caso clínico hipoglicemia dra. baeza
DESCRIPTION
Caso clínico hipoglicemiaTRANSCRIPT
Caso cliacutenico Reunioacuten Servicio de Urgencia
03 de Junio 2011
Dra Catalina Baeza R
Residente Medicina de Urgencia
PUC
Santiago de Chile Servicio de Urgencia
Traiacutedo por amigo de la juventud (meacutedico)
-ldquoEacutel ya no es el mismo de siemprehelliprdquo
GHR Masculino
72 antildeos PA 12275
FC 78 x rsquo FR 20 x rsquo Sat 98
Evaluacioacuten primaria
bull Paciente paacutelido decaiacutedo
A Responde preguntas
B FR 20xrsquo sat 100 MP conservado sin dificultad respiratoria
C Bien perfundido FC 78x PA 12275
U ----
D vigil y orientado inatento bradipsiacutequico labilidad emocional +++
HGT
43
Luego de las acciones correspondienteshellip
Evaluacioacuten primaria
Evaluacioacuten secundaria
- Hace 3 semanas CEG labilidad emocional irritabilidad
fluctuante
- Episodios de desorientacioacuten
- iquestCaiacutedas
Antecedentes
bull DM2 en tto metformina y glibenclamida en regular control
bull HTA
HIPOGLICEMIA
Por tu culpa
Amputacioacuten de EEII o
Enf Vascular perifeacuterica fatal
UKPDS La reduccioacuten de un 1 en HbA1c reduce las complicaciones microvasculares y macrovasculares
Porc
enta
je d
e r
educcioacute
n d
el riesgo r
ela
tivo
co
n u
n 1
d
e r
educcioacute
n d
e la H
bA
1c
ndash50
ndash45
ndash40
ndash35
ndash30
ndash25
ndash20
ndash15
ndash10
ndash5
0
21
P lt 00001
Todo endpoint
relacionado
a DM
21
P lt 00001
Muerte
relacinada
a DM
14
P lt 00001
Mortalidad
total
14
P lt 00001
Infarto al
Miocardio
12
P = 0035
AVE
43
P lt 00001
Enfermedad
Vascular
Perifeacuterica
37
P lt 00001
Enf
Micro-
vascular
19
P lt 00001
Cx
catarata
Adaptado de Stratton IM et al UKPDS 35 BMJ 2000 321405ndash412
HIPOGLICEMIA una mirada general
bull Complicacioacuten maacutes peligrosa de la DM
bull Morbilidad y mortalidad significativas
bull Maacutes frecuente en DM1 control estricto (relativo)
- 2 a 4 episodios levessemana
- 30 crisis severa anual
bull Episodios recurrentes severos - Deterioro cognitivo y demencia
- Hypoglycaemia unawareness
Acute consequences of hypoglycaemia in diabetic patients
S Halimi Diabetes amp Metabolism 36 (2010) S75ndash83
Definicioacuten
Aunque por mucho tiempo
Concentracioacuten glucosa plasmaacutetica que provoca siacutentomas glucopenia en SNC le 45 le 55 le 60hellip
ADA 2005
Glicemia le 70 mgdl (39 nml)
American Diabets Association Workgroup on Hypoglycemia Defi ning
and reporting hypoglycemia in diabetes a report from the American
Diabetes Association Workgroup on Hypoglycemia Diabetes Care
2005281245-9
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Santiago de Chile Servicio de Urgencia
Traiacutedo por amigo de la juventud (meacutedico)
-ldquoEacutel ya no es el mismo de siemprehelliprdquo
GHR Masculino
72 antildeos PA 12275
FC 78 x rsquo FR 20 x rsquo Sat 98
Evaluacioacuten primaria
bull Paciente paacutelido decaiacutedo
A Responde preguntas
B FR 20xrsquo sat 100 MP conservado sin dificultad respiratoria
C Bien perfundido FC 78x PA 12275
U ----
D vigil y orientado inatento bradipsiacutequico labilidad emocional +++
HGT
43
Luego de las acciones correspondienteshellip
Evaluacioacuten primaria
Evaluacioacuten secundaria
- Hace 3 semanas CEG labilidad emocional irritabilidad
fluctuante
- Episodios de desorientacioacuten
- iquestCaiacutedas
Antecedentes
bull DM2 en tto metformina y glibenclamida en regular control
bull HTA
HIPOGLICEMIA
Por tu culpa
Amputacioacuten de EEII o
Enf Vascular perifeacuterica fatal
UKPDS La reduccioacuten de un 1 en HbA1c reduce las complicaciones microvasculares y macrovasculares
