High dose insulin (HDI) improves shock via at least four mechanisms. What are they?
1. HDI acts as a potent inotrope, increasing stroke volume and therefore cardiac output by calcium-dependent and calcium-independent pathways in myocardial cells. 2. HDI optimizes myocardial energy utilization as stressed myocardial tissue tends to use glucose for energy rather than free fatty acids. 3. HDI improves the endocrine dysfunction and resultant hyperglycemia seen in CCB poisoning. HDI acts as a vasodilator via enhancement of endothelial nitric oxide synthase (eNOS). This vasodilation results in increased cardiac output and improves the microvascular dysfunction associated with cardiogenic shock
Cole JB, Lee SC, Prekker ME, Kunzler NM, Considine KA, Driver BE, Puskarich MA, Olives TD. Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines. Clin Toxicol (Phila). 2022 Nov;60(11):1205-1213. doi: 10.1080/15563650.2022.2131565. Epub 2022 Oct 25. PMID: 36282196.