High Dose Insulin Therapy Guidelines

Primary Indications for HDIT

The American College of Critical Care Medicine recommends HDIT as a first-line treatment for calcium channel blocker poisoning with documented myocardial dysfunction (Grade 1D recommendation) 1, 2
HDIT is suggested for calcium channel blocker poisoning even without documented myocardial dysfunction (Grade 2D recommendation) 1, 2
HDIT is indicated for severe beta-blocker toxicity causing hemodynamic compromise (Grade 1, Level B-NR) 4
HDIT is indicated for bradycardia and cardiac conduction delay associated with drug toxicity that is refractory to conventional treatments 5

Standard initial dosing for HDIT includes a bolus of 1 U/kg followed by an infusion of 1 U/kg/hr 1, 2, 3
For refractory shock or periarrest conditions, incremental doses up to 10 U/kg/hr may be used if evidence of myocardial dysfunction is present 6, 7
Even without documented myocardial dysfunction, incremental doses up to 10 U/kg/hr may be considered in refractory shock (Grade 2D recommendation) 6, 7
Concurrent dextrose infusion is required to maintain euglycemia, with close monitoring of serum potassium 1, 2, 3

HDIT improves cardiac contractility in the setting of cardiogenic shock from CCB or beta-blocker poisoning 1, 2, 3

Initial assessment should evaluate for signs of toxicity including hypotension, bradycardia, and cardiac dysfunction 1, 2
First-line treatments include IV calcium to increase contractility and blood pressure (Grade 1D) 1, 2, 3
HDIT is recommended to increase contractility (Grade 1D) and blood pressure (Grade 2D) 1, 2, 3
For refractory cases, increase HDIT up to 10 U/kg/hr 6, 7

D10 solution running at 60 mL/hour provides 6 grams of carbohydrates per hour, which may be used for glucose supplementation during HDIT 8
Administering dextrose solutions too rapidly can cause hyperglycemia with adverse effects on the central nervous system 8