Protocol

• Prepare a solution of 250 units of rapid-acting insulin (Regular, Actrapid) in 250 ml 0.9 percent normal saline (1 U = 1 ml).

• Measure blood glucose with a usual portable meter.

• Evaluate the patient's general status.

• Categorize the patient into one of two groups based on the Killip classification. (The Killip classification, published in 1967, categorizes patients with an acute myocardial infarction based upon the presence or absence of simple physical examination findings that suggest left ventricular dysfunction: Class I - no evidence of heart faliure (HF): Class II - finding consistent with mild to modulate HF (S3, lung rates less than one-half way up the posterior lung fields, or jugular venous distension); Class III - pulmonary oedema; class IV - cardiogenic shock.)

- Group A: Patients without heart failure (Killip stage I), patients with mild heart failure (Killip stage II).

- Group B: Patients with severe heart failure (Killip stage III), patients with cardiogenic shock (Killip stage IV).

Table 16.2. Infusion of insulin solution in diabetic persons with acute myocardial infarction (AMI)

Serum glucose

Insulin infusion rate (U/h)

mg/dl (mmol/L)

Group A

Group B

< 75 (4.2)

0

0

75-120 (4.2-6.7)

1

2

120-200 (6.7-11.1)

2

S

200-240 (11.1-1S.S)

S

5

> 240 (1S.S)

6

9

Infusion of the solution is done as shown in Table 16.2.

• The infusion rate is increased by 50 percent in obese patients (BMI > 28 kg/m2).

• Hourly blood glucose monitoring is necessary, until it stabilizes around 75-100 mg/dl (4.1-5.6 mmol/L) in three consecutive measurements. Afterwards, monitoring is done every two hours for four hours and then every four hours for twelve hours.

• Serum K+ levels are measured every twelve hours. Addition of K+ in the solution is done when levels are < 3.6 mmol/L.

We evaluate precision of the portable meter's measurements by comparing them with those of the laboratory every 4-6 hours. This protocol was proposed by Hendra and Yudkin in 1992.

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