GIK by Paramedics... New Study

18G

18G

Paramedic
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Full Study

http://jama.ama-assn.org/content/early/2012/03/21/jama.2012.426.full

Link to full study.

Mechanisms still not fully understood. Search PubMed for other studies, some of them go over the underlying principles....in the past GIK was shown to decrease levels of C reactive protein (biomarker of inflammation) by 40% in ACS, theorized due to anti-inflammatory effects of insulin. It was researched back in the 90's but kinda pushed aside in favor of PCI/thrombolytic therapy. It seems to be making a resurgence now.

Quoted from the study:

"Experimental and clinical studies have shown intravenous glucose-insulin-potassium (GIK) to have 2 types of benefits in cardiac ischemic syndromes. One is protecting against myocardial injury by providing metabolic support to ischemic myocardium, which should limit progression of unstable angina pectoris to myocardial infarction (MI), lessen infarct size, and thereby preserve left ventricular (LV) function.1​,2,3​,4,5​,6,7​,8 The other is preventing arrhythmias and cardiac arrest associated with ischemia-related metabolic derangements thought to be promoted by the elevated free fatty acid (FFA) levels during acute coronary syndromes (ACS).1​,9 One or both mechanisms could be expected to reduce short- and long-term mortality."

On a side note, it seems the EMSWorld article is alot more encouraging than the actually study data is...

Quoted:

"In conclusion, among patients with suspected ACS, out-of-hospital administration of intravenous GIK by paramedics, compared with administration of glucose placebo, did not reduce progression to MI. Compared with placebo, GIK administration was not associated with improvement in 30-day survival but was associated with lower rates of the composite outcome of cardiac arrest or in-hospital mortality. Further studies are needed to assess the out-of-hospital use of GIK as therapy for patients with ACS."
 
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Ischemic cells lack ATP and have an influx of sodium due to a breakdown of the sodium potassium pump. My guess* is that the combination of the 3 results in a boost of ATP and helps get it into the cells providing a more favorable environment for the cells to function and resuscitation to happen.

*completely uneducated guess.
 
Dig into the references at the end of the study, they are good for helping explain the theorized effects
 
I love whenever a prehospital study gets top billing in JAMA or NEJM, especially when it's a positive study ("Paramedics can save lives with IM Versed!"), and maybe less so when it's a negative study ("Paramedics are killing cardiac arrest patients with epinephrine!").

Nonetheless, it's probably a little early too get too involved in the mechanism, when the effect hasn't really been well-demonstrated. Keep in mind that the primary outcome was negative - giving G-I-K early did not prevent progression to MI. It's a negative study, and the authors are classy about making that clear.

Now, the reduction in hospital mortality/cardiac arrest is an interesting finding, but as the authors note, this is best seen as hypothesis-generating, rather than solid proof. Still, it's good to see EMS taking center stage in ACS management, with a larger role than "drive real fast to the cath lab!"
 
I was listening to a recorded lecture of a well known EM physician who mentioned studies into GIK... something along the lines of "they're wasting their time - it didn't work then and it won't work now". I guess he may have to reconsider a little. I just skimmed the study and it certainly looks promising, but I personally would conclude that more research is needed before adding it to any protocols.

The researchers and medics involved certainly deserve a pat-on-the-back for their effort.
 
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