Porc
enta
je d
e r
educcioacute
n d
el riesgo r
ela
tivo
co
n u
n 1
d
e r
educcioacute
n d
e la H
bA
1c
ndash50
ndash45
ndash40
ndash35
ndash30
ndash25
ndash20
ndash15
ndash10
ndash5
0
21
P lt 00001
Todo endpoint
relacionado
a DM
21
P lt 00001
Muerte
relacinada
a DM
14
P lt 00001
Mortalidad
total
14
P lt 00001
Infarto al
Miocardio
12
P = 0035
AVE
43
P lt 00001
Enfermedad
Vascular
Perifeacuterica
37
P lt 00001
Enf
Micro-
vascular
19
P lt 00001
Cx
catarata
Adaptado de Stratton IM et al UKPDS 35 BMJ 2000 321405ndash412
HIPOGLICEMIA una mirada general
bull Complicacioacuten maacutes peligrosa de la DM
bull Morbilidad y mortalidad significativas
bull Maacutes frecuente en DM1 control estricto (relativo)
- 2 a 4 episodios levessemana
- 30 crisis severa anual
bull Episodios recurrentes severos - Deterioro cognitivo y demencia
- Hypoglycaemia unawareness
Acute consequences of hypoglycaemia in diabetic patients
S Halimi Diabetes amp Metabolism 36 (2010) S75ndash83
Definicioacuten
Aunque por mucho tiempo
Concentracioacuten glucosa plasmaacutetica que provoca siacutentomas glucopenia en SNC le 45 le 55 le 60hellip
ADA 2005
Glicemia le 70 mgdl (39 nml)
American Diabets Association Workgroup on Hypoglycemia Defi ning
and reporting hypoglycemia in diabetes a report from the American
Diabetes Association Workgroup on Hypoglycemia Diabetes Care
2005281245-9
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Evaluacioacuten primaria
bull Paciente paacutelido decaiacutedo
A Responde preguntas
B FR 20xrsquo sat 100 MP conservado sin dificultad respiratoria
C Bien perfundido FC 78x PA 12275
U ----
D vigil y orientado inatento bradipsiacutequico labilidad emocional +++
HGT
43
Luego de las acciones correspondienteshellip
Evaluacioacuten primaria
Evaluacioacuten secundaria
- Hace 3 semanas CEG labilidad emocional irritabilidad
fluctuante
- Episodios de desorientacioacuten
- iquestCaiacutedas
Antecedentes
bull DM2 en tto metformina y glibenclamida en regular control
bull HTA
HIPOGLICEMIA
Por tu culpa
Amputacioacuten de EEII o
Enf Vascular perifeacuterica fatal
UKPDS La reduccioacuten de un 1 en HbA1c reduce las complicaciones microvasculares y macrovasculares
Porc
enta
je d
e r
educcioacute
n d
el riesgo r
ela
tivo
co
n u
n 1
d
e r
educcioacute
n d
e la H
bA
1c
ndash50
ndash45
ndash40
ndash35
ndash30
ndash25
ndash20
ndash15
ndash10
ndash5
0
21
P lt 00001
Todo endpoint
relacionado
a DM
21
P lt 00001
Muerte
relacinada
a DM
14
P lt 00001
Mortalidad
total
14
P lt 00001
Infarto al
Miocardio
12
P = 0035
AVE
43
P lt 00001
Enfermedad
Vascular
Perifeacuterica
37
P lt 00001
Enf
Micro-
vascular
19
P lt 00001
Cx
catarata
Adaptado de Stratton IM et al UKPDS 35 BMJ 2000 321405ndash412
HIPOGLICEMIA una mirada general
bull Complicacioacuten maacutes peligrosa de la DM
bull Morbilidad y mortalidad significativas
bull Maacutes frecuente en DM1 control estricto (relativo)
- 2 a 4 episodios levessemana
- 30 crisis severa anual
bull Episodios recurrentes severos - Deterioro cognitivo y demencia
- Hypoglycaemia unawareness
Acute consequences of hypoglycaemia in diabetic patients
S Halimi Diabetes amp Metabolism 36 (2010) S75ndash83
Definicioacuten
Aunque por mucho tiempo
Concentracioacuten glucosa plasmaacutetica que provoca siacutentomas glucopenia en SNC le 45 le 55 le 60hellip
ADA 2005
Glicemia le 70 mgdl (39 nml)
American Diabets Association Workgroup on Hypoglycemia Defi ning
and reporting hypoglycemia in diabetes a report from the American
