• Kartik R Shah, Thomas M Przybysz, Deepu Ushakumari, and Ann-Jeannette Geib.
• Division of Medical Toxicology, Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA.
• Medicine (Baltimore). 2022 Aug 26; 101 (34): e30267.

RationaleHigh-dose insulin (HDI) therapy has been used as inotropic support for toxin-induced cardiogenic shock, but literature suggests that it can also be used in non-toxin-induced cardiogenic shock states. Its use has not been reported in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation.Patient ConcernsA 56-year-old male presented with progressive dyspnea and lower extremity edema without any reported toxic ingestion.DiagnosisAfter left heart catheterization, he was diagnosed with acute biventricular nonischemic cardiac failure that ultimately required VA-ECMO support for 8 days, after which decannulation was planned.InterventionsDuring decannulation, he was initiated on HDI therapy via a 1 U/kg regular insulin bolus with 25 g of dextrose and a 1 U/kg/hr insulin infusion.OutcomesDuring the decannulation, he was monitored with transesophageal echocardiography. Initially, left ventricular (LV) ejection fraction (EF) was estimated at 10% to 15%. Transesophageal echocardiography after HDI but prior to decannulation showed LVEF 30% to 40%. Transthoracic echocardiography 3.5 hours after HDI bolus and decannulation revealed normal LV systolic function; LVEF 50% to 55%.LessonsWhile multiple interventions occurred during decannulation, HDI therapy may have assisted in transitioning off ECMO support, and HDI should be investigated as an adjunctive option in future decannulations and other non-toxin-induced cardiogenic shock states.Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

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