2011 EBM-hyperglycemia

1. 2011 EBM-hyperglycemia 陳莉瑋醫師

4. 一定要打bolus insulin嗎?

5. Question 1 • Is bolus insulin necessary in DKA? • P:DKA adult patient • I:initial bolus insulin+insulin line • C:insulin line • O:reach the goal of glucose <250, pH>7.3, HCO3>15

6. Is a Priming Dose of Insulin Necessary in a Low-Dose Insulin Protocol for the Treatment of Diabetic Ketoacidosis? Abbas E Kitabchi, Mary Beth Murphy, Judy Spencer, Robert Matteri, Jim Karas. Diabetes Care. Alexandria:Nov 2008. Vol. 31, Iss. 11, p. 2081-5 (5 pp.)

7. The Evidence Pyramid Meta - analysis Randomized Controlled Double Blind Studies Randomized Controlled Studies Cohort studies Case Control Studies Case series/ Reports Meta-analysisForest plot Ideas, Editorials, Opinions Animal research In vitro (test tube) research Hierarchy of evidence that arranges study designs by their susceptibility to bias.

8. objective • The purpose of this study was to assess the efficacy of an insulin priming dose with a continuous insulin infusion versus two continuous infusions without a priming dose.

9. RESEARCH DESIGN AND METHODS • This prospective randomized protocol used three insulin therapy methods: • load group(12人):using a priming dose of 0.07 units of regular insulin per kg body weight followed by a dose of 0.07 unit /kg/ h i.v. • no load group(12人) :using an infusion of regular insulin of 0.07 unit /kg/ h without a loading dose • twice no load group(13人): using an infusion of regular insulin of 0.14 unit /kg/ h without a loading dose

10. Outcome • based on the effects of insulin therapy on biochemical and hormonal changes during treatment and recovery of DKA.

11. RESULTS • The load group reached a peak in free insulin value (460 µU/ml) within 5 min and plateaued at 88 µU/ml in 60 min. The twice no load group reached a peak (200 µU/ml) at 45 min. The no load group reached a peak (60 µU/ml) in 60-120 min. • 5/12 in the no load group required supplemental insulin doses to decrease initial glucose levels by 10%; patients in the twice no load and load groups did not. • Times to reach glucose ≤250 mg/dl, pH ≥7.3, and HCO- ≥15 mEq/l did not differ significantly among the three groups.

14. CONCLUSIONS • A priming dose in low-dose insulin therapy in patients with DKA is unnecessary if an adequate dose of regular insulin of 0.14 U/Kg/H is given.

15. DKA and NKHS是要住ICU的 代表要多花很多錢 所以 ..有其他替代方法?

16. Q2:Any alternative to IV insulin in uncomplicate DKA? • P: uncomplicate DKA patient • I:SC rapid-acting insulin analogs • O:IV insulin infusion • C: correction of DKA

17. Treatment of Diabetic Ketoacidosis With Subcutaneous Insulin Aspart DIABETES CARE, VOLUME 27, NUMBER 8, AUGUST 2004

18. The Evidence Pyramid Meta - analysis Randomized Controlled Double Blind Studies Randomized Controlled Studies Cohort studies Case Control Studies Case series/ Reports Meta-analysisForest plot Ideas, Editorials, Opinions Animal research In vitro (test tube) research Hierarchy of evidence that arranges study designs by their susceptibility to bias.

19. OBJECTIVE • In this prospective, randomized, open trial, we compared the efficacy and safety of aspart insulin given subcutaneously at different time intervals to a standard low-dose intravenous (IV) infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis (DKA). 排除challenge1000仍低血壓,heart ischemia,ESRD,liver failure,general edema Dementia,or pregnancy

20. RESEARCH DESIGN AND METHODS • A total of 45 consecutive patients admitted with DKA were randomly assigned to receive subcutaneous (SC) aspart insulin every hour (SC-1h, n = 15) or every 2 h (SC-2h, n = 15) or to receive IV infusion of regular insulin (n = 15). • Response to medical therapy was evaluated by assessing the duration of treatment until resolution of hyperglycemia and ketoacidosis. • Additional end points included total length of hospitalization, amount of insulin administration until resolution of hyperglycemia and ketoacidosis, and number of hypoglycemic events.

22. RESULTS • Admission biochemical parameters in patients treated with SC-1h (glucose: 44 ± 21 mmol/l [means ± SD], bicarbonate: 7.1 ± 3 mmol/l, pH: 7.14 ± 0.09) were similar to those treated with SC-2h (glucose: 42 ± 21 mmol/l, bicarbonate: 7.6 ± 4 mmol/l, pH: 7.15 ± 0.12) and IV regular insulin (glucose: 40 ± 13 mmol/l, bicarbonate 7.1 ± 4 mmol/l, pH: 7.11 ± 0.17). • There were no statistical differences in the mean duration of treatment until correction of hyperglycemia (6.9 ± 4, 6.1 ± 4, and 7.1 ± 5 h) or until resolution of ketoacidosis (10 ± 3, 10.7 ± 3, and 11 ± 3 h) among patients treated with SC-1h and SC-2h or with IV insulin, respectively (NS). • There was no mortality and no differences in the length of hospital stay, total amount of insulin administration until resolution of hyperglycemia or ketoacidosis, or the number of hypoglycemic events among treatment groups.

24. CONCLUSIONS • Our results indicate that the use of subcutaneous insulin aspart every 1 or 2 h represents a safe and effective alternative to the use of intravenous regular insulin in the management of patients with uncomplicated DKA.

25. 綜合Q1和Q2的結論Insulin control 0.14U/KG/hr IV continuous Insulin infusion

28. Back to our protocol…

29. cardiorespiratory stable Determine hydration status Fluid supplement first hyperG-2 1.ABC 2.CBC/DC,CRP 3.Blood osmo,sugar,BUN,Cr,Na,K,Cl,urine and blood ketone,ALT,CKMB,Trop-I 4.Vein gas 5.EKG 6.CXR,urine routine..ect fever survey and culture 7. NS 1L/Hr 8. +- RI 0.1U/Kg bolus IV stat Urine routine and ketone Infection control B/C,U/C,Sp/C if need

30. Hyper A1 Diagnosis:HHNK 1.On ciritical 2.Vital sign Q4H 3.If k<3.3,give K first and hold RI line 4.Fluid and RI line a)RI line:RI50U+N/S 500 ml run 1ml/kg/hr b) Half saline 250ml/hr Or NS 250 ml/hr if low Na 5.F/S Q1H 6.Na,K,vein gas Q2H 7.Record I/O如果可以 8.K supply in fluid if K<5.3 to keep k level(4-5) 9.Admission to meta Hyper A2 Diagnosis:DKA 1.On ciritical 2.Vital sign Q4H 3.If k<3.3,give K first and hold RI line 4.Fluid and RI line a)RI line:RI50U+N/S 500 ml run 1ml/kg/hr b) Half saline 250ml/hr Or NS 250 ml/hr if low Na 5.F/S Q1H 6.Na,K,vein gas Q2H 7.Record I/O如果可以 8.K supply in fluid if K<5.3 to keep k level(4-5) 9.Give NaHCO3 only if pH<6.9 10.Admission to meta

31. 觀察室時 DKA:200 HHNK:300

32. Thank you for your attention!