Zinc phosphide poisoning - Revision history

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 * All intentional ingestions: psychiatric evaluation mandatory prior to discharge
 *Contact [[Poison control]] (1-800-222-1222 in the US) for all cases
 ==See Also==

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Ostermayer: Created page with "Zinc phosphide (Zn₃P₂) poisoning is a potentially lethal toxicity caused by ingestion of a widely available rodenticide. Upon contact with gastric acid, zinc phosphide is hydrolyzed into '''phosphine gas (PH₃)''', which inhibits mitochondrial cytochrome C oxidase and causes multiorgan cellular hypoxia and death.Arroyo-Arcos CR, et al. Zinc Phosphide Poisoning: From A to Z. ''Toxics''. 2023;11(7):555. doi:10.3390/toxics11070555 There is ''..."

2026-03-17T23:11:11Z

Created page with "Zinc phosphide (Zn₃P₂) poisoning is a potentially lethal toxicity caused by ingestion of a widely available rodenticide. Upon contact with gastric acid, zinc phosphide is hydrolyzed into '''phosphine gas (PH₃)''', which inhibits mitochondrial cytochrome C oxidase and causes multiorgan cellular hypoxia and death.<ref name="Diaz2023">Arroyo-Arcos CR, et al. Zinc Phosphide Poisoning: From A to Z. ''Toxics''. 2023;11(7):555. doi:10.3390/toxics11070555</ref> There is ''..."

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Zinc phosphide (Zn₃P₂) poisoning is a potentially lethal toxicity caused by ingestion of a widely available rodenticide. Upon contact with gastric acid, zinc phosphide is hydrolyzed into '''phosphine gas (PH₃)''', which inhibits mitochondrial cytochrome C oxidase and causes multiorgan cellular hypoxia and death.<ref name="Diaz2023">Arroyo-Arcos CR, et al. Zinc Phosphide Poisoning: From A to Z. ''Toxics''. 2023;11(7):555. doi:10.3390/toxics11070555</ref> There is '''no specific antidote'''; mortality ranges from 37-100% in severe cases.<ref name="Dogan2014">Dogan E, Güzel A, Ciftçi T, et al. Zinc Phosphide Poisoning. ''Case Rep Crit Care''. 2014;2014:589712. doi:10.1155/2014/589712</ref>

==Background==
*Zinc phosphide is a dark gray/black crystalline powder used as a rodenticide against mice, rats, gophers, and squirrels
*Registered for pesticide use in the United States since 1947; widely available in developing countries<ref name="NPIC">Zinc Phosphide Technical Fact Sheet. National Pesticide Information Center (NPIC). Oregon State University.</ref>
*Most cases of significant poisoning are '''intentional''' (self-harm) in adults, particularly in the Indian subcontinent, Iran, Thailand, and Mexico<ref name="Trakul2017">Trakulsrichai S, et al. Clinical characteristics of zinc phosphide poisoning in Thailand. ''Ther Clin Risk Manag''. 2017;13:335-340. doi:10.2147/TCRM.S129610</ref>
*Accidental ingestion occurs in children (attracted to bait formulations) and through contaminated food
*'''Toxic dose:''' symptoms may occur with >40 mg/dose; lethal dose estimated at 4-5 g in adults (approximately 40-80 mg/kg)<ref name="Proudfoot2009">Proudfoot AT. Aluminium and zinc phosphide poisoning. ''Clin Toxicol (Phila)''. 2009;47(2):89-100. doi:10.1080/15563650802016425</ref>

===Mechanism of toxicity===
*Zinc phosphide reacts with gastric HCl → liberates '''phosphine gas (PH₃)'''
**Gastric acid and recent food intake accelerate phosphine release
**An empty stomach may delay symptom onset up to 12 hours<ref name="NPIC"/>
*Phosphine is absorbed through the GI tract and lungs → distributed to liver, kidneys, heart, brain, and adrenals
*Phosphine '''inhibits cytochrome C oxidase''' (complex IV of mitochondrial electron transport chain) → disrupts oxidative phosphorylation → cellular anoxia<ref name="Diaz2023"/>
*Additionally causes direct '''oxidative stress''' with lipid peroxidation, glutathione depletion, and free radical formation
*Primary target organs: '''heart''' (most common cause of early death), '''lungs''', '''liver''', '''kidneys'''
*Zinc phosphide is '''radiopaque''' on abdominal radiography due to its zinc component<ref name="Hassanian2014">Hassanian-Moghaddam H, Shahnazi M, Zamani N, Bahrami-Motlagh H. Abdominal imaging in zinc phosphide poisoning. ''Emerg Radiol''. 2014;21(3):329-331. doi:10.1007/s10140-014-1195-3</ref>

