Contraindications for High-Dose Insulin Euglycemia Therapy in Aluminum Phosphide Poisoning
There are only two absolute contraindications to high-dose insulin (HDI) euglycemia therapy in aluminum phosphide poisoning: active hypoglycemia at the time of administration and known hypersensitivity to insulin or its excipients. 1
Absolute Contraindications
- Active hypoglycemia - HDI therapy cannot be initiated during episodes of hypoglycemia 1
- Known hypersensitivity - Documented allergy to insulin or any excipient components is an absolute contraindication 1
Critical Monitoring Requirements (Not Contraindications)
While the following are not contraindications, they require intensive monitoring and management during HDI therapy:
Metabolic Monitoring
- Hyperglycemia management - Hyperglycemia occurs significantly more frequently with HDI therapy but is easily managed with dextrose titration 2
- Hypokalemia risk - Potassium levels must be monitored closely as insulin drives potassium intracellularly; supplementation is typically required 3
- Volume overload - The large dextrose infusions required to maintain euglycemia can cause fluid overload 3
Practical Implementation Considerations
HDI therapy should NOT be withheld in aluminum phosphide poisoning based on relative concerns, as the mortality benefit is substantial:
- Mortality reduction from 73-96% to 47-65% with HDI therapy 2, 4
- Significant improvement in hemodynamics (blood pressure, vasopressor requirements) 4
- Reduced need for mechanical ventilation 2, 4
Dosing Protocol for Aluminum Phosphide Poisoning
Based on evidence from calcium channel blocker and beta-blocker poisoning protocols adapted for aluminum phosphide:
- Initial bolus: 1 U/kg regular insulin IV 5
- Continuous infusion: 1 U/kg/hour, titrated to clinical effect 5
- Dextrose co-administration: Maintain euglycemia with dextrose infusion as needed 3
- Potassium supplementation: Monitor and replace potassium to maintain normal levels 3
Key Clinical Pitfalls
- Do not delay HDI therapy waiting for "ideal" conditions - aluminum phosphide poisoning has 90% mortality without aggressive intervention 6
- Do not withhold due to hyperglycemia concerns - this is expected and manageable 2
- Do not use vasopressors alone - vasopressor-only therapy is associated with very poor outcomes in aluminum phosphide poisoning 4