Evaluation of high-dose insulin/euglycemia therapy for suspected β-blocker or calcium channel blocker overdose following guideline implementation

Use of Concentrated Insulin in the Management of Calcium Channel Blocker Overdose: A Case Report

INTRODUCTION

Hyperinsulinemia-euglycemia therapy [HIE] is a first line therapy recommended in symptomatic calcium channel blocker overdose patients. HIE, particularly if administered in concentrations typically used for glycemic control, would result in a substantial amount of hypotonic fluid administration, which places patients at risk of volume overload. Therefore, it may be beneficial to utilize a concentrated insulin as a strategy to mitigate fluid overload risks. We report the case of a 73 years old, 69.9 kg female, who presented to the emergency department after an accidental ingestion of 70 mg amlodipine and was treated with HIE utilizing a uniquely concentrated insulin infusion.

CASE PRESENTATION

HIE at 10 units/kg/hr. was used for approximately 17 hours. Insulin was changed from a 1 unit/mL concentration to 16 unit/mL. Dextrose 10% infusion was initiated up to a max of 650 mL/hr. and norepinephrine infusion up to a max of 10 mcg/min.

DISCUSSION

Approximate fluid requirements from the 16 unit/mL concentration of insulin totaled 1 L as compared to a 1 unit/mL concentration which would have required 17 L, a total savings of 16 L. This savings potentially decreased the risk of cerebral or pulmonary edema associated with fluid overload.

CONCLUSION

Use of a concentrated insulin in the setting of a calcium channel blocker or beta blocker overdose provides a unique strategy to mitigate the effects associated with fluid overload.

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.