Diabetes Association Workgroup on Hypoglycemia Diabetes Care
2005281245-9
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
HGT
43
Luego de las acciones correspondienteshellip
Evaluacioacuten primaria
Evaluacioacuten secundaria
- Hace 3 semanas CEG labilidad emocional irritabilidad
fluctuante
- Episodios de desorientacioacuten
- iquestCaiacutedas
Antecedentes
bull DM2 en tto metformina y glibenclamida en regular control
bull HTA
HIPOGLICEMIA
Por tu culpa
Amputacioacuten de EEII o
Enf Vascular perifeacuterica fatal
UKPDS La reduccioacuten de un 1 en HbA1c reduce las complicaciones microvasculares y macrovasculares
Porc
enta
je d
e r
educcioacute
n d
el riesgo r
ela
tivo
co
n u
n 1
d
e r
educcioacute
n d
e la H
bA
1c
ndash50
ndash45
ndash40
ndash35
ndash30
ndash25
ndash20
ndash15
ndash10
ndash5
0
21
P lt 00001
Todo endpoint
relacionado
a DM
21
P lt 00001
Muerte
relacinada
a DM
14
P lt 00001
Mortalidad
total
14
P lt 00001
Infarto al
Miocardio
12
P = 0035
AVE
43
P lt 00001
Enfermedad
Vascular
Perifeacuterica
37
P lt 00001
Enf
Micro-
vascular
19
P lt 00001
Cx
catarata
Adaptado de Stratton IM et al UKPDS 35 BMJ 2000 321405ndash412
HIPOGLICEMIA una mirada general
bull Complicacioacuten maacutes peligrosa de la DM
bull Morbilidad y mortalidad significativas
bull Maacutes frecuente en DM1 control estricto (relativo)
- 2 a 4 episodios levessemana
- 30 crisis severa anual
bull Episodios recurrentes severos - Deterioro cognitivo y demencia
- Hypoglycaemia unawareness
Acute consequences of hypoglycaemia in diabetic patients
S Halimi Diabetes amp Metabolism 36 (2010) S75ndash83
Definicioacuten
Aunque por mucho tiempo
Concentracioacuten glucosa plasmaacutetica que provoca siacutentomas glucopenia en SNC le 45 le 55 le 60hellip
ADA 2005
Glicemia le 70 mgdl (39 nml)
American Diabets Association Workgroup on Hypoglycemia Defi ning
and reporting hypoglycemia in diabetes a report from the American
Diabetes Association Workgroup on Hypoglycemia Diabetes Care
2005281245-9
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Luego de las acciones correspondienteshellip
Evaluacioacuten primaria
Evaluacioacuten secundaria
- Hace 3 semanas CEG labilidad emocional irritabilidad
fluctuante
- Episodios de desorientacioacuten
- iquestCaiacutedas
Antecedentes
bull DM2 en tto metformina y glibenclamida en regular control
bull HTA
HIPOGLICEMIA
Por tu culpa
Amputacioacuten de EEII o
Enf Vascular perifeacuterica fatal
UKPDS La reduccioacuten de un 1 en HbA1c reduce las complicaciones microvasculares y macrovasculares
Porc
enta
je d
e r
educcioacute
n d
el riesgo r
ela
tivo
co
n u
n 1
d
e r
educcioacute
n d
e la H
bA
1c
ndash50
ndash45
ndash40
ndash35
ndash30
ndash25
ndash20
ndash15
ndash10
ndash5
0
21
P lt 00001
Todo endpoint
relacionado
a DM
21
P lt 00001
Muerte
relacinada
a DM
14
P lt 00001
Mortalidad
total
14
P lt 00001
Infarto al
Miocardio
12
P = 0035
AVE
43
P lt 00001
Enfermedad
Vascular
Perifeacuterica
37
P lt 00001
Enf
Micro-
vascular
19
P lt 00001
Cx
catarata
Adaptado de Stratton IM et al UKPDS 35 BMJ 2000 321405ndash412
HIPOGLICEMIA una mirada general
bull Complicacioacuten maacutes peligrosa de la DM
bull Morbilidad y mortalidad significativas
bull Maacutes frecuente en DM1 control estricto (relativo)
- 2 a 4 episodios levessemana
- 30 crisis severa anual
bull Episodios recurrentes severos - Deterioro cognitivo y demencia
- Hypoglycaemia unawareness
Acute consequences of hypoglycaemia in diabetic patients
S Halimi Diabetes amp Metabolism 36 (2010) S75ndash83
Definicioacuten
Aunque por mucho tiempo
