(158) Evaluation of Time to Initiation of Hyperinsulinemia Euglycemia Therapy

Introduction: Hyperinsulinemia euglycemia therapy (HIET) is established as a treatment option for patients with hemodynamic compromise due to calcium channel blocker (CCB) or beta blocker (BB) overdose, but the optimal timing of initiation is unknown. This study evaluated the effect of early versus late initiation of HIET on morbidity and mortality in CCB/BB overdose.

Methods: This was a two-center, retrospective, observational cohort study of adult patients presenting with presumed CCB/BB overdose and treated with HIET at doses ≥0.5 units/kg/hr from 2013 through 2023. Patients were stratified into the early initiation cohort or late initiation cohort based on the median time from presumed ingestion to time to initiation of HIET in the study population. The primary outcome was the incidence of all-cause, in-hospital mortality. Secondary outcomes included hospital length of stay (LOS), vasopressor-free days, median norepinephrine equivalents, incidence of renal replacement therapy (RRT), use of additional supportive therapies, and risk factor determination for mortality.

Results: Forty-three patients (22 [51%] early, 21 [49%] late) were included. Median time from presumed ingestion to HIET initiation was 5.9 hours (IQR 3.8-8.9). Demographics were similar between groups, except the early initiation cohort had increased ingestion of BB (12 [55%] vs 5 [24%], p=0.04), and significantly lower MAP at baseline (60 [IQR 49-75] vs 77 [IQR 65-95] mmHg, p=0.009). All-cause, in-hospital mortality occurred in 7 patients (32%) in the early versus 5 patients (24%) in the late initiation cohort (hazard ratio, 0.69 [95% CI, 0.22 to 2.2], p=0.52). There were no differences in hospital LOS (6.5 [IQR 2.1-14] vs 7.2 [4.3-13] days, p=0.51) and incidence of RRT (8 [36%] vs 8 [38%], p=0.91) between groups. Vasopressor-free days (24 [IQR 0-26] vs 25 [IQR 9.5-26] days, p=0.98) and median norepinephrine equivalents (10 [IQR 0-36] vs 25.1 [0-50] mcg/min, p=0.44) were similar between groups. Patients who received methylene blue, plasma exchange, and >4 additional supportive therapies had increased incidence of mortality. APACHE II score was identified as an independent risk factor for mortality.

Conclusions: Early initiation of HIET for CCB/BB overdose had similar morbidity and mortality outcomes when compared to late initiation.