2011 EBM-hyperglycemia

陳莉瑋醫師

一定要打 bolus insulin 嗎 ?

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

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.)

Is a Priming Dose of Insulin Necessary in a Low-Dose Insulin Protocol for the Treatment of Diabetic Ketoacidosis?

The Evidence Pyramid

Animal research

In vitro (test tube) research

Case series/ Reports

Ideas, Editorials, Opinions

Case Control Studies

Cohort studies

Randomized Controlled Studies

Randomized Controlled Double Blind Studies

Meta - an

alysis

Meta-analysisMeta-analysis Forest plot

Hierarchy of evidence that arranges study designs by their susceptibility to bias.

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.

RESEARCH DESIGN AND METHODS This prospective randomized protocol used three

insulin therapy methods: 1. load group (12 人 ):using a priming dose of 0.07 uni

ts of regular insulin per kg body weight followed by a dose of 0.07 unit /kg/ h i.v.

2. no load group(12 人 ) :using an infusion of regular insulin of 0.07 unit /kg/ h without a loading dose

3. twice no load group(13 人 ): using an infusion of regular insulin of 0.14 unit /kg/ h without a loading dose

Outcome

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

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.

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.

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 ?

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

Treatment of Diabetic Ketoacidosis With Subcutaneous Insulin Aspart

DIABETES CARE, VOLUME 27, NUMBER 8, AUGUST 2004

The Evidence Pyramid

Animal research

In vitro (test tube) research

Case series/ Reports

Ideas, Editorials, Opinions

Case Control Studies

Cohort studies

Randomized Controlled Studies

Randomized Controlled Double Blind Studies

Meta - an

alysis

Meta-analysisMeta-analysis Forest plot

Hierarchy of evidence that arranges study designs by their susceptibility to bias.

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 edemaDementia,or pregnancy

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.

RESULTS Admission biochemical parameters in patients treated with S

C-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.

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.

綜合 Q1 和 Q2 的結論Insulin control

0.14U/KG/hrIV continuousInsulin infusion

Back to our protocol…

cardiorespiratory stable

Urine routine and ketoneInfection controlB/C,U/C,Sp/C if need

Determine hydration statusFluid supplement first

hyperG-21.ABC2.CBC/DC,CRP3.Blood osmo,sugar,BUN,Cr,Na,K,Cl,urine and blood ketone,ALT,CKMB,Trop-I4.Vein gas5.EKG6.CXR,urine routine..ect fever survey and culture7. NS 1L/Hr8. +- RI 0.1U/Kg bolus IV stat

Hyper A1Diagnosis:HHNK1.On ciritical 2.Vital sign Q4H3.If k<3.3,give K first and hold RI line4.Fluid and RI linea)RI line:RI50U+N/S 500 ml run 1ml/kg/hrb) Half saline 250ml/hrOr NS 250 ml/hr if low Na5.F/S Q1H6.Na,K,vein gas Q2H7.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 A2Diagnosis:DKA1.On ciritical 2.Vital sign Q4H3.If k<3.3,give K first and hold RI line4.Fluid and RI linea)RI line:RI50U+N/S 500 ml run 1ml/kg/hrb) Half saline 250ml/hrOr NS 250 ml/hr if low Na5.F/S Q1H6.Na,K,vein gas Q2H7.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<6.910.Admission to meta

觀察室時

DKA:200HHNK:300

Thank you for your attention!