===Healthcare worker safety===
*'''Phosphine gas may be released from the patient's vomitus and gastric contents''' — this is hazardous to healthcare workers<ref name="NPIC"/>
*Treat in a '''well-ventilated area''' or negative-pressure room
*Use appropriate personal protective equipment
*Gastric lavage effluent should be handled as hazardous material

==Clinical features==
*Onset of systemic symptoms is typically '''delayed''' compared to aluminum phosphide (hours to >12 hours post-ingestion)<ref name="Trakul2017"/>
*'''Patients may be initially asymptomatic and then deteriorate suddenly''' — including '''sudden cardiac arrest in asymptomatic patients'''<ref name="Parhizgar2020">Parhizgar P, et al. Sudden Cardiac Arrest in an Asymptomatic Zinc Phosphide-Poisoned Patient: A Case Report. ''Cardiovasc Toxicol''. 2020;20(5):525-530. doi:10.1007/s12012-020-09578-2</ref>

===Gastrointestinal (earliest)===
*Nausea, vomiting (may have garlic/fishy odor), retching
*Epigastric and abdominal pain
*Diarrhea (may be bloody)
*Hematemesis

===Cardiovascular (most common cause of death)===
*[[Hypotension|Hypotension]], circulatory collapse, refractory shock
*Myocarditis, pericarditis
*Cardiac dysrhythmias (most common terminal event)
*[[Acute pulmonary edema]]
*[[Congestive heart failure]]

===Respiratory===
*Dyspnea, tachypnea, cyanosis
*Acute pulmonary edema (cardiogenic and non-cardiogenic)
*[[ARDS]]
*Respiratory failure

===Metabolic===
*'''Severe metabolic acidosis''' (high anion gap; elevated lactate) — correlates with severity<ref name="Trakul2017"/>
*Hyperkalemia, hyponatremia, hypocalcemia, hypomagnesemia
*Hypoglycemia (poor prognostic indicator)

===Hepatic===
*Hepatocellular injury (elevated AST, ALT)
*Acute hepatic failure — may progress over the first week<ref name="Saraf2015">Saraf V, et al. Acute liver failure due to zinc phosphide containing rodenticide poisoning: clinical features and prognostic indicators of need for liver transplantation. ''Indian J Gastroenterol''. 2015;34(4):325-329. doi:10.1007/s12664-015-0583-2</ref>
*Coagulopathy

===Renal===
*[[Acute kidney injury]]
*Oliguria/anuria

===Neurologic===
*Headache, dizziness, agitation, restlessness
*Altered mental status, delirium
*Seizures, coma

===Hematologic===
*[[Methemoglobinemia]] (less common than in aluminum phosphide poisoning)
*Intravascular hemolysis (rare)
*[[DIC]]

==Differential diagnosis==
*[[Aluminum phosphide poisoning]] (more rapidly fatal; similar mechanism)
*[[Organophosphate poisoning]]
*[[Iron toxicity]]
*[[Arsenic poisoning]]
*[[Caustic ingestion]]
*[[Mushroom poisoning]] (amatoxin — for hepatic failure presentation)
*[[Copper sulfate toxicity]]
*[[Acetaminophen toxicity]] (for isolated hepatic failure)
*[[Myocardial infarction]] or [[Myocarditis|myocarditis]] (other causes)
*[[Septic shock]]

==Evaluation==
===Workup===
*'''Abdominal radiograph''' — zinc phosphide is '''radiopaque'''; positive X-ray is an indication for aggressive GI decontamination and portends worse prognosis<ref name="Hassanian2014"/>
**Serial abdominal X-rays to confirm complete decontamination
*'''ABG/VBG''' — metabolic acidosis with elevated lactate is the earliest and most sensitive marker of systemic toxicity; severity correlates with prognosis<ref name="Trakul2017"/>
*'''CBC, BMP, hepatic function panel, coagulation studies (PT/INR), lipase'''
*'''Cardiac biomarkers''' (troponin, BNP) — myocardial injury monitoring
*'''ECG''' — continuous monitoring for dysrhythmias; sinus tachycardia is common; may progress to fatal rhythm
*'''Blood glucose''' — hypoglycemia is a poor prognostic indicator
*'''Serum magnesium, calcium, phosphorus'''
*'''Methemoglobin level''' (co-oximetry)
*'''CK''' — for rhabdomyolysis
*'''Chest radiograph''' — for pulmonary edema, ARDS
*'''Salicylate, acetaminophen, ethanol levels''' — if intentional ingestion
*Phosphine levels are not routinely available or clinically useful in acute management
*'''Echocardiography''' — to assess myocardial function if hemodynamically unstable