Concentracioacuten glucosa plasmaacutetica que provoca siacutentomas glucopenia en SNC le 45 le 55 le 60hellip
ADA 2005
Glicemia le 70 mgdl (39 nml)
American Diabets Association Workgroup on Hypoglycemia Defi ning
and reporting hypoglycemia in diabetes a report from the American
Diabetes Association Workgroup on Hypoglycemia Diabetes Care
2005281245-9
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
HIPOGLICEMIA
Por tu culpa
Amputacioacuten de EEII o
Enf Vascular perifeacuterica fatal
UKPDS La reduccioacuten de un 1 en HbA1c reduce las complicaciones microvasculares y macrovasculares
Porc
enta
je d
e r
educcioacute
n d
el riesgo r
ela
tivo
co
n u
n 1
d
e r
educcioacute
n d
e la H
bA
1c
ndash50
ndash45
ndash40
ndash35
ndash30
ndash25
ndash20
ndash15
ndash10
ndash5
0
21
P lt 00001
Todo endpoint
relacionado
a DM
21
P lt 00001
Muerte
relacinada
a DM
14
P lt 00001
Mortalidad
total
14
P lt 00001
Infarto al
Miocardio
12
P = 0035
AVE
43
P lt 00001
Enfermedad
Vascular
Perifeacuterica
37
P lt 00001
Enf
Micro-
vascular
19
P lt 00001
Cx
catarata
Adaptado de Stratton IM et al UKPDS 35 BMJ 2000 321405ndash412
HIPOGLICEMIA una mirada general
bull Complicacioacuten maacutes peligrosa de la DM
bull Morbilidad y mortalidad significativas
bull Maacutes frecuente en DM1 control estricto (relativo)
- 2 a 4 episodios levessemana
- 30 crisis severa anual
bull Episodios recurrentes severos - Deterioro cognitivo y demencia
- Hypoglycaemia unawareness
Acute consequences of hypoglycaemia in diabetic patients
S Halimi Diabetes amp Metabolism 36 (2010) S75ndash83
Definicioacuten
Aunque por mucho tiempo
Concentracioacuten glucosa plasmaacutetica que provoca siacutentomas glucopenia en SNC le 45 le 55 le 60hellip
ADA 2005
Glicemia le 70 mgdl (39 nml)
American Diabets Association Workgroup on Hypoglycemia Defi ning
and reporting hypoglycemia in diabetes a report from the American
Diabetes Association Workgroup on Hypoglycemia Diabetes Care
2005281245-9
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Por tu culpa
Amputacioacuten de EEII o
Enf Vascular perifeacuterica fatal
UKPDS La reduccioacuten de un 1 en HbA1c reduce las complicaciones microvasculares y macrovasculares
Porc
enta
je d
e r
educcioacute
n d
el riesgo r
ela
tivo
co
n u
n 1
d
e r
educcioacute
n d
e la H
bA
1c
ndash50
ndash45
ndash40
ndash35
ndash30
ndash25
ndash20
ndash15
ndash10
ndash5
0
21
P lt 00001
Todo endpoint
relacionado
a DM
21
P lt 00001
Muerte
relacinada
a DM
14
P lt 00001
Mortalidad
total
14
P lt 00001
Infarto al
Miocardio
12
P = 0035
AVE
43
P lt 00001
Enfermedad
Vascular
Perifeacuterica
37
P lt 00001
Enf
Micro-
vascular
19
P lt 00001
Cx
catarata
Adaptado de Stratton IM et al UKPDS 35 BMJ 2000 321405ndash412
HIPOGLICEMIA una mirada general
bull Complicacioacuten maacutes peligrosa de la DM
bull Morbilidad y mortalidad significativas
bull Maacutes frecuente en DM1 control estricto (relativo)
- 2 a 4 episodios levessemana
- 30 crisis severa anual
bull Episodios recurrentes severos - Deterioro cognitivo y demencia
- Hypoglycaemia unawareness
Acute consequences of hypoglycaemia in diabetic patients
S Halimi Diabetes amp Metabolism 36 (2010) S75ndash83
Definicioacuten
Aunque por mucho tiempo
Concentracioacuten glucosa plasmaacutetica que provoca siacutentomas glucopenia en SNC le 45 le 55 le 60hellip
ADA 2005
Glicemia le 70 mgdl (39 nml)
American Diabets Association Workgroup on Hypoglycemia Defi ning
and reporting hypoglycemia in diabetes a report from the American
Diabetes Association Workgroup on Hypoglycemia Diabetes Care
2005281245-9
