High Dose Insulin Dextrose Therapy

Liverpool Hospital Emergency Department


  • High dose insulin dextrose therapy is used as an INOTROPE in combination or in lieu of  other adrenergic agents in significant shock
  • It has neither chronotropic or vasopressor properties and may in fact cause hypotension as a  result of mild vasodilation
  • Additional agents must be added in the case of vasoplegia or the need for chronotropy.
  • It can be used in
    • Beta blocker overdose
    • Calcium channel blocker overdose
    • Refractory shock from other agents generally with a cardioplegic element
  • Consider a bedside TTE in undifferentiated toxin associated shock 

Formulation / drugs required: 

  • Short acting intravenous insulin (actrapid) 
  • 50% dextrose 50ml 

Dosage and Administration 

  • Given in ICU setting and in discussion with clinical toxicology
  • 500iu of short-acting insulin in 50ml NaCl 0.9% (put in driver / insulin can bind to plastic fluid  bags and aim to minimise large fluid volume) 


  • Dextrose: 
    • 50ml of 50% dextrose IV bolus followed by
    • Infusion of 100ml of 10% dextrose / hour (can use 50% dextrose at 50ml  per hour but high doses of dextrose may not be required and will require  CVC)
    • (in children: 2.5 mL/kg of 10% dextrose as slow IV bolus FOLLOWED BY  infusion 3-5 mL/kg/hour 10% dextrose)
  • Insulin
    • IV Bolus: 1iu/kg bolus
    • IV Infusion: 1iu/kg/hour
  • Titrate to end points below every 15 minutes
  • Titration is increasing by 1iu/kg/hr of insulin at a time
  • Can go to levels of 10iu/kg/hr (there are case reports of higher doses)
  • Maintain BSL 5.5-11mmol/L
  • Maintain K between >3mmol/L (can give 10-20mmol KCL over 1-2 hours every 2-4  hours)
  • End Points: 
    • Improvement of myocardial ejection fraction / SBP >90mmHg
    • Resolution of acidaemia / euglycaemia and adequate urine output
    • Improved mentation
    • Reversal of conduction abnormalities
    • Wean other vasoactives prior to weaning HIET – wean by 1iu/kg/hr
    • Can be used in paediatrics and in pregnancy

Side Effects:

  • Hypoglycaemia and hypokalaemia

Pit Falls:  

  • Adjust the dextrose infusion to BSL – increase the insulin for clinical effect (do not adjust  insulin for BSL)
  • Therapy needs to be initiated early and takes time to take effect
  • Monitor BSL and K post cessation for 24 hours