HIGH DOSE INSULIN IN BETA BLOCKER AND CALCIUM CHANNEL BLOCKER OVERDOSE
TOM SCULLARD RN MSN CCRN CLINICAL CARE SUPERVISOR MEDICAL INTENSIVE CARE UNIT HENNEPIN COUNTY MEDICAL CENTER MINNEAPOLIS MINNESOTA
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.
OVERDOSE Intentional ingestion Unintentional ingestion Patient error Medication interaction Children
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
AMERICAN ASSOCIATION OF POISON CONTROL CENTERS NATIONAL POISON DATA SYSTEM 2012 10691 beta blocker overdoses 5076 calcium channel blocker overdoses Fatalities beta blocker 13 calcium channel blocker 24
BETA BLOCKERS & CALCIUM CHANNEL BLOCKERS Beta Blockers 128 million prescriptions for β-blockers filled in 2009 5 th most commonly prescribed medication class Calcium channel blockers 98 million prescriptions filled in 2010
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
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
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
CARDIAC MYOCTES Myocte: Type of cell found in muscle tissue Cardiac myoctes responsible for: Electrical impulses Contractility Exchange ions
BETA AND CALCIUM CHANNEL RECEPTORS What do they do?
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
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
BETA- BLOCKERS Beta-blockers selectively antagonize the effects of catecholamines at the beta-adrenergic receptor that are linked to G proteins
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
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
L-TYPE CALCIUM CHANNELS Found on myocardial cells contractility Vascular smooth muscle cells Contractility Conducting cells Pacemaker cells β-islet cells of the pancreas
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
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.
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).
CALCIUM CHANNEL BLOCKER OVERDOSE SYMPTOMS Hypotension Bradycardia Hyperglycemia Hypoinsulinemia Warm extremities (vasodilation) Conduction delays Metabolic Acidosis (poor perfusion)
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
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
TREATMENT Airway Breathing Circulation Decontamination (Gastrointestinal) Gastric lavage Activated charcoal Whole bowel irrigation
TREATMENT Fluids Atropine Calcium Glucagon Pacing Adrenergic drugs dopamine, norepinephrine, epinephrine Insulin
INSULIN Case series Animal models
INSULIN When to use Conventional therapies fail Fluids Atropine Calcium Glucagon Pacing Adrenergic drugs dopamine, norepinephrine, epinephrine
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
INSULIN DOSING 1 unit/kg bolus dose ( regular insulin) 10 units/kg/ bolus continuous infusion 0.5-1 unit/kg /hr 10-20 units/kg/hr Titrate to response (20-30 minutes) Heart rate 50 Systolic blood Pressure 100
INSULIN DOSING Onset of action = 15-45 minutes? 2 hours Continue until hemodynamically stable Duration hemodynamic status 9-72 hours
DEXTROSE Dextrose bolus 0.5g/kg with initial insulin bolus if blood sugar < 400 mg/dl Infusion 125-250 ml/hr of 10% solution Goal glucose- 100-200 mg/dl
COMPLICATIONS OF HIGH DOSE INSULIN Hypoglycemia Supplemental glucose Hypokalemia Extracellular intracellular shift Monitor every hour while insulin titration Every 6 hours once stable Target 2.8-3.2
NURSING CARE General nursing care Frequent glucose monitoring 20-30 minutes for the 1 st hour then hourly Insulin/dextrose titration Frequent labs
WEANING INSULIN Slow taper Do not stop abruptly Continue to monitor blood glucose for 24 hour after insulin discontinued
CASE STUDY
ED BP 88/54 Pulse 57 Temp(Src) 37 C 98.6 F Resp 15 Wt 47.9 kg
MEDICATIONS
MEDICATIONS
ED ED Hypotensive and Bradycardic HR 55, BP 60/30 Norepinephrine drip started.01 50 Units Regular insulin IV Central line D50 drip Calcium
ED Insulin drip started at 1 unit/kg/hr Norepinephrine weaned off Transferred to MICU
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
ARRIVAL TO MICU 1600
6/23
6/23 D5 @ 75 D50 @ 80
6/23
6/23
6/24 D5 @ 75 D50 @80 MAP-68-72
6/24
D50 = 60 D5 =100
D50 = 40 cc/hr D5 = 100 cc/hr Levophed 0.17 mcg/kg/min
CALCIUM
QUESTIONS Tom.Scullard@hcmed.org
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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: 10.1186/2008-2231-22-36