifically targets the risk factors for prereperfusion hyperkalemia is associated with significantly lower prereperfusion potassium and pre- and postreperfusion glucose levels and provides a useful alternative to the conventional large-bolus method in management of intraoperative hyperkalemia during liver transplantation.