Hyperinsulin Therapy for Calcium Channel Antagonist Poisoning

Espinoza, Tamara R.; Bryant, Sean M.; Aks, Steve

doi:10.1097/mjt.0b013e31824d5fbd

Cited by 19 publications

(18 citation statements)

References 5 publications

(5 reference statements)

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“…High-dose insulin (intravenous (IV) bolus of 1.0 unit/kg followed by a 0.5–2.0 unit/kg/h infusion) showed an improvement in hemodynamics in one of two human observational studies, 20 , 21 all five human case series, 31–35 and all four animal studies 36–39 assessing that outcome, while a survival benefit was reported in animal studies. 36 , 39 Hypoglycemia (1 of 7 21 and 2 of 4 32 subjects) and hypokalemia (2 of 7 21 and 2 of 4 32 subjects) were reported as adverse effects in human cohort studies and case series, respectively.…”

Section: Resultsmentioning

confidence: 99%

Treatment for calcium channel blocker poisoning: A systematic review

St‐Onge

Dubé

Gosselin

et al. 2014

Clinical Toxicology

155

135

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ContextCalcium channel blocker poisoning is a common and sometimes life-threatening ingestion.ObjectiveTo evaluate the reported effects of treatments for calcium channel blocker poisoning. The primary outcomes of interest were mortality and hemodynamic parameters. The secondary outcomes included length of stay in hospital, length of stay in intensive care unit, duration of vasopressor use, functional outcomes, and serum calcium channel blocker concentrations.MethodsMedline/Ovid, PubMed, EMBASE, Cochrane Library, TOXLINE, International pharmaceutical abstracts, Google Scholar, and the gray literature up to December 31, 2013 were searched without time restriction to identify all types of studies that examined effects of various treatments for calcium channel blocker poisoning for the outcomes of interest. The search strategy included the following Keywords: [calcium channel blockers OR calcium channel antagonist OR calcium channel blocking agent OR (amlodipine or bencyclane or bepridil or cinnarizine or felodipine or fendiline or flunarizine or gallopamil or isradipine or lidoflazine or mibefradil or nicardipine or nifedipine or nimodipine or nisoldipine or nitrendipine or prenylamine or verapamil or diltiazem)] AND [overdose OR medication errors OR poisoning OR intoxication OR toxicity OR adverse effect]. Two reviewers independently selected studies and a group of reviewers abstracted all relevant data using a pilot-tested form. A second group analyzed the risk of bias and overall quality using the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist and the Thomas tool for observational studies, the Institute of Health Economics tool for Quality of Case Series, the ARRIVE (Animal Research: Reporting In Vivo Experiments) guidelines, and the modified NRCNA (National Research Council for the National Academies) list for animal studies. Qualitative synthesis was used to summarize the evidence. Of 15,577 citations identified in the initial search, 216 were selected for analysis, including 117 case reports. The kappa on the quality analysis tools was greater than 0.80 for all study types.ResultsThe only observational study in humans examined high-dose insulin and extracorporeal life support. The risk of bias across studies was high for all interventions and moderate to high for extracorporeal life support. High-dose insulin. High-dose insulin (bolus of 1 unit/kg followed by an infusion of 0.5–2.0 units/kg/h) was associated with improved hemodynamic parameters and lower mortality, at the risks of hypoglycemia and hypokalemia (low quality of evidence). Extracorporeal life support. Extracorporeal life support was associated with improved survival in patients with severe shock or cardiac arrest at the cost of limb ischemia, thrombosis, and bleeding (low quality of evidence). Calcium, dopamine, and norepinephrine. These agents improved hemodynamic parameters and survival without documented severe side effects (very low quality of evidence). 4-Aminopyridine. Use of 4-aminopyridine was assoc...

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Section: Resultsmentioning

confidence: 99%

Treatment for calcium channel blocker poisoning: A systematic review

St‐Onge

Dubé

Gosselin

et al. 2014

Clinical Toxicology

155

135

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“…In animal models of verapamil and propranolol poisoning, HIET provided greater haemodynamic stability and survival compared to adrenaline or glucagon alone . In clinical cases, significant improvements in blood pressure (BP) and haemodynamic stability have been reported following poisoning in mono‐ and multidrug intoxications of verapamil, diltiazem, amlodipine, propranolol and other BBs . The onset of effect for HIET has been reported to occur between 15 min and 60 min after initiating therapy .…”

Section: High‐dose Insulin Euglycaemic Therapy (Hiet) In Bb and Ccb Pmentioning

confidence: 99%

Calcium channel antagonist and beta‐blocker overdose: antidotes and adjunct therapies

Graudins

Lee

Druda

2015

Brit J Clinical Pharma

119

150

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Management of cardiovascular instability resulting from calcium channel antagonist (CCB) or beta-adrenergic receptor antagonist (BB) poisoning follows similar principles. Significant myocardial depression, bradycardia and hypotension result in both cases. CCBs can also produce vasodilatory shock. Additionally, CCBs, such as verapamil and diltiazem, are commonly ingested in sustained-release formulations. This can also be the case for some BBs. Peak toxicity can be delayed by several hours. Provision of early gastrointestinal decontamination with activated charcoal and whole-bowel irrigation might mitigate this. Treatment of shock requires a multimodal approach to inotropic therapy that can be guided by echocardiographic or invasive haemodynamic assessment of myocardial function. High-dose insulin euglycaemia is commonly recommended as a first-line treatment in these poisonings, to improve myocardial contractility, and should be instituted early when myocardial dysfunction is suspected. Catecholamine infusions are complementary to this therapy for both inotropic and chronotropic support. Catecholamine vasopressors and vasopressin are used in the treatment of vasodilatory shock. Optimizing serum calcium concentration can confer some benefit to improving myocardial function and vascular tone after CCB poisoning. High-dose glucagon infusions have provided moderate chronotropic and inotropic benefits in BB poisoning. Phosphodiesterase inhibitors and levosimendan have positive inotropic effects but also produce peripheral vasodilation, which can limit blood pressure improvement. In cases of severe cardiogenic shock and/or cardiac arrest post-poisoning, extracorporeal cardiac assist devices have resulted in successful recovery. Other treatments used in refractory hypotension include intravenous lipid emulsion for lipophilic CCB and BB poisoning and methylene blue for refractory vasodilatory shock.

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“…Toxicity from cardiac drugs is associated with a large number of fatalities and significant morbidity ( 1 , 2 ). Furthermore, the advice given by poison control centers are often not followed ( 2 – 4 ). Consensus recommendations were published for out-of-hospital management of calcium channel blocker (CCB) ingestion ( 5 ), but recommendations for in-hospital care have not been systematically developed.…”

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confidence: 99%