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Case report n°1 Metabolic disorder

Case report n°1 Metabolic disorder. A&E meeting 22 february 2012. Presentation of the case. Male Korean patient 39 years old, coming for confusion anorexia, hypothermia. Past history: HTN, diabetes (according his friend), depressive mood. Unknown treatment (Insuline?)

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Case report n°1 Metabolic disorder

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  1. Case report n°1 Metabolic disorder A&E meeting 22 february 2012

  2. Presentation of the case • Male Korean patient 39 years old, coming for confusion anorexia, hypothermia. • Past history: HTN, diabetes (according his friend), depressive mood. • Unknown treatment (Insuline?) • 5 days ago, after drinking alcohol, he presented abdominal pain & vomiting, after that, he didn’t eat/drink much. • Today, his girlfriend discovered him with confusion and major asthenia.

  3. Clinical examination • Shock status with blood pressure 80/50, tachycardia 92/min , “marbrures”, dehydration with “pli cutane”. • Crackels in both lungs, confusion syndrome with Glasgow score 14, no focal neurodeficit. • ECG

  4. Electric sign of hyperkaliemia

  5. Abdominal CT scanner Motif: • Pancréatite?  Technique: Coupes axiales avant et après Injection de contraste des coupoles diaphragmatiques à la symphyse pubienne. Le patient ne peut bloquer sa respiration.  Résultat: • Aspect normal du parenchyme hépatique.  • Vésicule et voies biliaires sans particularité.  • Aspect normal de la rate.  • Aspect normal du pancréas sans syndrome de masse. Absence d'infiltration péripancréatique. • Aspect normal des surrénales et des deux reins.  • Pas d'épaississement pariétal intestinal.  • Absence d'épanchement péritonéal.  • Aspect normal de l'aorte, absence d'adénopathies coelio-mésentériques ou rétro péritonéales.  • Absence de masse pelvienne. • Pneumopathie basale bilatérale.  AU TOTAL:Pneumopathie basale.

  6. Prescriptions in A&E • 12h50: arrival in A&E, Immediate evaluation by A&E nurse & Doctor , Dextro HI + confusion & dehydration; hypotension • 13h00 Start rehydration with Ringer 500ml rapid followed by NaCL 0.9% 500ml x 4 rapid then 50ml/h • 13h00 Start Insuline bolus 10UI • 13h15 Start Insulin IV continuous 10UI/h • 14h17: Blood gas available • 15h15: blood test available (ionogram) • 15h30 Ceftriaxon 1g

  7. Biological results Creat 179 micromole/l Na 102 mmol/l & Cl 65mmol/l K 7,2 mmol/l Ca 2,33mmol/l Alcalin Reserve 3mmol/l Glycemy 16g/l Urine: Glucose ++++, Cetone ++

  8. Biologic results at 14h17 & 15h15 • 14h17: pH 6.96, pCO2 6.9mmHg, pO2 132mmHg, Bicar 1.6mmol/l (23-29), CO2T 1.8mmol/l (20-30); Base Excess -29mmol/l, SaO2 95% • 15H15: Creat 179micmol, Na 102mmol/l, K 7.2mmol/l, Glycemie 16g/l (89mmol/l), RA 3mmol/l • WBC 38600 (93%PN), Hb 15.1g, Pl 321.000 • CRP 1.5mg, Lipase 249 (N<60), ASAT 20, ALAT 25, TP 58% • Urine test: Glucose ++++, Ketosis ++

  9. Anion Gap calculation • Anion Gap* = Na –(Cl + HCO3) • Anion Gap = 35 mmol/l (very increased) * Normal Anion Gap = 12 +/-2mmol/l

  10. Evolution of acidosis & kaliemia

  11. A&E Diabeticketoacidosis “DKA” protocol

  12. 1) Rehydration

  13. 2) Insulino-therapy

  14. 3) Potassium supplementation

  15. Interest of bicarbonates? • SFAR 2006: Complications metaboliques du diabete: “L’acidose metabolique severe a ete accusee de nombreuses dysfonctions d’organe, notamment cardiaque. Un travail montre clairement qu’il n’existe pas de dysfonction myocardique chez les patients presentant une acicocetose diabetique (ACD). L’administration de bicarbonates n’a aucun effet benefique dans cette indication et n’est donc pas recommendee dans le traitenent de l’ACD.” • XIX conference de consensus en reanimation – medecine d’urgence (juin 1999): Les bicarbonates permettent de corriger le pH plasmatique mais tendent a augmenter la PCO2 tissulaire et veineuse entrainant une acidose intra-cellulaire paradoxale. L’alcalinisation relance la glycolyse et la production de lactates et de corps cetoniques. Cet effet peut etre deletere en cas d’acido-cetose ou d’acidose lactique.

  16. Controversial use of bicarbonates in DKA

  17. Problem of hyponatremia • Hyponatremia is ususal in case of diabetic ketoacidosis. This is due to hyperglycemia. • The real natremia can be calculated by the following formula: Nac = Nam + ((Glycemia g/l – 1) x 1.6) • Do not try to correct this false hyponatremia Nac: Corrected Na (Real Na) Nam: Mesured Na (Lab. Result)

  18. Calcul of the corrected Natremia • Nam = 102mmol/l Glycemia = 16g/l • Nac = 102 + ((16-1) x 1.6) = 102 + 24 = 126 Real Na = 126mmol/l • Always look at the glycemia when you see a hyponatremia in diabetic patients

  19. Conclusion • Correction of hypovolemia and dehydration are the 1st therapeutic measures • Insulinotherapy IV (0.1UI/Kg/h) has to be started quickly • Potassium supplementation must be administrated as soon as K < 5mmol/l • Hyponatremia is “normal” and doesn’t reflect the real natremia (correction according glycemia) • The place of bicarbonate in DKA is not clearly established. Most of guidelines recommend not to use it.

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