1021: CALCIUM CHANNEL AND BETA BLOCKER TOXICITY: IMPLEMENTING USE OF HIGH-DOSE INSULIN EUGLYCEMIA THERAPY

Abstract

Introduction: Calcium channel blockers (CCB) and beta blockers (BB) account for 4% and 3% of fatal overdoses in the US, respectively. High-dose insulin euglycemia therapy (HIET) has been shown to effectively treat CCB and BB overdose through their positive inotropic effects. Insulin is a high-alert medication per the Institute for Safe Medication Practice (ISMP) and bedside nursing titration as a hemodynamic agent is an unfamiliar practice and at risk for medication errors. An index patient presenting with CCB overdose at our hospital uncovered the need to create and improve safe use and monitoring of this therapy. Methods: An interdisciplinary team consisting of Critical Care, ED, Poison Control/Toxicology, Diabetes Specialist, Clinical Nurse Specialists and Pharmacists convened to review current practice and establish standardized practices to optimize safety and quality. The group reviewed evidence, expert practices, and other hospitals’ workflows to develop 1) an ED/Inpatient Adult Calcium Channel/Beta Blocker Overdose Roadmap and 2) Orderset. The workflow standardized elements such as: weight-based dosing units, concentrated insulin infusion, concentrated dextrose maintenance infusion and dextrose rescue dosing, lab monitoring, nursing assessments and titrations based on mean arterial pressure and blood glucose and provider notification parameters. After each patient encounter using HIET, the QI group meets and review the case to further optimize orders and processes. Results: Post-implementation of roadmap and orderset, 4 patients used the standardized insulin infusion concentrations of 16 unit/mL, decreasing the fluid burden from 8.4L/day to 0.5L/day for a 70kg patient. Insulin bolus was used in 3 of 4 (75%) patients. Average insulin dose was 7 unit/kg/hr (range 3-10 units/kg/hr) and average duration of infusion was 117 hours (range 57-150 hrs). One of four patients (25%) proceeded to require ECMO, 3 of 4 (75%) patients survived, and no patient experienced hypoglycemia (BG< 70 mg/dL) using the protocol. Conclusions: Roadmap and orderset with standardized concentrations, specified titration parameters, and protocolized dextrose titration for this unfamiliar insulin inotropic therapy provided a safe environment to practice this high-risk HIET medication therapy. Research Snapshot Theater: Quality and Patient Safety/Pharmacology II