===Diagnosis===
*Clinical: history of rodenticide ingestion + GI symptoms + metabolic acidosis + cardiovascular collapse
*'''Radiopaque material on abdominal X-ray''' in the setting of rodenticide ingestion is highly suggestive
*Garlic or decaying fish odor to breath/vomitus is a classic but unreliable finding
*Patients with positive abdominal X-ray are at higher risk for sudden deterioration even if asymptomatic<ref name="Hassanian2014"/>

==Management==
'''No specific antidote exists.''' Treatment is supportive with GI decontamination and organ support.<ref name="Diaz2023"/>

===GI decontamination===
*'''Gastric lavage with coconut oil''' (200 mL) '''+ sodium bicarbonate (NaHCO₃ 7.5%, 50 mL):'''<ref name="Diaz2023"/>
**Coconut oil forms a protective mucosal layer and may reduce phosphine liberation
**Bicarbonate decreases gastric acid–driven conversion of phosphide to phosphine
**'''Do NOT use water for lavage''' — water promotes phosphine gas formation
**Alternative lavage solutions: potassium permanganate (1:10,000), liquid paraffin, or olive oil
*'''Activated charcoal''' (50 g) — may reduce absorption; administer after lavage<ref name="Trakul2017"/>
*'''Whole-bowel irrigation''' with polyethylene glycol (PEG) — if radiopaque material visible beyond the stomach on X-ray
**Some authors caution that PEG's water base could promote phosphine release; castor oil is an alternative for bowel evacuation<ref name="Marashi2016">Shakoori V, et al. Successful management of zinc phosphide poisoning. ''Indian J Crit Care Med''. 2016;20(6):368-370. doi:10.4103/0972-5229.183907</ref>
*'''Repeat abdominal X-rays''' to confirm clearance of all radiopaque material

===Cardiovascular support===
*Aggressive IV fluid resuscitation
*'''Vasopressors''' (norepinephrine, dopamine) for refractory hypotension
*Continuous cardiac monitoring ('''sudden cardiac arrest may occur in asymptomatic patients''')<ref name="Parhizgar2020"/>
*'''Hyperinsulinemia-euglycemia therapy (HIE):''' case reports suggest benefit in refractory cardiogenic shock<ref name="Diaz2023"/>
**Insulin loading dose 1 IU/kg/h, maintenance 1-7 IU/kg/h; dextrose infusion to maintain euglycemia
*'''Intravenous lipid emulsion (ILE)''' — case reports of use for refractory shock; mechanism unclear<ref name="Diaz2023"/>

===Magnesium sulfate===
*'''IV magnesium sulfate''' — membrane stabilizer and antioxidant; case-control studies suggest mortality reduction >50%<ref name="Diaz2023"/>
*Multiple regimens described; one common protocol: 1 g/hour for 24 hours, then 1 g every 6 hours for 5-7 days
*Monitor serum magnesium; avoid toxicity (loss of deep tendon reflexes, respiratory depression)

===Antioxidant therapy===
*'''N-acetylcysteine (NAC):''' loading dose 140 mg/kg, maintenance 70 mg/kg for 17 doses — hepatoprotective, replenishes glutathione<ref name="Diaz2023"/>
*'''Vitamin C:''' 1 g IV q8h for the first 24 hours (antioxidant; limited evidence)
*'''Vitamin E:''' 100 IU q12h for 72 hours (antioxidant; limited evidence)
*'''Alpha-lipoic acid:''' iron chelation and antioxidant properties; case report of use in combination therapy<ref name="Hungary2020">Takacs A, et al. Successful management of zinc phosphide poisoning — a Hungarian case. ''Int J Emerg Med''. 2020;13:51. doi:10.1186/s12245-020-00307-8</ref>

