指南实施后对疑似β受体阻滞剂或钙通道阻滞剂过量使用进行高剂量胰岛素/正常血糖疗法的评估。
Evaluation of high-dose insulin/euglycemia therapy for suspected β-blocker or calcium channel blocker overdose following guideline implementation.
作者信息
Schult Rachel F, Nacca Nicholas, Grannell Tori L, Jorgensen Rachel M, Acquisto Nicole M
机构信息
Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, USA.
Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA.
出版信息
Am J Health Syst Pharm. 2022 Mar 21;79(7):547-555. doi: 10.1093/ajhp/zxab439.
PURPOSE
High-dose insulin/euglycemia (HDIE) is targeted therapy for β-blocker and calcium channel blocker overdose. A guideline using concentrated insulin infusions (20 units/mL), aggressive monitoring, and supportive recommendations was implemented. We sought to evaluate safety before and after HDIE guideline implementation and describe the patient population, insulin doses, supplemental dextrose, vasopressor use, hospital and intensive care unit (ICU) lengths of stay, and mortality.
METHODS
Retrospective review was performed of patients receiving HDIE before and after guideline implementation at an academic medical center and community hospital from March 2011 through December 2019. Information on patient and overdose demographics, ingestion data, vital signs, interventions, adverse events, and disposition was collected. Data are presented descriptively with comparisons using Mann-Whitney U analysis and Fisher's exact tests.
RESULTS
During the study period, 27 patients were treated with HDIE, 10 before guideline implementation (37%; mean [SD] initial insulin dose, 0.49 [0.35] units/kg/h; mean [SD] maximum insulin dose, 2.25 [3.29] units/kg/h; median [interquartile range] duration, 10 [5.5-18.75] hours) and 17 after guideline implementation (63%; mean [SD] initial insulin dose, 1.01 [0.34] units/kg/h; mean [SD] maximum insulin dose, 2.99 [5.05] unit/kg/h; median [interquartile range] duration, 16 [11.5-37] hours). Hypoglycemia, hypokalemia, and volume overload occurred in 80% vs 29% (P = 0.018), 40% vs 53% (P = 0.69), and 50% vs 65% (P = 0.69) of patients in the preguideline vs postguideline group, respectively. Most patients received an initial insulin bolus (85%; mean [SD], 70.3 [21.8] units, 0.9 [0.26] units/kg) and vasopressor infusion (85%). More postguideline patients received a dextrose infusion with a concentration of 20% or higher (93% vs 50%, P = 0.015). There were no differences in cardiac arrest, in-hospital mortality, or hospital or ICU length of stay between the groups.
CONCLUSION
Hypoglycemia was reduced using an HDIE guideline and concentrated insulin.
目的
高剂量胰岛素/血糖正常化（HDIE）是β受体阻滞剂和钙通道阻滞剂过量中毒的靶向治疗方法。实施了一项使用浓缩胰岛素输注（20单位/毫升）、积极监测和支持性建议的指南。我们试图评估HDIE指南实施前后的安全性，并描述患者群体、胰岛素剂量、补充葡萄糖、血管升压药的使用、住院时间和重症监护病房（ICU）住院时间以及死亡率。
方法
对2011年3月至2019年12月在一家学术医疗中心和社区医院接受HDIE治疗的患者进行回顾性研究。收集了患者和过量中毒的人口统计学信息、摄入数据、生命体征、干预措施、不良事件和处置情况。数据采用描述性呈现，并使用Mann-Whitney U分析和Fisher精确检验进行比较。
结果
在研究期间，27例患者接受了HDIE治疗，10例在指南实施前（37%；平均[标准差]初始胰岛素剂量，0.49[0.35]单位/千克/小时；平均[标准差]最大胰岛素剂量，2.25[3.29]单位/千克/小时；中位数[四分位间距]持续时间，10[5.5-18.75]小时），17例在指南实施后（63%；平均[标准差]初始胰岛素剂量，1.01[0.34]单位/千克/小时；平均[标准差]最大胰岛素剂量，2.99[5.05]单位/千克/小时；中位数[四分位间距]持续时间，16[11.5-37]小时）。指南实施前组与实施后组患者低血糖、低钾血症和容量超负荷的发生率分别为80%对29%（P = 0.018）、40%对53%（P = 0.69）和50%对65%（P = 0.69）。大多数患者接受了初始胰岛素推注（85%；平均[标准差]，70.3[21.8]单位，0.9[0.26]单位/千克）和血管升压药输注（85%）。更多指南实施后的患者接受了浓度为20%或更高的葡萄糖输注（93%对50%，P = 0.015）。两组之间在心脏骤停、住院死亡率或住院时间或ICU住院时间方面没有差异。
结论
使用HDIE指南和浓缩胰岛素可降低低血糖发生率。
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