New Orleans—Emergency department pharmacists in Minnesota have developed a standardized order set for hyperinsulinemia-euglycemia (HIE) treatment that may reduce apprehension about using the uncommon but effective therapy for severe calcium channel blocker (CCB) and β-blocker (BB) toxicity.
Presenting the order set at the American Society of Health-System Pharmacists Midyear Clinical Meeting (poster 5-082), investigator Kimberly Glasoe, PharmD, noted that the impetus for development of the order set was inconsistencies and confusion when HIE had been initiated. “The first time HIE was tossed around as an option for CCB and BB toxicity, my pharmacist colleagues were uncomfortable filling the orders,” recalled Dr. Glasoe, an emergency medicine clinical pharmacist at Mercy Hospital, part of Allina Health, in Coon Rapids, Minn., who developed the order set with Stacey VanSickle, PharmD, also an emergency medicine clinical pharmacist at Mercy. “We had experienced a lot of hesitation with both the nursing staff and the physicians caring for patients administered HIE,” said Dr. Glasoe.
She and Dr. VanSickle examined pharmacy orders for four patients who had received HIE treatment for CCB or BB overdose and found that the patients received different activated charcoal doses, dextrose and insulin concentrations and calcium salt formulations, as well as different potassium replacement products and vasopressors. There also were inconsistencies in the monitoring of arterial blood gases and ionized calcium and the interval between blood glucose measurements, as well as variations in lactate testing.
After reviewing the literature and consulting with local toxicology experts, they developed a standardized protocol that specifies, among other parameters, administering an initial IV bolus of 1 unit/kg followed by a concentrated infusion of 10 units/mL at a rate of 1 to 10 units/kg per hour. It also recommends concurrent dextrose infusion, electrolyte administration and measurement of glucose every 10 minutes when insulin is being titrated and every 30 minutes once insulin is stabilized. The protocol also recommends measuring ionized calcium every 30 minutes with calcium gluconate administration, monitoring a basic metabolic panel and measuring lactate and arterial blood gas.
Dr. Glasoe added that “because we had to build the drip into our electronic medical record each time we ordered an infusion, we built it in permanently.” She suggested other pharmacies should do the same to avoid potential treatment delays.
Daniel Hays, PharmD, the clinical coordinator of emergency pharmacy services in the Departments of Pharmacy and Emergency Medicine at the University of Arizona Health Network, in Tucson, who was not involved in the research, said an order set like this should indeed make HIE treatment more manageable and shorten the time between the decision to go ahead with HIE and actual initiation of treatment. “Pharmacists should feel more comfortable, less apprehensive and know exactly what they need to order,” Dr. Hays said. “From a clinician’s point of view, the order set would be a reassuring guide to an unusual treatment.”
Drs. Glasoe and Hays reported no
relevant financial conflicts of interest.