Glucose-Insulin-Potassium sometimes useful in post-op cases of low ejection fraction also useful in cases who are on diuretics for a prolonged period, one should be careful of rebound hyperkalemia after stopping the infusion

To Dr. Vikas Goyal, thank you for your answer.

I'm interesting in your approach.

Which protocol do you use in this situation (dosage of Glucose, Insuline, Potassium) and the time of its administration.

Greetings from Moldova.

Veaceslav SAVAN

In my experience the key is to mantein a good potassium level(specific in bad ventricle when you came out off pump and also in off pump cases) and good glucose level eventually we used when we need to correct a situation but not in all cases

I have used it in low EF patients frequently from 10h preoperative till to aortic declamping. It is associated with less pro BNP post operatively and need to inotropes. My suggested formula:50ml/h

D/W 10% 500 ml+ KCl 40 meq+ Insulin regular 25 u( in diabetic patients:40 u)+ 2g MgSO4

It is generally accepted that GIK improves outcome. However level of evidence is not high. Regarding the formula there are many formulas that are just common in having glucose, insulin and potassium!

We used to use this formula in our daily practice in OR in low EF patients:

50 cc Syringe: D50W 40 ml, KCl 20 mEq, Insulin 20 IU (regardless of being diabetic or not, of course with repeated serum BS and potassium tests), MgSO4 2g

infusion rate: 20 ml/h

Literature does not strongly support employing GIK and we cannot find clinically significant effect. So in our center, we don't use it anymore.

Dear colleagues, I thank you greatly for your interest in this subject.

As you have seen, in every medical center GIK formulas are different, as result the outcomes are different.

Although some studies have demonstrated the ineffectiveness of GIK, in the last year some publications raise the interest in returning to this therapeutic approach.

Some results are presented below.

Straus S, Gerc V, Kacila M, Faruk C. Glucosa-Insulin-Potassium (GIK) solution used with diabetic patients provides better recovery after coronary bypass operations. Med Arh. 2013;67(2):84-7. They found that intraoperative GIK solution given to diabetic patients with CABG operation provides more stable CI, shorter time of MV, more stable values of potassium which provides normal rhythm and less AF onset, less insulin to maintain target glycemia. All the above mentioned provides more stable intraoperative hemodynamic and better recovery of diabetic.

Shim JK, Yang SY, Yoo YC, Yoo KJ, Kwak YL.

Myocardial protection by glucose-insulin-potassium in acute coronary syndrome patients undergoing urgent multivessel off-pump coronary artery bypass surgery. Br J Anaesth. 2013 Jan;110(1):47-53. It is a randomized and controlled trial. They used GIK in Acute Coronarian Syndrome patients undergoing urgent multivessel OPCAB. They observed that GIK significantly attenuated the degree of ensuing myocardial injury without complications related to glycemic control. Their formula in studied group: 0.3 ml kg(-1) h(-2) GIK solution (potassium 80 mEq and regular insulin 325 IU in 500 ml of 50% glucose upon anesthetic induction until 6 h after reperfusion.

Howell NJ, Ashrafian H, Drury NE, et al. Glucose-insulin-potassium reduces the incidence of low cardiac output episodes after aortic valve replacement for aortic stenosis in patients with left ventricular hypertrophy: results from the Hypertrophy, Insulin, Glucose, and Electrolytes (HINGE) trial. Circulation. 2011 Jan 18;123(2):170-7.

The trial was double-blind and conducted at a single center. (217 patients).

Perioperative treatment with GIK was associated with a significant reduction in the incidence of low cardiac output state and the need for inotropic support.

I think that GIK may have her place in perioperative management of cardiac surgery, especially in patient with preoperative low cardiac output. A use of significant insulin dosage (minimum 1UI/kg at induction of anesthesia during one hour, for example) may be of interest in the physiology of cardiac protection during aortic clamping. Glucose and potassium are needed in this therapeutic approach as correction of secondary effect of insulin.

What is your opinion in this attitude?

I have been used GIK since 2005 in all of CABG patients ,regardless of ejection fraction, age, and history of MI .

My protocol in nondiabetic patients is 500 cc D/W 10% +15 meq KCl +5 units insulin with speed of 50 cc/ hour.

In diabetics 500 cc D/W 5 % +15 meq KCl + 10 units insulin with speed of 50 cc/hour.

Mortality, morbidity ,IABP insertion,and hospital stay is dramatically less than my other colleagues, and i am collecting my data for publishing in the future.

we use insulin infusion in the night of admission, and first 24 hours post-operative , then convert to s/c injection if the patient stable, and before transfer to the word.

Acutely we did not use potassium in combination with insulin, but we check the level of serum potassium frequently through ABG, or when we check the laytes , and be careful second day, especially if the patient required big dose of insulin day of operation, as second day the patients will be hyperkalemic and will require to be on hyperkalemic protocol as sometimes the serum potassium sometimes exceed 6.5, so we advice frequent check of serum level of potassium in this case to control

the induced killing hyperkalmia

We use GIK + MgSO4 in all "on pump" cases, starting before opening the chest and we keep the infusion 6 hours pos-operatively.

He ´ve seen a reduction in pos-op. arritmias, including atrial fibrillation, but no difference in mortality.