Endocrinology and Metabolism in Intensive care

馬偕醫院內分泌暨新陳代謝科 陳偉哲

Hyperglycemia crisis

Hyperglycemia Crisis

Management

• Hydration

• Insulin administration

• Monitor and keep electrolyte balance

• Correct metabolic acidosis?

Hyperglycemia crisis

Do you run as fast as possible?

Hyperglycemia crisis

Do you touch down?

Hyperglycemia Crisis

Etiology

• DM control at usual

• Underlying disease and previous medication

• Predisposing factors

Intractable hyperglycemia in Intensive care

• Stress-related hormone act as insulin antagonistic hormones: cortisol, epinephrine, nor-epinephrine, glucagon.

• Hepatic glucose production is enhanced by an upregulation of both gluconeogenesis and glycogenolysis

• Insulin-stimulated glucose uptake by glucose transporter-4 (GLUT-4) is compromised

Current Opinion in Critical Care 2005, 11:304—311

DM diagnosis

• Plasma glucose of 126mg/dl or greater

• Symptoms of diabetes and a random plasma glucose of 200mg/dl or greater

• Oral glucose tolerance test(OGTT)

DM diagnosis

• Diabetes mellitusDiabetes mellitus

• Hyperglycemia related to stressHyperglycemia related to stress

• Pre-diabetes: IGT(impaired glucose Pre-diabetes: IGT(impaired glucose tolerance) and IFG (impaired fasting tolerance) and IFG (impaired fasting glucose)glucose)

What should you survey for an inpatient with DM

• Vital signs• BH and BW• Hemogram• GluAC/PC, HbA1c• Liver function: GOT/GPT, Bil.T/D• Renal function: BUN/Cre• Total cholesterol, triglyceride, LDL, HDL• Urinalysis• CxR• EKG• Skin and sensory

Continuous HRI IV infusion

• Critical condition

• Intractable hyperglycemia

以時間換取空間

Continuous HRI IV infusion

• Actrapid 100U in NS 100ml ivdrip by surestep(capillary blood sugarmonitering ) q4h

• - 啟始 run 2ml/hr, 而後劑量隨 surestep 增減 • - surestep <70 ng/ml, 1) insulin ivdrip -0.5ml/hr, 2) D50W

2Amp iv stat and 3) 兩小時後補驗 surestep stat. 一次 • - surestep 70~100 ng/ml, insulin ivdrip -0.5ml/hr

• - surestep 101~200, insulin ivdrip 不變 • - surestep 201~300 ng/ml, insulin ivdrip +0.5ml/hr

• - surestep 301~400 ng/ml, insulin ivdrip +1ml/hr

• - surestep >= 401, insulin ivdrip +1ml/hour and insulin iv bolus 4U stat.

Euglycemia in ICU care

• A meta-analysis of myocardial infarction revealed an association between stress hyperglycemia and increased risk of in-hospital mortality and congestive heart failure or cardiogenic Lancet 2000; 355:773—778.

• Similarly, hyperglycemia predicted a higher risk of death after stroke and a poor functional recovery in patients who survived Stroke 2001; 32:2426—2432.

Euglycemia in ICU care

• Elevated glucose levels also predicted increased mortality and length of ICU and hospital stay of trauma patients and were associated with infectious morbidity Conclusions

J Trauma 2003; 55:33—38. 2004; 56:1058—1062.• Retrospective analysis of a heterogeneous

population of critically ill patients showed that even a modest degree of hyperglycemia was associated with substantially increased hospital mortality contribute to these clinical benefits. In the past few years

Mayo Clin Proc 2003; 78:1471—1478.

Mechanisms explaining the improvedoutcome with intensive insulin therapy

• Both glucose control and insulin dose contributed to the reduced inflammation, albeit with a superior effect of lowering glucose levels.

Definition of hypoglycemia

• Sometimes define as plasma glucose level <2.8 to 3.9mmol/L (<50 to 70mg/dl)

• Whipple triad: (1) symptoms of hypoglycemia

(2) low plasma concentration

(3) relief of symptoms after the plasma glucose

raised

From Willians 10th

Common Cause of hypoglycemia in ICU

• Drugs: Especially insulin, sulfonylureas, ethanol Sometimes pentamidine, quinine Rarely salicylates, sulfonamides, and others• Critical illnesses Hepatic, renal, or cardiac failure Sepsis Starvation and inanition• Postprandial Reactive (after gastric surgery) Ethanol-induced Autonomic symptoms without true hypoglycemia• Factitious Insulin, sulfonylureas

Hypoglycemia in DiabetesInsulin excess => Inadequate physiologic and counterregulatory and

behavioral responses :

hypoglycemia-associated autonomic failure (1) absolute insulin excess and absent glucagon response (2)reduce autonomic response (adrenomedullary epinephrine) (3) reduce symptom and hypoglycemia unawareness

From Willians 10th

Thyrotoxic storm

• Thyrotoxic storm def :

exaggeration of the clinical manifestation

of thyrotoxicosis

• if left untreated, mortality range from 20% to 30 %

Predisposing factor

Clinical manefestation

• Fever

• Sinus tachycardia

• CNS symptomatology: agitation, restless, emotional lability to confusion

• GI disturbance: vomiting, diarrhea, intestinal obstruction, acute abdomen

Lab finding

• Serum total T4 and free T4 increase

• Mild hypercalcemia

• Hyperglycemia in some pts

• Hepatic dysfunction

• Leukocytosis with left shift

Treatment• Reduction of the production/ secretion of thyroid

hormone by the thyroid gland: 1. PTU 200~250mg q6h (addition block

peripheral conversion of T4) or methimazole 20mg q4h

2. lugol’s solution (30 drops daily in 3 or 4 divided doses) or SSKI(8 drops every q6h) to decrease T4 synthesis

3. sodium ipodate or iopanoic acid- additional block /T4 to /T3

4. lithium carbonate 300mg po q6h to keep serum Li around 1mg/dl for allergy to thionamide or iodine

Treatment

• Inhibition of thyroid hormone peripheral action-administration of anti-adrenergic drug delpete catecholamine stores such as guanethidine or reserpine or block b-adrenergic receptor

inderal 80~120mg q6h or 0.5~1mg iv bolus followed 1~3mg iv every several hrs

administration of high doses cholecystyramine

Treatment

• Reverse of systemic disturbance:

acetaminophen rather than aspirin ( inhibit thyroid hormone binding to globulin)

ice pack

fluid replacement

Treatment

• Measure to remove or abrogate the effect of the precipitating factor

treatment underly dx

Sick euthyroidism syndrome

Adrenal insufficiency Crisis

• Primary adrenal insufficiency? Secondary adrenal insufficiency?

• Acute? Chronic?

Adrenal insufficiency Crisis

• Hypotension

• Hypoglycemia

• Hypothermia

• Nausea, vomiting

• Epigastragia

• Hyponatremia

Adrenal insufficiency Crisis

• Check ACTH/Cortisol immediately

• Then given Dexamethsone 4mg q6h(Decardone 1AMp iv q6h) or Solucortef 1amp iv q12h to q6h

Thanks for your attention