===Metabolic acidosis===
*Correct with IV sodium bicarbonate as needed
*'''Refractory acidosis is a poor prognostic sign'''
*Treat underlying cause (tissue hypoperfusion)

===Organ failure management===
*'''Hepatic failure:''' supportive; vitamin K, FFP for coagulopathy; liver transplant if fulminant<ref name="Saraf2015"/>
*'''Acute kidney injury:''' hemodialysis for standard indications (uremia, hyperkalemia, volume overload, refractory acidosis)
**Hemodialysis does not effectively remove phosphine
*'''Methemoglobinemia:''' [[Methylene blue]] 1-2 mg/kg IV if symptomatic
*'''Intubation and mechanical ventilation''' for respiratory failure/pulmonary edema

==Disposition==
*'''All patients with confirmed or suspected zinc phosphide ingestion must be admitted''' — even if initially asymptomatic<ref name="Parhizgar2020"/>
*'''ICU admission''' for all significant ingestions — continuous cardiac monitoring is mandatory
*'''Monitoring period:''' minimum 72 hours; risk of cardiovascular collapse greatest in first 24-48 hours but delayed hepatic failure may occur through the first week<ref name="Saraf2015"/>
*Serial ABGs, LFTs, coagulation studies, renal function, and ECGs every 6-12 hours
*Serial abdominal X-rays until all radiopaque material has cleared
*Prognosis is worse with:<ref name="Trakul2017"/>
**Large ingested volume
**Delayed presentation to hospital
**Metabolic acidosis or elevated lactate at presentation
**Hypotension, tachycardia, or tachypnea on arrival
**Hyperkalemia, hypoglycemia
**Acute kidney injury, need for vasopressors or intubation
*'''All intentional ingestions:''' psychiatric evaluation mandatory prior to discharge
*Contact [[Poison control]] (1-800-222-1222 in the US) for all cases

==See Also==
*[[Aluminum phosphide poisoning]]
*[[Organophosphate poisoning]]
*[[Caustic ingestion]]
*[[Mushroom poisoning]]
*[[Iron toxicity]]
*[[Copper sulfate toxicity]]
*[[Methemoglobinemia]]
*[[Acute kidney injury]]
*[[Acute liver failure]]

==External Links==
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC10386637/ Toxics — Zinc Phosphide Poisoning: From A to Z (2023)]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC4101206/ Case Rep Crit Care — Zinc Phosphide Poisoning (2014)]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC5360397/ Ther Clin Risk Manag — Clinical characteristics of zinc phosphide poisoning in Thailand (2017)]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC4922293/ Indian J Crit Care Med — Successful management of zinc phosphide poisoning (2016)]
*[https://npic.orst.edu/factsheets/znpgen.html NPIC — Zinc Phosphide Fact Sheet]

==References==
<references/>

[[Category:Toxicology]]

← Older revision		Revision as of 09:31, 22 March 2026
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	*Zinc phosphide is a dark gray/black crystalline powder used as a rodenticide against mice, rats, gophers, and squirrels		*Zinc phosphide is a dark gray/black crystalline powder used as a rodenticide against mice, rats, gophers, and squirrels
	*Registered for pesticide use in the United States since 1947; widely available in developing countries<ref name="NPIC">Zinc Phosphide Technical Fact Sheet. National Pesticide Information Center (NPIC). Oregon State University.</ref>		*Registered for pesticide use in the United States since 1947; widely available in developing countries<ref name="NPIC">Zinc Phosphide Technical Fact Sheet. National Pesticide Information Center (NPIC). Oregon State University.</ref>
	*Most cases of significant poisoning are ~~'''~~intentional~~'''~~ (self-harm) in adults, particularly in the Indian subcontinent, Iran, Thailand, and Mexico<ref name="Trakul2017">Trakulsrichai S, et al. Clinical characteristics of zinc phosphide poisoning in Thailand. ''Ther Clin Risk Manag''. 2017;13:335-340. doi:10.2147/TCRM.S129610</ref>		*Most cases of significant poisoning are intentional (self-harm) in adults, particularly in the Indian subcontinent, Iran, Thailand, and Mexico<ref name="Trakul2017">Trakulsrichai S, et al. Clinical characteristics of zinc phosphide poisoning in Thailand. ''Ther Clin Risk Manag''. 2017;13:335-340. doi:10.2147/TCRM.S129610</ref>
	*Accidental ingestion occurs in children (attracted to bait formulations) and through contaminated food		*Accidental ingestion occurs in children (attracted to bait formulations) and through contaminated food
	* Toxic dose: symptoms may occur with >40 mg/dose; lethal dose estimated at 4-5 g in adults (approximately 40-80 mg/kg)<ref name="Proudfoot2009">Proudfoot AT. Aluminium and zinc phosphide poisoning. ''Clin Toxicol (Phila)''. 2009;47(2):89-100. doi:10.1080/15563650802016425</ref>		* Toxic dose: symptoms may occur with >40 mg/dose; lethal dose estimated at 4-5 g in adults (approximately 40-80 mg/kg)<ref name="Proudfoot2009">Proudfoot AT. Aluminium and zinc phosphide poisoning. ''Clin Toxicol (Phila)''. 2009;47(2):89-100. doi:10.1080/15563650802016425</ref>

