HIGH DOSE INSULIN IN BETA BLOCKER AND CALCIUM CHANNEL BLOCKER OVERDOSE

Transcription

1 HIGH DOSE INSULIN IN BETA BLOCKER AND CALCIUM CHANNEL BLOCKER OVERDOSE

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3 TOM SCULLARD RN MSN CCRN CLINICAL CARE SUPERVISOR MEDICAL INTENSIVE CARE UNIT HENNEPIN COUNTY MEDICAL CENTER MINNEAPOLIS MINNESOTA

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5 OBJECTIVES 1. Identify the cardiovascular effects of beta blocker and calcium channel blocker overdoses 2. Describe the proposed mechanism of high dose insulin use in beta blocker and calcium channel blocker overdose 3. Describe the role of the nurse when caring for the patient receiving high dose insulin therapy.

6 OVERDOSE Intentional ingestion Unintentional ingestion Patient error Medication interaction Children

7 BETA BLOCKER & CALCIUM CHANNEL BLOCKER OVERDOSE Overdose is associated with a high incidence of morbidity and mortality due to cardiovascular toxicity including profound hypotension and conduction disturbances

8 AMERICAN ASSOCIATION OF POISON CONTROL CENTERS NATIONAL POISON DATA SYSTEM beta blocker overdoses 5076 calcium channel blocker overdoses Fatalities beta blocker 13 calcium channel blocker 24

9 BETA BLOCKERS & CALCIUM CHANNEL BLOCKERS Beta Blockers 128 million prescriptions for β-blockers filled in th most commonly prescribed medication class Calcium channel blockers 98 million prescriptions filled in 2010

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11 BETA BLOCKER USES Beta blockers are used for treating: Abnormal heart rhythm High blood pressure Heart failure Angina (heart pain) Tremor Pheochromocytoma Prevention of migraines

12 CALCIUM CHANNEL BLOCKERS Amlodipine (Norvasc) Diltiazem (Cardizem LA, Tiazac) Felodipine (Plendil) Isradipine (Dynacirc) Nifedipine (Adalat, Procardia) Nicardipine (Cardene) Nimodipine (Nimotop) Nisoldipine (Sular) Verapamil (Covera-hs, Verelan PM, Calan) Diltiazem Nicardipine

13 CALCIUM CHANNEL BLOCKER USES Calcium channel blockers are approved for treating: High blood pressure Angina Abnormal heart rhythms (for example, atrial fibrillation, paroxysmal supraventricular tachycardia) Subarachnoid hemorrhage Raynaud's phenomenon Cardiomyopathy Migraine headaches

14 CARDIAC MYOCTES Myocte: Type of cell found in muscle tissue Cardiac myoctes responsible for: Electrical impulses Contractility Exchange ions

15 BETA AND CALCIUM CHANNEL RECEPTORS What do they do?

16 BETA RECEPTORS Beta 1 Primarily regulate myocardial tissue and affect the rate of contraction via impulse conduction Beta 2 smooth muscle tone and influence vascular and bronchiolar relaxation Beta 3 thought to primarily affect lypolysis and may have effects on cardiac inotropy

17 BETA RECEPTORS ACTION Beta receptors coupled with Gs protiens Activate adenylate cyclase Form camp from ATP activates camp dependent protein kinase (PK-A) Causes increase calcium into the cell Leads to increased release calcium by sarcoplasmic reticulum in the heart Increased contractility heart rate

18 BETA- BLOCKERS Beta-blockers selectively antagonize the effects of catecholamines at the beta-adrenergic receptor that are linked to G proteins

19 BETA BLOCKERS Beta-adrenergic antagonists competitively antagonize the effects of catecholamines at the beta-adrenergic receptor and blunt the chronotropic and inotropic response to catecholamines

20 BETA BLOCKER OVERDOSE SYMPTOMS Hypotension Bradycardia Bronchospasms Cool extremities r/t vasoconstriction Beta 2 blockade and alpha -1 activity Low blood sugars? Inhibition of release of glucagon in the pancreas

21 L-TYPE CALCIUM CHANNELS Found on myocardial cells contractility Vascular smooth muscle cells Contractility Conducting cells Pacemaker cells β-islet cells of the pancreas

22 CALCIUM CHANNELS Calcium enters open voltage-sensitive calcium channels to promote the release of calcium from the sarcoplasmic reticulum. The released calcium combines with troponin to cause muscle contraction via actin and myosin fibers

23 CALCIUM CHANNEL BLOCKER OVERDOSE Calcium channel blockers prevent the opening of the voltage-gated calcium channels and reduce calcium entry into cells during phase 2 of an action potential.

24 CALCIUM CHANNEL BLOCKERS Dihydropyridines Preferentially block L-type calcium channels in the vasculature (vasodilators) Nondihydropyridines Selectively block L-type calcium channels in the myocardium (depressive effect on conduction and contractility).

