Insulin

High-dose insulin infusion also has provided benefit in two models of verapamil toxicity. 1820 Insulin appears to improve myocardial mechanical efficiency and contractility by accelerating carbohydrate oxidation. Insulin is also potent a positive inotrope that operates through a mechanism similar to the postreceptor action of the a1 adrenoreceptor. Insulin does not produce a sharp improvement in hemodynamic indexes when bolus infused. Instead, insulin slowly but steadily improves heart contractility. Insulin has no direct effect on cardiac conduction but may lower plasma potassium concentrations and indirectly improve automaticity and conduction. Perhaps the best role of insulin is as an adjunctive therapy for suspected massive overdose, and it is more effective in humans when administered before profound hypodynamic shock supervenes.21 A suggested infusion dose is 1.0 unit/kg/h for the first hour, followed by 0.5 unit/kg/h. 21 Depending on the severity of overdose, resistance to insulin-mediated glucose clearance may be significant; in general, adults require 20 to 30 g of glucose per hour to maintain euglycemia with a high-dose insulin infusion. The concomitant use of catecholamines should not deter the use of insulin. When insulin infusion is added to catecholamine infusion, an additional positive inotropic effect is observed, even in the depressed heart. 22

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