Experience using high-dose glucose-insulin-potassium (GIK) in critically ill patients

Abstract

Purpose To audit the use of GIK in terms of safety, haemodynamic effects, and impact on catecholamine dosage.Materials and methods A retrospective, descriptive, evaluative audit of GIK use within the adult ICU of a London teaching hospital was conducted. Rescue therapy of GIK (up to 1.0 Units insulin/kg/hour) was administered to improve cardiac function. Outcomes were ICU survival, change in cardiac index (CI) and blood lactate levels, events of hypoglycaemia, hyperglycaemia, hypokalaemia and hyperkalaemia, and discontinuation time of catecholamine inotropes. ResultsOf 85 patients treated with GIK, 13 (15.3%) survived their ICU stay and 9 (10.5%) were discharged home. In patients surviving until 72 hours, a trend of improved CI and lactate levels was seen, often with reductions in catecholamine dosing. Inotropes were discontinued in 35 (54%) patients. Severe hypoglycaemia (<2 mmol/l), hyperglycaemia (>20 mmol/l), hypokalaemia (<2.5 mmol/l) and hyperkalaemia (>7 mmol/l) during GIK affected 1, 6, 8 and 1 patients, respectively. These abnormalities were quickly identified. No measurable harm was noted.Conclusions High-dose GIK can be safely used in critically ill patients, though blood glucose and potassium levels must be monitored frequently. GIK was associated with improved CI and blood lactate levels. Impact on survival requires prospective evaluation.

High-Dose Insulin Euglycemic Therapy in the Treatment of a Massive Caffeine Overdose

“…So-called "glucose-insulin-potassium" infusions have improved serum lactate levels and cardiac indices in other critical low-output states (eg, septic shock, resistant heart failure) without adverse effects. 14,15 Unlike HIET, however, these regimens typically incorporate much lower insulin doses of up to 1 IU/kg/h. 14 In contrast to catecholamines, insulin forces the myocardium to metabolize glucose in preference to less efficient free fatty-acid chains, while also enhancing intracellular calcium signaling and lactate clearance.…”

“…14,15 Unlike HIET, however, these regimens typically incorporate much lower insulin doses of up to 1 IU/kg/h. 14 In contrast to catecholamines, insulin forces the myocardium to metabolize glucose in preference to less efficient free fatty-acid chains, while also enhancing intracellular calcium signaling and lactate clearance. [15][16][17][18] The global effect of vasodilation, microvascular recruitment, and enhanced glucose metabolism improves myocardial perfusion and provides nonadrenergic inotropy to increase cardiac output.…”

Sudden cardiac arrest in hypertrophic cardiomyopathy with dynamic cavity obstruction: The case for a decatecholaminisation strategy

“…Myocardial metabolic resuscitation with high-dose glucose-insulin-potassium (HDI) regimes looks promising according to a recent audit from a London teaching hospital but prospective evaluation is yet to be undertaken. 43 Lastly, mechanical support has received unprecedented attention. Not only a catecholamine-sparing strategy, veno-arterial extracorporeal membrane oxygenation could provide the optimum ventriculo-arterial coupling through its amplifying effect on LV afterload, 44 hence opposing the MVO.…”

Insulin therapy in organ donation and transplantation

“…Intensive insulin therapy is also now an established treatment for the management of profound cardiogenic shock secondary to β‐blocker and calcium channel blocker overdose . More recently, the safety, haemodynamic effects and impact on catecholamine dosage of high‐dose insulin therapy in patients with inotropic resistant myocardial dysfunction have been demonstrated in critically ill patients without β‐blocker and calcium channel blocker overdose . In multi‐organ donors high‐dose catecholamine infusions are commonly required to provide inotropic support and maintain cardiovascular stability, but this can have detrimental effects on organ quality .…”

“…[36][37][38] More recently, the safety, haemodynamic effects and impact on catecholamine dosage of high-dose insulin therapy in patients with inotropic resistant myocardial dysfunction have been demonstrated in critically ill patients without β-blocker and calcium channel blocker overdose. 39 In multi-organ donors high-dose catecholamine infusions are commonly required to provide inotropic support and maintain cardiovascular stability, but this can have detrimental effects on organ quality. 40 Hormone therapy with insulin infusion may have a role to play in maintaining cardiovascular stability in organ donors without the concomitant adverse effects from catecholamines.…”