Use of a Porcine Model to Evaluate the Risks and Benefits of Vasopressors in Propranolol Poisoning

Cole, Jon B.; Corcoran, Justin N; Engebretsen, Kristin M.; Stellpflug, Samuel J.

doi:10.1007/s13181-020-00758-8

Cited by 8 publications

(3 citation statements)

References 41 publications

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“…[1][2][3] It is important to note that HIE is an inotrope and vasodilator but is not a vasopressor (with a pharmacologic profile similar to dobutamine). 4 Insulin, in general, is considered a high-alert medication by the Institute of Safe Medication Practice due to risk of causing patient harm or death if used in error. Most institutions utilize a standard admixture of 100 units of human regular insulin added to 100 mL of .9% sodium chloride to yield a 1 unit/1 mL concentration of insulin, which is sufficient for the general body of patients requiring glycemic control in the setting of diabetes or hyperglycemia in the ICU.…”

Section: Introductionmentioning

confidence: 99%

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Use of Concentrated Insulin in the Management of Calcium Channel Blocker Overdose: A Case Report

Rafeq

Salzman

2022

Journal of Pharmacy Practice

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Introduction Hyperinsulinemia-euglycemia therapy [HIE] is a first line therapy recommended in symptomatic calcium channel blocker overdose patients. HIE, particularly if administered in concentrations typically used for glycemic control, would result in a substantial amount of hypotonic fluid administration, which places patients at risk of volume overload. Therefore, it may be beneficial to utilize a concentrated insulin as a strategy to mitigate fluid overload risks. We report the case of a 73 years old, 69.9 kg female, who presented to the emergency department after an accidental ingestion of 70 mg amlodipine and was treated with HIE utilizing a uniquely concentrated insulin infusion. Case Presentation HIE at 10 units/kg/hr. was used for approximately 17 hours. Insulin was changed from a 1 unit/mL concentration to 16 unit/mL. Dextrose 10% infusion was initiated up to a max of 650 mL/hr. and norepinephrine infusion up to a max of 10 mcg/min. Discussion Approximate fluid requirements from the 16 unit/mL concentration of insulin totaled 1 L as compared to a 1 unit/mL concentration which would have required 17 L, a total savings of 16 L. This savings potentially decreased the risk of cerebral or pulmonary edema associated with fluid overload. Conclusion Use of a concentrated insulin in the setting of a calcium channel blocker or beta blocker overdose provides a unique strategy to mitigate the effects associated with fluid overload.

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Section: Introductionmentioning

confidence: 99%

“…1-3 It is important to note that HIE is an inotrope and vasodilator but is not a vasopressor (with a pharmacologic profile similar to dobutamine). 4…”

Section: Introductionmentioning

confidence: 99%

Use of Concentrated Insulin in the Management of Calcium Channel Blocker Overdose: A Case Report

Rafeq

Salzman

2022

Journal of Pharmacy Practice

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“…Therapy with calcium, pacing, and atropine produces variable responses in human case series [2]. Vasopressor therapy is frequently used; however, animal evidence suggests the possibility of harm when used in the setting of beta-blocker toxicity without inotropic support [3,4]. Due to these limitations, therapy with high-dose insulin (HDI) has been increasingly recognized as beneficial [5,6].…”

Section: Introductionmentioning

confidence: 99%

Persistent Hyperinsulinemia Following High-Dose Insulin Therapy: A Case Report

Corcoran¹,

Jacoby²,

Olives³

et al. 2020

J. Med. Toxicol.

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Introduction Overdoses of beta-adrenergic antagonists and calcium channel antagonists represent an uncommonly encountered but highly morbid clinical presentation. Potential therapies include fluids, calcium salts, vasopressors, intravenous lipid emulsion, methylene blue, and high-dose insulin. Although high-dose insulin is commonly used, the kinetics of insulin under these conditions are unknown. Case Report We present a case of a 51-year-old male who sustained a life-threatening overdose after ingesting approximately 40 tablets of a mixture of amlodipine 5 mg and metoprolol tartrate 25 mg. Due to severe bradycardia and hypotension, he was started on high-dose insulin (HDI) therapy; this was augmented with epinephrine. Despite the degree of his initial shock state, he ultimately recovered, and HDI was discontinued. Insulin was infused for a total of approximately 37 hours, most of which was dosed at 10 U/kg/hour; following discontinuation, serial serum insulin levels were drawn and remained at supraphysiologic levels for at least 24 hours and well above reference range for multiple days thereafter. Conclusion The kinetics of insulin following discontinuation of high-dose insulin therapy are largely unknown, but supraphysiologic insulin levels persist for some time following therapy; this may allow for simple discontinuation rather than titration of insulin at the end of therapy. Dextrose replacement is frequently needed; although the duration is often difficult to predict, prolonged infusions may not be necessary.Keywords High dose insulin . Overdose . Beta-blocker . Calcium channel-blocker . Poisoning

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Part II: Interactive case: Toxicology and poison control

Stanton¹

2022

J Am Coll Clin Pharm

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LEARNING OBJECTIVES1. Justify the role of poison control centers in current and future toxicology practice.2. Distinguish among the current treatments of acetaminophen toxicity.3. Assess the role and place in therapy of physostigmine and rivastigmine for anticholinergic toxicity.4. Evaluate a patient with methanol or ethylene glycol toxicity.5. Design a therapeutic regimen for a patient with β-blocker or calcium channel blocker poisoning.

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Use of a Porcine Model to Evaluate the Risks and Benefits of Vasopressors in Propranolol Poisoning

Cited by 8 publications

References 41 publications

Use of Concentrated Insulin in the Management of Calcium Channel Blocker Overdose: A Case Report

Use of Concentrated Insulin in the Management of Calcium Channel Blocker Overdose: A Case Report

Persistent Hyperinsulinemia Following High-Dose Insulin Therapy: A Case Report

Part II: Interactive case: Toxicology and poison control

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