Glucose Potassium Insulin Infusions in the Treatment of Acute Stroke Patients With Mild to Moderate Hyperglycemia

Abstract

Background and Purpose-Hyperglycemia following acute stroke is strongly associated with subsequent mortality and impaired neurological recovery, but it is unknown whether maintenance of euglycemia in the acute phase improves prognosis. Furthermore, the safety of such intervention is not established. Methods-In an explanatory, randomized, controlled trial to test safety, 53 acute (within 24 hours of ictus) stroke patients with mild to moderate hyperglycemia (plasma glucose between 7.0 and 17.0 mmol/L) were randomized to receive either a 24-hour infusion of 0.9% (154 mmol/L) saline or a glucose potassium insulin (GKI) infusion at 100 mL/h. The GKI consisted of 16 U human soluble insulin and 20 mmol potassium chloride in 500 mL 10% glucose. Blood glucose was measured every 2 hours with Boehringer Mannheim Glycaemie test strips, pulse and blood pressure were measured every 4 hours, and plasma glucose samples were taken every 8 hours. Insulin concentration in the GKI was altered according to BM glucose values. Results-There were no statistically significant differences between the 2 groups at baseline. Twenty-five patients received GKI, 1 of whom required intravenous glucose for symptomatic hypoglycemia. Plasma glucose levels were nonsignificantly lower in the GKI group throughout the infusion period. Four-week mortality in the GKI group was 7 (28%), compared with 8 (32%) in the control group. Conclusions-GKI infusions can be safely administered to acute stroke patients with mild to moderate hyperglycemia producing a physiological but attenuated glucose response to acute stroke, the effectiveness of which remains to be elucidated. (Stroke. 1999;30:793-799.)

Management of blood glucose in patients with stroke

“…A few exploratory randomised trials showed that glucose-potassium-insulin (GKI) infusions can be safely administered to acute stroke patients with mild to moderate hyperglycaemia producing a physiological but attenuated glucose response to acute stroke, the effectiveness of which remains to be elucidated [25,26]. The large multicentre trial called "GIST-UK trial » (for Glucose Insulin in Stroke Trial) aimed to demonstrate whether treatment with GKI infusions to maintain euglycaemia immediately after the acute event reduces death at 90 days [27].…”

Management of Hyperglycemia in Critical Illness: Review of Targets and Strategies

“…Continuous intravenous insulin infusion is the most rational and physiologic method of management of hyperglycemia in ICU. Various studies have demonstrated that this method is safe, effective and flexible [2,[26][27][28]. It is imperative however to monitor blood glucose hourly and titrate the rate.…”

“…Insulin can be started either as insulin and glucose infused separately or glucose insulin potassium (GIK) combined solution. While a number of validated and effective protocols for insulin infusion are in use [6,20,27,29], we suggest the following as a simplified method.…”

“…Protocol for GIK Solution (Adapted from The Glucose Insulin in Stroke Trial) [27]: This is acceptable for patients with hyperglycemia not permitted oral feeding. Prepare GlK solution in 500 ml 5 % dextrose solution with 10 meq of potassium and add 10 units of short acting insulin and start infusing at a uniform rate (usually 100 mlI hr).…”

Intensive Insulin Therapy in Critically Ill Patients

“…Only one patient required treatment for symptomatic hypoglycemia. 64 When hyperglycemia is present before an ischemic or anoxic event, neurologic damage is worse. 62 These findings are more consistent in cases of global versus focal ischemia.…”