The safety of high-dose insulin euglycaemia therapy in toxin-induced cardiac toxicity

Figures & data

Table 1. Cases of HIE use.

	Age/Sex	Drug(s) ingested & dose	Lowestheartrate(bpm)	Lowestblood pressure(systolic)	Ventilated(Yes/No)	Inotropes used [1]	HIE commencementpost admission(hours)	Insulinbolus(units)	Insulinmaximuminfusion units/hour (units/kg/hr)	Insulinduration(hours)	Lowest BSL(mmol/L)	Lowest BSLpost ceasinginsulin(mmol/L)	Maximumglucoseinfusion(g/hr)	Glucoseduration postceasing insulin(hours)	LowestPotassium(mmol/L)	Outcome
1	30 F	Propranolol 1000mg	58	60	Yes	Metaraminol Noradrenaline	3.5	50	200 (4)	9.75	1.9	7.4	37.5	18	2.6	Alive
2	67 M	Metoprolol 1400mg Irbesartan 4200mg Amlodipine 70mg	54	71	No	Dobutamine Metaraminol Noradrenaline	1.16	80	400 (5)	15.5	1.6	1.6	37.5	24	3.5	Alive
3	65 F	Atenolol 175mg Trandolapril 56mg	44	60	Yes	Adrenaline Metaraminol Noradrenaline	1.75	80	800 (10)	15	0.9	0.9	25	30	2.6	Alive
4	33 M	Funnel web spider	75	80	No	Dobutamine Noradrenaline	9	100	1500 (15)	43.75	3.7	3.7	60	34	3.2	Alive
5	87 F	Metoprolol 75mg	25	63	No		0.75	70	70 (1)	6	3.0	1.2	25	13.5	3.2	Alive
6	56 F	Metoprolol 3500mg	62	54	Yes	Adrenaline Metaraminol	0.75	80	800 (10)	30.5	4.6	5.6	30	15	3.4	Alive
7	24 F	Propranolol 3200mg	65	99	No		4.33	75	38 (0.5)	10.5	2.6	2.6	75	5	2.8	Alive
8	15 F	Verapamil 4000mg	70	75	No	Calcium	6	64	128 (2)	24	1.9	3.7	20	4	2.6	Alive
9	45 F	Metoprolol 5000mg	54	52	No	Isoprenaline	2.33	60	500 (5)	13.5	1.4	2.9	50	28	2.6	Alive
10	88 M	Metoprolol unknown	20	45	Yes	Dobutamine Isoprenaline Noradrenaline	3.5	80	600 (6)	4.25	2.2	2.2	20	25	2.6	Died
11^a	64 M	Propranolol 16000mg	35	55	Yes	Adrenaline Calcium Glucagon Isoprenaline Noradrenaline	11.75	0	150 (2)	30	2.8	2.6	22.5	18	3.5	Died
12	57 F	Amlodipine 300mg Perindopril 300mg	52	63	No	Adrenaline Calcium Noradrenaline Vasopressin	2.33	100	200 (4)	44	2.5	3.3	25	11	2.1	Alive
13	57 M	Verapamil 7200mg Telmisartan 560mg	45	75	Yes	Adrenaline Calcium Noradrenaline	2.5	90	880 (10)	34.66	4.3		20		1.6	Died
14	17 F	Verapamil 1000mg	55	69	No	Adrenaline Calcium	4.33	80	100 (1)	5.5	9.9	2.6	4	0	2.9	Alive
15	51 M	Atenolol 2100mg	60	72	No	Noradrenaline	3.75	75	50 (0.5)	4.75	2.4	2.8	40	6	3.5	Alive
16	69 M	Sotalol 4200mg Irbesartan 2700mg	52	68	Yes	Glucagon Isoprenaline Milrinone	12.5	60	90 (1)	37.5	3.8	1.8	30	45	3.7	Alive
17	33 M	Verapamil 3600mg Atenolol 750mg Fosinopril 200mg	45	68	No	Adrenaline Calcium	4	0	150 (2)	36	2.2	2.6	55	9	3.2	Alive
18	79 F	Metoprolol 700mg Amlodipine 70mg	30	94	Yes	Adrenaline Calcium	11.5	0	120 (2)	20	2.6	3.4	50	15	3.4	Alive
19	37 F	Verapamil 3600mg Irbesartan 4500mg	54	60	Yes	Calcium Dopamine	5	70	72 (1)	29	3.4	3.7	37.5	24	3.1	Alive
20	75 M	Nifedipine 3000mg	55	78	Yes	Calcium Noradrenaline	3	80	80 (1)	22	3.3	2.2	60	21	2.6	Alive
21	33 F	Propranolol 3920mg	70	75	Yes		0.75	100	65 (1)	15	1.7	5.5	50	21	2.7	Alive
22	64 M	Bispropolol 45mg Perindopril 48mg	40	52	Yes	Noradrenaline	3	125	900 (10)	40	9.1	2.2	37.5	24	3.4	Alive

^a HIE commencement was delayed (transfer logistics), other agents were commenced soon after ingestion.

Figure 1. Minimum BSL vs maximum insulin infusion rate (a) and total insulin (b). Mean regression line (thick black) and 95% confidence intervals (dashed black).

Figure 2. Minimum BSL in verapamil and beta blocker overdose patients p value = 0.22.

Figure 3. Total insulin administered versus minimum serum potassium (a), potassium replacement (b), minimum serum magnesium (c) and minimum serum phosphate (d). Mean regression line (thick black) and 95% confidence intervals (dashed black).

Figure 4. Maximum insulin infusion rate versus maximum glucose replacement (a), and total insulin administered versus total glucose during HIE (b). Mean regression line (thick black) and 95% confidence intervals (dashed black).

Figure 5. Glucose duration versus maximum insulin infusion rate (a) and total insulin administered (b) during HIE. Mean regression line (thick black) and 95% confidence intervals (dashed black).

Kline JA, Tomaszewski CA, Scsoeder JD, et al. Insulin is a superior antidote for cardiovascular toxicity induced by verapamil in the anesthetized canine. J Pharmacol Exp Ther. 1993;267:744–750.

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