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INTRODUCTION

  1. Pharmacology1

    1. Insulin, a hormone secreted by the beta cells of the pancreas, promotes cellular uptake of glucose into skeletal and cardiac muscles and adipose tissue. Insulin shifts potassium intracellularly.

    2. There are several mechanisms by which high-dose insulin (hyperinsulinemia-euglycemia [HIE]) therapy may improve cardiac output:

      1. In calcium antagonist and beta-adrenergic blocker overdose, myocardial metabolism shifts from free fatty acid to carbohydrate metabolism; insulin increases myocardial uptake of glucose, lactate, and oxygen.

      2. High-dose insulin increases calcium-dependent inotropic effects.

      3. High-dose insulin enhances nitric oxide synthase activity, which dilates coronary, pulmonary and systemic blood vessels, leading to improved cellular perfusion.

    3. Human regular insulin is biosynthetically prepared with recombinant DNA technology. The onset of action to decrease blood glucose for regular insulin is 30 minutes to 1 hour, and the duration of action is 5–8 hours. The onset of action for high-dose insulin is not known but is frequently stated to be 15–45 minutes. The serum half-life of regular insulin at normal doses is 4–5 minutes after IV administration.

  2. Indications

    1. Hyperglycemia and diabetic ketoacidosis.

    2. Severe hyperkalemia.

    3. Administration with dextrose for hypotension induced by calcium antagonists and beta-adrenergic blockers. Improved hemodynamics have been reported in case reports of patients with calcium antagonist toxicity and beta-adrenergic blocker overdose.

  3. Contraindications. Known hypersensitivity to the drug (less frequent with human insulin than with animal-derived insulin).

  4. Adverse effects

    1. Hypoglycemia.

    2. Hypokalemia.

    3. Lipohypertrophy or lipoatrophy at injection site (more common with repeated use).

    4. Fluid overload and hyponatremia with high-dose insulin infusion. Consider using concentrated solutions of insulin and dextrose, given via a central line.

    5. Use in pregnancy. FDA Category B (Introduction). Human insulin does not cross the placental barrier.

  5. Drug or laboratory interactions

    1. Hypoglycemia may be potentiated by ethanol, sulfonylureas, and salicylates.

    2. Corticosteroids (by decreasing peripheral insulin resistance and promoting gluconeogenesis), glucagon (by enhanced glycogenolysis), and epinephrine (via beta-adrenergic effects) may antagonize the effects of insulin.

  6. Dosage and method of administration

    1. Hyperglycemia. Administer regular insulin 5–10 U IV initially, followed by infusion of 5–10 U/h, while monitoring the effect on serum glucose levels (children: 0.1 U/kg initially, then 0.1 U/kg/h).

    2. Hyperkalemia. Administer regular insulin 0.1 U/kg IV with 50 mL of 50% dextrose (children: 0.1 U/kg insulin with 2 mL/kg of 25% dextrose).

    3. Hypotension from calcium antagonists and beta-adrenergic blockers unresponsive to conventional therapy (hyperinsulinemia-euglycemia therapy):

      1. Bolus of regular human insulin 1 U/kg IV. If blood glucose is below 200 mg/dL, give 50 mL (25 g) of 50% dextrose IV (children: 0.25 g/kg of 25% dextrose).

      2. Continuous infusion. Wide variations in insulin dose and duration have been reported. Doses as high as 10 U/kg/h have been administered. The most commonly recommended infusion rate is 1–10 U/kg/h. Start at 1 U/kg/h and increase by 1–2 U/kg/h every 10 minutes as needed to maintain satisfactory perfusion of vascular beds. Because of the vasodilation associated with HIE therapy, do not make dose adjustments based on the blood pressure alone.

      3. Insulin solutions are often made by diluting 500 U of regular human insulin ...

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