Transcript Endocrinology and Metabolism in Intensive care

Endocrinology and Metabolism
in Intensive care
馬偕醫院內分泌暨新陳代謝科
陳偉哲
Hyperglycemia crisis
Hyperglycemia Crisis
Management
• Hydration
• Insulin administration
• Monitor and keep electrolyte balance
• Correct metabolic acidosis?
Hyperglycemia crisis
Do you run as fast as possible?
Hyperglycemia crisis
Do you touch down?
Hyperglycemia Crisis
Etiology
• DM control at usual
• Underlying disease and previous
medication
• Predisposing factors
Intractable hyperglycemia
in Intensive care
• Stress-related hormone act as insulin
antagonistic hormones: cortisol, epinephrine,
nor-epinephrine, glucagon.
• Hepatic glucose production is enhanced by
an upregulation of both gluconeogenesis and
glycogenolysis
• Insulin-stimulated glucose uptake by glucose
transporter-4 (GLUT-4) is compromised
Current Opinion in Critical Care 2005, 11:304—311
DM diagnosis
• Plasma glucose of 126mg/dl or greater
• Symptoms of diabetes and a random
plasma glucose of 200mg/dl or greater
• Oral glucose tolerance test(OGTT)
DM diagnosis
• Diabetes mellitus
• Hyperglycemia related to stress
• Pre-diabetes: IGT(impaired glucose
tolerance) and IFG (impaired fasting
glucose)
What should you survey for an
inpatient with DM
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Vital signs
BH and BW
Hemogram
GluAC/PC, HbA1c
Liver function: GOT/GPT, Bil.T/D
Renal function: BUN/Cre
Total cholesterol, triglyceride, LDL, HDL
Urinalysis
CxR
EKG
Skin and sensory
Continuous HRI IV infusion
• Critical condition
• Intractable hyperglycemia
以時間換取空間
Continuous HRI IV infusion
• Actrapid 100U in NS 100ml ivdrip by surestep(capillary
blood sugarmonitering ) q4h
• - 啟始 run 2ml/hr, 而後劑量隨surestep增減
• - surestep <70 ng/ml, 1) insulin ivdrip -0.5ml/hr, 2) D50W
2Amp iv stat and 3) 兩小時後補驗surestep stat. 一次
• - surestep 70~100 ng/ml, insulin ivdrip -0.5ml/hr
• - surestep 101~200, insulin ivdrip 不變
• - surestep 201~300 ng/ml, insulin ivdrip +0.5ml/hr
• - surestep 301~400 ng/ml, insulin ivdrip +1ml/hr
• - surestep >= 401, insulin ivdrip +1ml/hour and insulin iv
bolus 4U stat.
Euglycemia in ICU care
• A meta-analysis of myocardial infarction
revealed an association between stress
hyperglycemia and increased risk of inhospital mortality and congestive heart failure
or cardiogenic Lancet 2000; 355:773—778.
• Similarly, hyperglycemia predicted a higher
risk of death after stroke and a poor
functional recovery in patients who survived
Stroke 2001; 32:2426—2432.
Euglycemia in ICU care
• Elevated glucose levels also predicted
increased mortality and length of ICU and
hospital stay of trauma patients and were
associated with infectious morbidity
Conclusions
J Trauma 2003; 55:33—38. 2004; 56:1058—1062.
• Retrospective analysis of a heterogeneous
population of critically ill patients showed
that even a modest degree of hyperglycemia
was associated with substantially increased
hospital mortality contribute to these clinical
benefits. In the past few years
Mayo Clin Proc 2003; 78:1471—1478.
Mechanisms explaining the improved
outcome with intensive insulin therapy
• Both glucose control and insulin dose
contributed to the reduced inflammation,
albeit with a superior effect of lowering
glucose levels.
Definition of hypoglycemia
• Sometimes define as plasma glucose
level <2.8 to 3.9mmol/L (<50 to 70mg/dl)
• Whipple triad:
(1) symptoms of hypoglycemia
(2) low plasma concentration
(3) relief of symptoms after the plasma glucose
raised
From Willians 10th
Common Cause of
hypoglycemia in ICU
• Drugs: Especially insulin, sulfonylureas, ethanol
Sometimes pentamidine, quinine
Rarely salicylates, sulfonamides, and others
• Critical illnesses
Hepatic, renal, or cardiac failure
Sepsis
Starvation and inanition
• Postprandial
Reactive (after gastric surgery)
Ethanol-induced
Autonomic symptoms without true hypoglycemia
• Factitious
Insulin, sulfonylureas
Hypoglycemia in Diabetes
Insulin excess =>
Inadequate physiologic and counterregulatory and
behavioral responses :
hypoglycemia-associated autonomic failure
(1) absolute insulin excess and absent glucagon
response
(2)reduce autonomic response (adrenomedullary
epinephrine)
(3) reduce symptom and hypoglycemia unawareness
From Willians 10th
Thyrotoxic storm
• Thyrotoxic storm def :
exaggeration of the clinical
manifestation
of thyrotoxicosis
• if left untreated, mortality range from
20% to 30 %
Predisposing factor
Clinical manefestation
• Fever
• Sinus tachycardia
• CNS symptomatology: agitation,
restless, emotional lability to confusion
• GI disturbance: vomiting, diarrhea,
intestinal obstruction, acute abdomen
Lab finding
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Serum total T4 and free T4 increase
Mild hypercalcemia
Hyperglycemia in some pts
Hepatic dysfunction
Leukocytosis with left shift
Treatment
• Reduction of the production/ secretion of thyroid
hormone by the thyroid gland:
1. PTU 200~250mg q6h (addition block
peripheral conversion of T4) or methimazole
20mg q4h
2. lugol’s solution (30 drops daily in 3 or 4 divided
doses) or SSKI(8 drops every q6h) to decrease
T4 synthesis
3. sodium ipodate or iopanoic acid- additional
block /T4 to /T3
4. lithium carbonate 300mg po q6h to keep serum
Li around 1mg/dl for allergy to thionamide or
iodine
Treatment
• Inhibition of thyroid hormone peripheral
action-administration of anti-adrenergic
drug delpete catecholamine stores such
as guanethidine or reserpine or block badrenergic receptor
inderal 80~120mg q6h or 0.5~1mg iv
bolus followed 1~3mg iv every several
hrs
administration of high doses
cholecystyramine
Treatment
• Reverse of systemic disturbance:
acetaminophen rather than aspirin
( inhibit thyroid hormone binding to
globulin)
ice pack
fluid replacement
Treatment
• Measure to remove or abrogate the
effect of the precipitating factor
treatment underly dx
Sick euthyroidism syndrome
Adrenal insufficiency Crisis
• Primary adrenal insufficiency?
Secondary adrenal insufficiency?
• Acute? Chronic?
Adrenal insufficiency Crisis
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Hypotension
Hypoglycemia
Hypothermia
Nausea, vomiting
Epigastragia
Hyponatremia
Adrenal insufficiency Crisis
• Check ACTH/Cortisol immediately
• Then given Dexamethsone 4mg
q6h(Decardone 1AMp iv q6h) or
Solucortef 1amp iv q12h to q6h
Thanks for your attention