Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
    • Numerical inputs and outputsFormula
    • Med treatment and moreTreatment
    • Suggested protocolsAlgorithm

    Disease

    Select...

    Specialty

    Select...

    Chief Complaint

    Select...

    Organ System

    Select...

    Patent Pending

    High-dose Insulin Euglycemia Therapy (HIET)

    Doses insulin for calcium-channel blocker or beta blocker overdose.
    Favorite

    IMPORTANT

    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.

    INSTRUCTIONS

    Use in patients with cardiac drug-induced myocardial depression (cardiogenic shock).

    When to Use
    Pearls/Pitfalls
    Why Use
    • Cardiac induced myocardial depression from CCB toxicity (strongest evidence).
    • May also be used in cardiac induced myocardial depression from beta blocker toxicity.
    • Ultimate goal of HIET is improvement in organ perfusion.
    • Glucose, potassium, and ejection fraction should be monitored.
    • Most common adverse effects of HIET include hypoglycemia and hypokalemia.
    • Hypoglycemia may occur up to several hours after the insulin infusion has been completed.
    • Concentrate insulin infusion to prevent fluid overload.
    • Works by increasing myocardial glucose uptake, resulting in improved contractility.

    HIET should be considered concurrently with, or even prior to, initiation of vasopressors. HIET alone may improve the patient’s hemodynamic status, thus making vasopressors unnecessary and avoiding potential complications of vasopressor use.

    lbs
    mg/dL
    D50
    D25
    D10

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    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.
    Content Contributors
    About the Creator
    Dr. Lewis Goldfrank
    Are you Dr. Lewis Goldfrank?
    Content Contributors