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Amputacioacuten de EEII o
Enf Vascular perifeacuterica fatal
UKPDS La reduccioacuten de un 1 en HbA1c reduce las complicaciones microvasculares y macrovasculares
Porc
enta
je d
e r
educcioacute
n d
el riesgo r
ela
tivo
co
n u
n 1
d
e r
educcioacute
n d
e la H
bA
1c
ndash50
ndash45
ndash40
ndash35
ndash30
ndash25
ndash20
ndash15
ndash10
ndash5
0
21
P lt 00001
Todo endpoint
relacionado
a DM
21
P lt 00001
Muerte
relacinada
a DM
14
P lt 00001
Mortalidad
total
14
P lt 00001
Infarto al
Miocardio
12
P = 0035
AVE
43
P lt 00001
Enfermedad
Vascular
Perifeacuterica
37
P lt 00001
Enf
Micro-
vascular
19
P lt 00001
Cx
catarata
Adaptado de Stratton IM et al UKPDS 35 BMJ 2000 321405ndash412
HIPOGLICEMIA una mirada general
bull Complicacioacuten maacutes peligrosa de la DM
bull Morbilidad y mortalidad significativas
bull Maacutes frecuente en DM1 control estricto (relativo)
- 2 a 4 episodios levessemana
- 30 crisis severa anual
bull Episodios recurrentes severos - Deterioro cognitivo y demencia
- Hypoglycaemia unawareness
Acute consequences of hypoglycaemia in diabetic patients
S Halimi Diabetes amp Metabolism 36 (2010) S75ndash83
Definicioacuten
Aunque por mucho tiempo
Concentracioacuten glucosa plasmaacutetica que provoca siacutentomas glucopenia en SNC le 45 le 55 le 60hellip
ADA 2005
Glicemia le 70 mgdl (39 nml)
American Diabets Association Workgroup on Hypoglycemia Defi ning
and reporting hypoglycemia in diabetes a report from the American
Diabetes Association Workgroup on Hypoglycemia Diabetes Care
2005281245-9
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
HIPOGLICEMIA una mirada general
bull Complicacioacuten maacutes peligrosa de la DM
bull Morbilidad y mortalidad significativas
bull Maacutes frecuente en DM1 control estricto (relativo)
- 2 a 4 episodios levessemana
- 30 crisis severa anual
bull Episodios recurrentes severos - Deterioro cognitivo y demencia
- Hypoglycaemia unawareness
Acute consequences of hypoglycaemia in diabetic patients
S Halimi Diabetes amp Metabolism 36 (2010) S75ndash83
Definicioacuten
Aunque por mucho tiempo
Concentracioacuten glucosa plasmaacutetica que provoca siacutentomas glucopenia en SNC le 45 le 55 le 60hellip
ADA 2005
Glicemia le 70 mgdl (39 nml)
American Diabets Association Workgroup on Hypoglycemia Defi ning
and reporting hypoglycemia in diabetes a report from the American
Diabetes Association Workgroup on Hypoglycemia Diabetes Care
2005281245-9
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Definicioacuten
Aunque por mucho tiempo
Concentracioacuten glucosa plasmaacutetica que provoca siacutentomas glucopenia en SNC le 45 le 55 le 60hellip
ADA 2005
Glicemia le 70 mgdl (39 nml)
American Diabets Association Workgroup on Hypoglycemia Defi ning
and reporting hypoglycemia in diabetes a report from the American
Diabetes Association Workgroup on Hypoglycemia Diabetes Care
2005281245-9
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Glucopenia
Siacutentomas SNC bajo 50 mgdl Siacutentomas bull Confusioacuten bull Irritabilidad bull Descoordinacioacuten
Siacutentomas bull Palpitaciones bull Ansiedad bull Temblor bull Sudoracioacuten
Signos
bull Sopor
bull Coma
bull Convulsiones
Signos bull Taquicardia
bull Diaforesis
Siacutentomas adreneacutergicos Bajo 70 mgdl
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Fisiopatologiacutea
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Sin embargo
bull Neuropatiacutea SNA en DM larga data disminuye respuesta adreneacutergica
