High Dose Insulin Dextrose Therapy
Liverpool Hospital Emergency Department
Indications:
- 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)
Protocol:
- 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