Treatment recommendations for HIET
In cardiogenic shock, if the inotropic response to adrenaline is inadequate, seek advice from a clinical toxicologist on whether to add high-dose insulin euglycaemia therapy (HIET). This treatment is used as second-line inotropic support. Do not use HIET in primary vasoplegic shock.
In HIET, intravenous glucose is given in combination with short-acting insulin to prevent the development of hypoglycaemia due to high-dose insulin.
If indicated, to initiate HIET for adults, use:
short-acting insulin 1 unit/kg intravenously, by slow injection1 resuscitation for poisonings - HIET
PLUS EITHER
1 glucose 50% 50 mL intravenously, by slow injection, preferably via a central venous catheter or a large peripheral vein resuscitation for poisonings - HIET
OR
1 glucose 10% 250 mL intravenously, by slow injection, via a large peripheral vein.
For follow-on HIET in adults, use:
short-acting insulin 1 unit/kg/hour by intravenous infusion1. If there is no inotropic response after 30 minutes, increase the infusion rate by 1 unit/kg/hour up to a maximum of 10 units/kg/hour in consultation with a clinical toxicologist
PLUS EITHER
1 glucose 50% by intravenous infusion via a central venous catheter; start at 20 mL/hour (10 g/hour), then titrate to achieve a blood glucose concentration between 4 and 8 mmol/L
OR
1 glucose 10% by intravenous infusion via a large peripheral vein; start at 100 mL/hour (10 g/hour), then titrate to achieve a blood glucose concentration between 4 and 8 mmol/L.
If indicated, to initiate HIET for children, use:
short-acting insulin 1 unit/kg intravenously, by slow injection1
PLUS
glucose 10% 2.5 mL/kg intravenously, by slow injection, via a large peripheral vein.
For follow-on HIET in children, use:
short-acting insulin 1 unit/kg/hour by intravenous infusion1. If there is no inotropic response after 30 minutes, increase the infusion rate by 1 unit/kg/hour up to a maximum of 10 units/kg/hour in consultation with a clinical toxicologist
PLUS
glucose 10% by intravenous infusion via a large peripheral vein; start at 2.5 mL/kg/hour up to 100 mL/hour (0.25 g/kg/hour up to 10 g/hour), then titrate to achieve a blood glucose concentration between 4 and 8 mmol/L.
Adverse effects of HIET are hypoglycaemia (despite the intravenous glucose infusion) and hypokalaemia. Monitor the blood glucose concentration every 30 to 60 minutes and give top-up intravenous bolus injections of glucose if the patient is hypoglycaemic (see Hypoglycaemia due to HIET). Check the serum potassium concentration every 2 to 4 hours and replace potassium if required (see Hypokalaemia due to HIET).