Phenotype-specific insulin strategies in shock states: A critical reappraisal
Phenotype-specific insulin in shock
DOI:
https://doi.org/10.54205/ccc.v34.279782Keywords:
Insulin, Septic shock, Cardiogenic shock, Septic cardiomyopathy, Metabolic resuscitation, High-dose insulin therapy, Glucose-Insulin-PotassiumAbstract
The use of insulin in critical care involves three distinct strategies: Intensive Insulin Therapy (IIT), High-Dose Insulin (HDI), and Glucose-Insulin-Potassium (GIK). This review clarifies their indications, mechanisms, and safety profiles. IIT primarily targets stress-induced hyperglycemia in sepsis; however, current guidelines recommend a moderate target (140–180 mg/dL) to avoid hypoglycemia, functioning as a supportive measure without direct mortality benefit. HDI serves as a potent inotropic antidote for refractory calcium channel blocker and beta-blocker poisoning. Its safe use requires concentrated dextrose to prevent fluid overload and strict "permissive hypokalemia" management. GIK is an investigational "metabolic resuscitation" therapy aimed at recruiting hibernating myocardium in septic cardiomyopathy. While potentially beneficial for hypodynamic states, GIK poses a significant risk of severe hypotension in vasoplegic patients due to insulin's vasodilatory effects. Matching the correct insulin strategy to the patient's specific hemodynamic phenotype is critical to maximize efficacy and prevent life-threatening complications.
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