Endocrinology and Metabolism in Intensive care

1. Endocrinology and Metabolism in Intensive care 馬偕醫院內分泌暨新陳代謝科 陳偉哲

2. Hyperglycemia crisis

4. Hyperglycemia Crisis Management • Hydration • Insulin administration • Monitor and keep electrolyte balance • Correct metabolic acidosis?

5. Hyperglycemia crisis Do you run as fast as possible?

9. Hyperglycemia crisis Do you touch down?

11. Hyperglycemia Crisis Etiology • DM control at usual • Underlying disease and previous medication • Predisposing factors

12. 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

13. 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)

14. DM diagnosis • Diabetes mellitus • Hyperglycemia related to stress • Pre-diabetes: IGT(impaired glucose tolerance) and IFG (impaired fasting glucose)

15. 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

16. Continuous HRI IV infusion • Critical condition • Intractable hyperglycemia 以時間換取空間

17. 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.

18. 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.

19. 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.

20. 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.

22. 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

23. 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

24. Hypoglycemia in Diabetes Insulin excess => Inadequate physiologic and counterregulatory and behavioral responses : hypoglycemia-associated autonomic failure (1) absolute insulin excess and absent glucagon response (2)reduce autonomic response (adrenomedullary epinephrine) (3) reduce symptom and hypoglycemia unawareness From Willians 10th

25. Thyrotoxic storm • Thyrotoxic storm def : exaggeration of the clinical manifestation of thyrotoxicosis • if left untreated, mortality range from 20% to 30 %

28. Predisposing factor

29. Clinical manefestation • Fever • Sinus tachycardia • CNS symptomatology: agitation, restless, emotional lability to confusion • GI disturbance: vomiting, diarrhea, intestinal obstruction, acute abdomen

30. Lab finding • Serum total T4 and free T4 increase • Mild hypercalcemia • Hyperglycemia in some pts • Hepatic dysfunction • Leukocytosis with left shift

31. 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

32. 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

33. Treatment • Reverse of systemic disturbance: acetaminophen rather than aspirin ( inhibit thyroid hormone binding to globulin) ice pack fluid replacement

34. Treatment • Measure to remove or abrogate the effect of the precipitating factor treatment underly dx

35. Sick euthyroidism syndrome

37. Adrenal insufficiency Crisis • Primary adrenal insufficiency? Secondary adrenal insufficiency? • Acute? Chronic?

38. Adrenal insufficiency Crisis • Hypotension • Hypoglycemia • Hypothermia • Nausea, vomiting • Epigastragia • Hyponatremia

39. Adrenal insufficiency Crisis • Check ACTH/Cortisol immediately • Then given Dexamethsone 4mg q6h(Decardone 1AMp iv q6h) or Solucortef 1amp iv q12h to q6h

40. Thanks for your attention