25 CALCIUM CHANNEL BLOCKER OVERDOSE SYMPTOMS Hypotension Bradycardia Hyperglycemia Hypoinsulinemia Warm extremities (vasodilation) Conduction delays Metabolic Acidosis (poor perfusion)

26 BETA BLOCKER/ CALCIUM CHANNEL BLOCKER DRUG INDUCED SHOCK Heart preferred energy source Free Fatty Acids Stress Carbohydrate Increased glucose (glycogenolysis) Decreased insulin (pancreatic b-islet cell blockage) Lack of fuel for energy production Aerobic Anaerobic metabolism

27 BETA BLOCKER AND CALCIUM CHANNEL OVERDOSE In overdose, β-blockers and CCBs often have similar presentation and there is much overlap in treatment. Cardiotoxicity characterized by hypotension and bradycardia is the common clinical feature

28 TREATMENT Airway Breathing Circulation Decontamination (Gastrointestinal) Gastric lavage Activated charcoal Whole bowel irrigation

29 TREATMENT Fluids Atropine Calcium Glucagon Pacing Adrenergic drugs dopamine, norepinephrine, epinephrine Insulin

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31 INSULIN Case series Animal models

32 INSULIN When to use Conventional therapies fail Fluids Atropine Calcium Glucagon Pacing Adrenergic drugs dopamine, norepinephrine, epinephrine

33 INSULIN Strong positive inotropic effect Increases uptake of carbohydrates The preferred fuel substrate of the heart under stressed conditions Inhibits free fatty acid metabolism Vasodilation Improves local microcirculation Accelerates oxidation of myocardial lactate and reversal of metabolic acidosis

34 INSULIN DOSING 1 unit/kg bolus dose ( regular insulin) 10 units/kg/ bolus continuous infusion unit/kg /hr units/kg/hr Titrate to response (20-30 minutes) Heart rate 50 Systolic blood Pressure 100

35 INSULIN DOSING Onset of action = minutes? 2 hours Continue until hemodynamically stable Duration hemodynamic status 9-72 hours

36 DEXTROSE Dextrose bolus 0.5g/kg with initial insulin bolus if blood sugar < 400 mg/dl Infusion ml/hr of 10% solution Goal glucose mg/dl

37 COMPLICATIONS OF HIGH DOSE INSULIN Hypoglycemia Supplemental glucose Hypokalemia Extracellular intracellular shift Monitor every hour while insulin titration Every 6 hours once stable Target

38 NURSING CARE General nursing care Frequent glucose monitoring minutes for the 1 st hour then hourly Insulin/dextrose titration Frequent labs

39 WEANING INSULIN Slow taper Do not stop abruptly Continue to monitor blood glucose for 24 hour after insulin discontinued

40 CASE STUDY

41 ED BP 88/54 Pulse 57 Temp(Src) 37 C 98.6 F Resp 15 Wt 47.9 kg

42 MEDICATIONS

43 MEDICATIONS

44 ED ED Hypotensive and Bradycardic HR 55, BP 60/30 Norepinephrine drip started Units Regular insulin IV Central line D50 drip Calcium

45 ED Insulin drip started at 1 unit/kg/hr Norepinephrine weaned off Transferred to MICU

46 CASE STUDY Transferred to MICU Hypotensive SBP ( 60-70s) Insulin 2 units/kg/hr 8 units kg/hr - MAP of 65 q15 minute glucose checks with D50 infusion Norepinephrine up to 0.4 mcg/kg/min Start dopamine as needed with goal MAP of 65 Hourly potassium checks with replacement as needed Calcium and ionized calcium

47 ARRIVAL TO MICU 1600

48 6/23

49 6/

50 6/23

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52 6/24 75 MAP-68-72

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54 6/24

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58 D50 = 60 D5 =100

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60 D50 = 40 cc/hr D5 = 100 cc/hr Levophed 0.17 mcg/kg/min

61 CALCIUM

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65 QUESTIONS

66 REFERENCES Doepker, B., Healy, W., Cortez, E., & Adkins, E. J. (2014). High-dose insulin and intravenous lipid emulsion therapy for cardiogenic shock induced by intentional calcium-channel blocker and beta-blocker overdose: A case series. The Journal of Emergency Medicine, 46(4), doi: Engebretsen, K. M., Kaczmarek, K. M., Morgan, J., & Holger, J. S. (2011). High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning. Clinical Toxicology, 49, doi: / Kerns, W. (2007). Management of b-adrenergic blocker and calcium channel antagonist toxicity. Emergency Medicine Clinics of North America, 25, doi: /j.emc Lheureux, P., Zahir, S., Gris, M., Derrey, N., & Penaloza, A. (2006). Bench-to-bedside review: Hyperinsulinaemia/euglycaemia. Critical Care, 10(3). Retrieved March 4, 2014, from Lyden AE, Cooper C, Park E (2014) Beta-Blocker Overdose Treated with Extended Duration High Dose Insulin Therapy. J Pharmacol Clin Toxicol 2(1):1015. Mowry, J., Spyker, D., Cantilena, L., Bailey, E., Ford, M., (2013) annual report of the american association of poisoncontrol centers national poison data system (npds): 30th annual report. Clinical Toxicology, doi: / Shepard, G. (2006). Treatment of poisoning caused by β-adrenergic. American Journal of Health-System Pharmacy, 63, doi: /ajhp060041

67 REFERENCES Woodward, C., Pourmand, A., & Mazer-Amirshahi, M. (2014). High dose insulin therapy, an evidence based approach to beta blocker/calcium channel blocker toxicity. DARU Journal of Pharmaceutical Sciences, 22, 36. doi: /