Transient extreme insulin resistance in a patient requiring extracorporeal membrane oxygenation for cardiogenic shock: A case report

Acute and extreme insulin resistance with persistent hyperglycemia requiring excessively high doses of insulin before rapidly resolving is rare and has been referred to as transient and extreme insulin resistance (TEIR). The underlying pathophysiology and optimal management of TEIR are poorly understood, and previous reports of TEIR in the literature are sparse. This report is the first description of TEIR in a patient requiring mechanical circulatory support (MCS).

A 62-year-old male developed cardiogenic shock and was placed on veno-arterial extracorporeal membrane oxygenation following percutaneous coronary intervention and successful revascularization. Over the next 24 hours, glucose levels rose and remained markedly elevated despite increasing insulin infusion rates and repeated boluses. The insulin infusion rate peaked at 450 units/hour, and the patient received 4300 units (33 units/kg) of insulin over the 24-hour period of peak insulin resistance. Insulin resistance resolved rapidly, necessitating an abrupt decrease in the insulin infusion rate and development of rebound hypoglycemia.

Onset of TEIR did not seem to correlate with end-organ hypoperfusion or vasoactive drug dosing.