Pulmonary Consolidation Associated with Infusion of a Glucose-Insulin-Potassium Solution in Acute Myocardial·tnfarction* Larry E. Dye, M.D.; Myung Soo Shin, M.D.; David M. Witten, M.D.; Richard 0. Russell, ]r., M.D., F.C.C.P.; Charles E. Rackley, M.D., F.C.C.P.; and David E. Hogg, M.D.

From 1972 to 1975, we have observed seven patients with localized pulmonary consolidation distal to the tip of a Swan-Ganz catheter. These seven instances occurred in a population of over 300 patients receiving a hypertonic solution of glucose, insulin, and potassium for acute myocardial infarction. In four patients the glucose-insuUnpotassium solution was instilled direcdy into the right

T he value of infusion of a solution of glucose,

insulin, and potassium during acute myocardial infarction is presently under investigation at our institution. During the period from 1972 to 1975, such an infusion was used in over 300 patients. Seven of these patients developed pulmonary consolidation in relation to the infusion and the position of the Swan-Ganz catheter. In only two of these patients could evidence of wedging of the catheter be incriminated, and we suspect that the pulmonary consolidation was related directly to the infusion of the glucose-insulin-potassium solution. The purpose of this communication is to describe the previously unreported roentgenographic appearance of this possible complication of infusion of a glucose-insulinpotassium solution and to discuss methods of preventing this complication. CLINICAL MATERIAL

All patients admitted to the Myocardial Infarction Research Unit for suspected acute myocardial infarction who are

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°From the Departments of Medicine and Diagnostic Radiology, School of Medicine, University of Alabama, Birmingham. Read before the 62nd scientific assembly and annual meeting, Radiological Society of North America, Chicago, Nov. 18, 1976 This research was supported in part by the Specialized Center of Research for Ischemic Heart Disease, Contract No. 1P17HL7667-03, the Cardiovascular Research Training Center, Program Project Grant No. HL 11,310 (Division of Heart and Vascular Disease, National Heart and Lung Institute), NIH Grant No. T01LM00154, the Clinical Research Unit Grant No. M01-R0003213 (General Clinical Research Centers Program, Division of Research Resources), National Institutes of Health, and VA Project No. 5566-01. Manuscript received March 10; revision accepted June 2. Reprint requests: Dr. Russell, University Station, Birmingham 35294

CHEST, 73: 2, FEBRUARY, 1978

pulmonary artery from the tip of the Swan-Ganz catheter. In the subsequent three patients the solution was administered via the right atrial port and thus perfused the entire pulmonary vascular bed. The roentgenographic appearance of this localized pulmonary consoUdation is inWstingnishable from infarction caused by pulmonary tbromboembolus or wedging of the catheter.

candidates for therapy with a glucose-insulin-potassium solution have a Swan-Ganz catheter inserted from the antecubital fossa. We insert all catheters under direct fluoroscopic control and position the tip in the right pulmonary artery. After the catheter is advanced from the right ventricle to the pulmonary artery, air is removed from the balloon under fluoroscopic guidance to ensure complete deflation of the balloon. Pulmonary capillary pressure is obtained by advancing the catheter in the pulmonary artery to the wedged position under fluoroscopic control, generally without using the balloon for wedging. Then the catheter is retracted to the main pulmonary artery. If the pulmonary capillary wedge pressure is in close agreement with the pulmonary arterial end-diastolic pressure, we use the latter for continuous hemodynamic monitoring; and the catheter is never repositioned in the wedged position. A continuous display of the pulmonary arterial pressure wave form is available, and nursing personnel are trained to observe changes in the pressure wave form that might indicate wedging of the catheter. In addition, pulmonary arterial pressures are recorded each hour and are stored in a computer that subsequently yields a printout of all pressures to become part of the hospital's record. A continuous infusion of heparinized saline solution is delivered through the catheter as well. The glucose-insulin-potassium solution is composed of a 30 percent solution of dextrose in 1,000 ml of water containing 50 units of regular insulin and 80 mEq of potassium chloride; the solution has an osmolality of 1,827 mOsm and a pH of 4.5.1 Infusion is maintained at a rate of 1.5 ml/kg/hr for 48 hours. Initially, the infusion was delivered directly into the pulmonary artery, and the first four patients to whom the solution was given developed pulmonary consolidations. In none of these patients was there evidence for wedging of the catheter. After the experience with these first four patients, the glucose-insulin-potassium solution has been delivered into the right atrial port of a triple-lumen Swan-Ganz catheter. Since then, we have observed only three instances of pulmonary infiltration in over 300 patients, and two of these instances were possibly related to wedging of the catheter.

PULMONARY CONSOLIDATION ASSOCIATED WITH INFUSION 179

Table !-Pulmonary Comolidation• during lnfu.ion of Gluco•e-ln•ulin-Pota..ium Solution OnsPt of Pulmonary Consolidation after Start of Infusion, hr

Case, Age (yr), Sex

Location of lnfuret

Site of Infusion

Complieating Faet.ors•

1, 55, M

Anterior

Pulmonary artery

Hypotension; arrhythmias; cardiac index, 0.8 L/ min / sq m

24

Fever

Rules; fever

No

2, 62, M

Anterior

Pulmonary artery

None

30

Fever; pleuritic pain

Friction rub

No

3, 43, M

Inferior

Pulmonary artery

Vcntricular fibrillation

72

Fever

Rales

No

4, 71, F

Inferior

Pulmonary artery

Hypotension ; pericarditis ; june! ional rhythm

48

None

None

No

5, 67, F

Inferior

Right atrium

Transv

Pulmonary consolidation associated with infusion of a glucose-insulin-potassium solution in acute myocardial infarction.

Pulmonary Consolidation Associated with Infusion of a Glucose-Insulin-Potassium Solution in Acute Myocardial·tnfarction* Larry E. Dye, M.D.; Myung Soo...
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