2011 EBM-hyperglycemia
陳莉瑋醫師
一定要打 一定要打 一定要打 一定要打bolus insulin嗎嗎嗎?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
Meta--analysisanalysis 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 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
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
Meta--analysisanalysis 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
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
8. +- 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<6.9
10.Admission to meta
觀察室時
DKA:200 HHNK:300