bull Nuevas evidenciashelliphellip
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Hipoglicemias inadvertidas
bull Peligrosa complicacioacuten DM insulino dependientes bull Exposicioacuten previa a bajas glicemias bull Disminucioacuten o ausencia de siacutentomas especiacuteficos previos a
neuroglucopenia bull Falla sistema contrarregulador especialmente respuesta adrenaliacutenica bull Hipoglicemia croacutenica lleva a aumento transportadores de glucosa en SNC
Prevencioacuten estricta de episodios de hipoglicemia restaura siacutentomas y
liberacioacuten adreneacutergica en DM IR recientes En DMID recuperacioacuten es incompleta
Hypoglycaemia unawareness BMJ 2011 Mar 8342d1474
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Manejo 1ordm Corregir glicemia
bull Despierto y cooperador hipoglicemia moderada glucosa viacutea oral
(vaso H2O + 2 cucharadas azuacutecar 12-15 gr HC)
bull Severa 25-75 g glucose (3 ampollas SG30 asymp 18 gr HC) ev
bull Si no hay VV Glucagoacuten 1-2 ampolla im Repetir c20 minutos Accioacuten 10-20 min
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
iquestQuieacuten se queda
bull Importancia de identificar causa (prevenir proacuteximo episodio)
- Aumento insulina
- Disminucioacuten uso glucosa
- Aumento utilizacioacuten glucosa
Sobredosis accidental Intencional Excrecioacuten disminuida (falla renal)
darrconsumo darr neoglucogenesis darr hormonas contrarreguladoras (cortisol glucagon epinefrina)
Ejercicio enfermedad
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
The utility of routine laboratory testing in hypoglycaemic emergency department patients
Emerg Med J 2009 Jan26(1)28-31 Sinert R Su M Zehtabchi S
Department of Emergency Medicine State University of New York BACKGROUND bull Despueacutes de tratar hipoglicemia iquestcuaacuten profundo debe ser el work-up para prevenir un proacuteximo episdio OBJETIVO bull Determinar la utilidad del laboratorio de rutina en el manejo de hipoglicemia METODOS bull Estudio observacional en 2 hospitales universitarios 2006 bull 291 pacientes adultos(gt o = 18 antildeos) con hipoglicemia (HGTlt o = 60 mgdl (333 mmoll) en Servicio de Urgencia o
compromiso de conciencia que se resolvioacute con glucosa o glucagoacuten bull Outcomes ELP leucocitos funcioacuten renal sedimento de orina RESULTADOS bull 200 pacientes (69 95 CI 63 to 74) al menos un examen alterado Incluyeron nueva falla renal (23) falla
renal pre- existente (32) hipokalemia (8) hiperkalemia (11) leucocitosis (42) and piuria (19) bull No hubieron diferencias significativas entre las tasas de anormalidades de los pacientes con hipoglicemia por
insulina vs HGO bull Mayores admisiones (p = 0001) en pacientes con examenes anormales (70) vs normal (53) CONCLUSION bull La alta tasa de alteraciones del laboratorio justificariacutea realizacioacuten de examenes generales de rutina enc paciente
con hipoglicemia
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Conocer los medicamentos
- Sobredosis de HGO prolongadas y severas bull Sulfonilureas 24- 72 hrs bull Clorpropamida particularmente peligrosa bull Observar miacutenimo 24 horas maacutes si recurre bull Infusioacuten continua SG 10 - Beta bloqueo bull Asociacioacuten DM y enfermedad cardiovascular (uso de otros
faacutermacos) bull Beta bloqueo no selectivos pueden retrasar la recuperacioacuten
de la hipoglicemia y enmascarar los siacutentomas adreneacutergicos previos
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
iquestQuieacuten se queda