	===Mechanism of toxicity===		===Mechanism of toxicity===
	*Zinc phosphide reacts with gastric HCl → liberates ~~'''~~phosphine gas (PH₃)~~'''~~		*Zinc phosphide reacts with gastric HCl → liberates phosphine gas (PH₃)
	**Gastric acid and recent food intake accelerate phosphine release		**Gastric acid and recent food intake accelerate phosphine release
	**An empty stomach may delay symptom onset up to 12 hours<ref name="NPIC"/>		**An empty stomach may delay symptom onset up to 12 hours<ref name="NPIC"/>
	*Phosphine is absorbed through the GI tract and lungs → distributed to liver, kidneys, heart, brain, and adrenals		*Phosphine is absorbed through the GI tract and lungs → distributed to liver, kidneys, heart, brain, and adrenals
	*Phosphine ~~'''~~inhibits cytochrome C oxidase~~'''~~ (complex IV of mitochondrial electron transport chain) → disrupts oxidative phosphorylation → cellular anoxia<ref name="Diaz2023"/>		*Phosphine inhibits cytochrome C oxidase (complex IV of mitochondrial electron transport chain) → disrupts oxidative phosphorylation → cellular anoxia<ref name="Diaz2023"/>
	*Additionally causes direct ~~'''~~oxidative stress~~'''~~ with lipid peroxidation, glutathione depletion, and free radical formation		*Additionally causes direct oxidative stress with lipid peroxidation, glutathione depletion, and free radical formation
	*Primary target organs: '''heart''' (most common cause of early death), '''lungs''', '''liver''', '''kidneys'''		*Primary target organs: '''heart''' (most common cause of early death), '''lungs''', '''liver''', '''kidneys'''
	*Zinc phosphide is ~~'''~~radiopaque~~'''~~ on abdominal radiography due to its zinc component<ref name="Hassanian2014">Hassanian-Moghaddam H, Shahnazi M, Zamani N, Bahrami-Motlagh H. Abdominal imaging in zinc phosphide poisoning. ''Emerg Radiol''. 2014;21(3):329-331. doi:10.1007/s10140-014-1195-3</ref>		*Zinc phosphide is radiopaque on abdominal radiography due to its zinc component<ref name="Hassanian2014">Hassanian-Moghaddam H, Shahnazi M, Zamani N, Bahrami-Motlagh H. Abdominal imaging in zinc phosphide poisoning. ''Emerg Radiol''. 2014;21(3):329-331. doi:10.1007/s10140-014-1195-3</ref>

	===Healthcare worker safety===		===Healthcare worker safety===
	*~~'''~~Phosphine gas may be released from the patient's vomitus and gastric contents~~'''~~ — this is hazardous to healthcare workers<ref name="NPIC"/>		*Phosphine gas may be released from the patient's vomitus and gastric contents — this is hazardous to healthcare workers<ref name="NPIC"/>
	*Treat in a ~~'''~~well-ventilated area~~'''~~ or negative-pressure room		*Treat in a well-ventilated area or negative-pressure room
	*Use appropriate personal protective equipment		*Use appropriate personal protective equipment
	*Gastric lavage effluent should be handled as hazardous material		*Gastric lavage effluent should be handled as hazardous material

