High-dose Insulin Euglycemia Therapy (HIET)
Doses insulin for calcium-channel blocker or beta blocker overdose.
This dosing tool is intended to assist with calculation, not to provide comprehensive or definitive drug information. Always double-check dosing of any drug and consult a pharmacist when necessary.
Use in patients with cardiac drug-induced myocardial depression (cardiogenic shock).
Advice
Give an initial insulin bolus to rapidly saturate insulin receptors to speed the physiological response.
- 1 unit/kg bolus of regular human insulin along with 0.5 g/kg bolus of dextrose.
- An infusion of regular insulin should immediately follow the bolus starting at 1 unit/kg/hr.
If blood glucose is greater than 250 mg/dL (16.7 mmol/L), then the dextrose bolus is not necessary.
Management
- Assess cardiac function every 10 to 15 minutes after starting HIET.
- If cardiac function remains depressed, then the insulin dose should be increased by 0.5-1 unit/kg increments.
- Dosing recommendations typically range up to 10 units/kg/hr; however, doses up to 22 units/kg/hr have been used, and the maximum dose is not established.
- Typical duration of therapy has been 1 to 2 days, although HIET has been used for up to 4 days.
Critical Actions
- A continuous dextrose infusion, beginning at 0.5 g/kg/hr, should be concurrently initiated.
- Dextrose can be started as D10, especially if central venous access not available, but it is ultimately best delivered as D25 or D50 via central venous access to lessen fluid overload.
- Reduce the insulin infusion rate by 1 unit/kg/hr once the patient has stabilized, and reassess hourly for additional infusion reduction.
- Reduction of insulin and dextrose may cause potassium shifting which should also be monitored.