bull Hipoglicemia causada por sulfonilureas o insulinas de accioacuten prolongada (NPH Lantus)
bull Episodio moderado sin otra enfermedad con causa identificada
- Educacioacuten
- Evaluar tolerancia oral
- Control precoz
Disminuir dosis insulina 15-25 (prevencioacuten hipoglicemia inadvertida)
Diabetes Educ 2008 Jul-Aug34(4)683-91
Hospitalization and discharge education of emergency department patients with hypoglycemia
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
Volviendo al caso
bull Evaluacioacuten primaria HGT
bull Accioacuten inmediata SG30 3 ampollas ev
bull Reevaluacioacuten (DINAacuteMICA)
bull Evaluacioacuten secundaria Buscar causas
Prevencioacuten nuevo episodio hipoglicemia inadvertida
Hospitalizacioacuten para observacioacuten y manejo (glucosa en infusioacuten continua)
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
En resumen
bull Evaluacioacuten primaria compromiso de conciencia
bull Hipoglicemia complicacioacuten maacutes peligrosa de la DM (no exclusiva de eacutesta)
bull Prevenir hipoglicemia severa y recurrente
bull Todos los episodios de hipoglicemia tienen causa (aunque no la encontremos)
bull Objetivo prevenir proacuteximos episodios porque el proacuteximo puede ser letal
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
bull J Med Toxicol 2010 Jun6(2)199-206 bull Octreotides role in the management of sulfonylurea-induced hypoglycemia bull Dougherty PP Klein-Schwartz W 1965 to 2008 using combinations of the terms octreotide
antidote sulfonylurea overdose poisoning and toxicity was performed References from identified articles were reviewed for additional sources Animal studies case reports case series and randomized controlled trials were evaluated An animal model of sulfonylurea overdose demonstrates that octreotide reduces the
bull Source bull Maryland Poison Center University of Maryland School of Pharmacy Baltimore MD 21201 USA
pdougherrxumarylandedu bull Abstract bull The objective is to evaluate the evidence regarding octreotides efficacy as a treatment for
sulfonylurea-induced hypoglycemia A search of PubMed for articles published from number of refractory sulfonylurea-induced hypoglycemic episodes Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events Two prospective controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events Based on animal and human data there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required
bull Emerg Med J 2006 Mar23(3)183-5 bull Emergency management of diabetes and hypoglycaemia bull Brackenridge A Wallbank H Lawrenson RA Russell-Jones D bull Source bull Royal Surrey County Hospital Guildford Surrey UK bull Abstract bull OBJECTIVE bull Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality
This study looked at the use of the emergency services by people with diabetes with particular reference to hypoglycaemia
bull METHOD bull Data were collected on all attendances related to diabetes at accident and emergency departments at two district
general hospitals in Surrey UK over a one year period bull RESULTS bull Hypoglycaemia was the commonest reason for attendance at accident and emergency The management of
hypoglycaemia was variable the most frequent method of treatment being intramuscular glucagon administered by the ambulance service Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department and half of these patients had no follow up arranged
bull CONCLUSIONS bull Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal Standardised
protocols and better education of healthcare professionals and patients are required