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 7.3, HCO3>15

Abbas E Kitabchi, Mary Beth Murphy, Judy Spencer, Robert Matteri, Jim Karas. Diabetes Care. Alexandria:Nov Vol. 31, Iss. 11, p (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 - analysis Meta-analysis Meta-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 units 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 µ U/ml) within 5 min and plateaued at 88 µ U/ml in 60 min. The twice no load group reached a peak (200 µ U/ml) at 45 min. The no load group reached a peak (60 µ U/ml) in 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 - analysis Meta-analysis Meta-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 edema Dementia,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 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.

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/hr IV continuous Insulin infusion

Back to our protocol …

cardiorespiratory stable Urine routine and ketone Infection control B/C,U/C,Sp/C if need 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 RI 0.1U/Kg bolus IV stat

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< Admission to meta

觀察室時 DKA:200 HHNK:300

Thank you for your attention!