	==Clinical features==		==Clinical features==
	*Onset of systemic symptoms is typically ~~'''~~delayed~~'''~~ compared to aluminum phosphide (hours to >12 hours post-ingestion)<ref name="Trakul2017"/>		*Onset of systemic symptoms is typically delayed compared to aluminum phosphide (hours to >12 hours post-ingestion)<ref name="Trakul2017"/>
	* Patients may be initially asymptomatic and then deteriorate suddenly — including ~~'''~~sudden cardiac arrest in asymptomatic patients~~'''~~<ref name="Parhizgar2020">Parhizgar P, et al. Sudden Cardiac Arrest in an Asymptomatic Zinc Phosphide-Poisoned Patient: A Case Report. ''Cardiovasc Toxicol''. 2020;20(5):525-530. doi:10.1007/s12012-020-09578-2</ref>		* Patients may be initially asymptomatic and then deteriorate suddenly — including sudden cardiac arrest in asymptomatic patients<ref name="Parhizgar2020">Parhizgar P, et al. Sudden Cardiac Arrest in an Asymptomatic Zinc Phosphide-Poisoned Patient: A Case Report. ''Cardiovasc Toxicol''. 2020;20(5):525-530. doi:10.1007/s12012-020-09578-2</ref>

	===Gastrointestinal (earliest)===		===Gastrointestinal (earliest)===
Line 88:		Line 88:
	==Evaluation==		==Evaluation==
	===Workup===		===Workup===
	* Abdominal radiograph — zinc phosphide is ~~'''~~radiopaque~~'''~~; positive X-ray is an indication for aggressive GI decontamination and portends worse prognosis<ref name="Hassanian2014"/>		* Abdominal radiograph — zinc phosphide is radiopaque; positive X-ray is an indication for aggressive GI decontamination and portends worse prognosis<ref name="Hassanian2014"/>
	**Serial abdominal X-rays to confirm complete decontamination		**Serial abdominal X-rays to confirm complete decontamination
	* ABG/VBG — metabolic acidosis with elevated lactate is the earliest and most sensitive marker of systemic toxicity; severity correlates with prognosis<ref name="Trakul2017"/>		* ABG/VBG — metabolic acidosis with elevated lactate is the earliest and most sensitive marker of systemic toxicity; severity correlates with prognosis<ref name="Trakul2017"/>
Line 110:		Line 110:

	==Management==		==Management==
	~~'''~~No specific antidote exists.~~'''~~ Treatment is supportive with GI decontamination and organ support.<ref name="Diaz2023"/>		No specific antidote exists. Treatment is supportive with GI decontamination and organ support.<ref name="Diaz2023"/>

	===GI decontamination===		===GI decontamination===
	* Gastric lavage with coconut oil (200 mL) ~~'''~~+ sodium bicarbonate (NaHCO₃ 7.5%, 50 mL):~~'''~~<ref name="Diaz2023"/>		* Gastric lavage with coconut oil (200 mL) + sodium bicarbonate (NaHCO₃ 7.5%, 50 mL):<ref name="Diaz2023"/>
	**Coconut oil forms a protective mucosal layer and may reduce phosphine liberation		**Coconut oil forms a protective mucosal layer and may reduce phosphine liberation
	**Bicarbonate decreases gastric acid–driven conversion of phosphide to phosphine		**Bicarbonate decreases gastric acid–driven conversion of phosphide to phosphine
Line 126:		Line 126:
	*Aggressive IV fluid resuscitation		*Aggressive IV fluid resuscitation
	* Vasopressors (norepinephrine, dopamine) for refractory hypotension		* Vasopressors (norepinephrine, dopamine) for refractory hypotension
	*Continuous cardiac monitoring (~~'''~~sudden cardiac arrest may occur in asymptomatic patients~~'''~~)<ref name="Parhizgar2020"/>		*Continuous cardiac monitoring (sudden cardiac arrest may occur in asymptomatic patients)<ref name="Parhizgar2020"/>
	* Hyperinsulinemia-euglycemia therapy (HIE): case reports suggest benefit in refractory cardiogenic shock<ref name="Diaz2023"/>		* Hyperinsulinemia-euglycemia therapy (HIE): case reports suggest benefit in refractory cardiogenic shock<ref name="Diaz2023"/>
	**Insulin loading dose 1 IU/kg/h, maintenance 1-7 IU/kg/h; dextrose infusion to maintain euglycemia		**Insulin loading dose 1 IU/kg/h, maintenance 1-7 IU/kg/h; dextrose infusion to maintain euglycemia