HOMELPAVI - EGRESO - Diabetes en Pacientes Criticos
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Transcript of HOMELPAVI - EGRESO - Diabetes en Pacientes Criticos
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TRATAMIENTO DE LA HIPERGLICEMIA EN
PACIENTES HOSPITALIZADOS
MARIA ANDREINA OVALLES PEREZMedico Cirujano
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• American Association of Clinical Endocrinologist
• American College of Endocrinology• American Diabetes Association• Endocrine Society• American Association of Diabetes Educators• American Heart Association• American Society of Anesthesiologist• Society of Critical care Medicine• Society of Hospital Medicine• Society of Thoracic Surgeons
American college of endocrinology. Position statement on inpatient diabetes and metabolic control. Endocr Pract 2004;10:77-82
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American College of Endocrinology. Position statement on inpatient diabetes and metabolic control. Endocr Pract 2004;10:77-82
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American Diabetes Association
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“Hiperglucemia secundaria a estrés”• Resistencia
• Higado• Musculo
• Respuesta adaptativa
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Inzucchi. Management of Hyperglycemia in the Hospital Setting. N Engl J Med. 2006; 355:1903-1911
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Van den Berghe et al.• 1.548 adultos con ventilación
mecánica.• Insulina IV: 80 – 110 mg/dL• Terapia convencional: 180 – 200 mg/dL
Van den Berghe et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359-67
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Van den Berghe. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359-67
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• Mortalidad < 80% por enf. Cardiovascular• Resistencia a la insulina e intolerancia a la
glucosa.
• Norhammar et al.• 181 Pct = Gluc < 200 mg/dL
• 35% con el evento.• 40% a los 3 meses• 56% DM
Norhammar et al. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet 2002;359:2140-4
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• Estudio DIGAMI 620 pacientes = Hiperglicemia + IAM.
Malberg et al. Glycometabolic state at admisison: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the diabetes and insulin-glucose infusion in acute myocardial infarction (DIGAMI) study. Circulation 1999;99:2626-32
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Capes et al. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke. Oct 2001;32(10):2426-32
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• Pomposelli et al.• 97 pacientes.
• Gluc. > 220 mg/dL = Infección nosocomial• Sepsis, neumonia, partes blandas.
• Radio 2,7
• Funary et al.• 1499 pacientes
• Gluc. > 200 mg/dL = Infección partes blandas• Radio 2,2
Pomposelli et al. Early postoperatory glucose control predicts nosocomial infectons rates in diabetics patients. JPEN, 1998;22:77-81
Funary. Clinical efects of hyperglycemia in the cardiac surgery population: the Porlant diabetic project. Endocr pract. 2006;34:612-616
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• Funary et al. • 1 dia por cada 50 mg/dL de gluc. > 150
mg/dL.• Insulinoteria IV disminuye 23% la estancia.
Funary. Clinical efects of hyperglycemia in the cardiac surgery population: the Porlant diabetic project. Endocr pract. 2006;34:612-616
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• Indicaciones• Pacientes críticos• Pacientes metabólicamente inestables
• Ventajas• Biodisponibilidad predecible• Facilidad • Seguridad
• “Escala móvil”
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• Severidad de la enfermedad• Medicación (esteroides)• Dieta• Antecedentes de Dm, tipo y tratamiento• Calidad de tratamiento previo (hemoglobina
glicosilada)
• Estado nutricional
Inzucchi. Management of Hyperglycemia in the Hospital Setting. N Engl J Med. 2006; 355:1903-1911
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Aspectos Necesarios de un Protocolo• Medición de la glucemia
• Horaria (Universidad de Washington)
• Mecanismo de cambio de infusión• Aporte de glucosa
• 5 – 10 g/h
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• Glucosa Basal• Glargina • NPH (Neutral Protamine
Hagedorn)
• Glucosa Prandial• Lispro • Asparto• Regular
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Inzucchi S. N Engl J Med 2006;355:1903-1911
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Insulinoterapia Intravenosa• Julio del 2002• Glucemia > 180 mg/dL = 16,7% (antes
40%)• Hipoglucemia
• < 60 mg/dL = 16% (antes 30%)• < 40 mg/dL = 3% (antes 14%)
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Generalidades
Meta 80 – 180 mg/dL80 – 110 mg/dL (UCI)
Infusión 1 u/1 cc100 u/100 cc Sol. 0,9% NaCl
Inicio Qx + Hipoglicemianta oral = Gluc > 120mg/dLResto = Gluc >70 mg/dL
Suspensión
Tolera VO1era dosis SC
Adaptado de: Trence et al. The racionale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-7
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Insulinoterapia Intravenosa• Hidratación Parenteral
• 5 – 10 g de glucosa/hora• Sol. Dextrosa al 5% o 0,45% = 100 – 200
cc/hora
Adaptado de: Trence et al. The racionale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-7
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Gluc. U/h
<70
70-109 0,2
110-119
0,5
120-149
1
150-179
1,5
180-239
2
240-299
3
300-359
4
>360 6
Glic. U/h
70-109 0,5
110-119
1
120-149
1,5
150-179
2
180-209
3
210-239
4
240-269
5
270-299
6
300-329
7
330-359
8
>360 12
Glic. U/h
70-109 1
110-119
2
120-149
3
150-179
4
180-209
5
210-239
6
240-269
8
270-299
10
300-329
12
330-359
14
>360 16
Glic. U/h
70-109 1,5
110-119
3
120-149
5
150-179
7
180-209
9
210-239
12
240-269
16
270-299
20
300-329
24
>330 28
>Rango o < 60 mg/dL/h
< 70 mg/dL x 2
Adaptado de: Trence et al. The racionale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-7
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Insulinoterapia Intravenosa• Monitorización
• Glucosa: 80 – 180 mg/dL• Glucemia Capilar
• C/h x 4 h• C/2h x 4 h• C/4 h
• Incluye pacientes con glucosa estable
Adaptado de: Trence et al. The racionale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-7
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Hipoglicemia (< 60 mg/dL)• Omitir insulina• Sol. Dextrosa al 50% IV
• Conciente: 25 mL• Inconciente: 50 mL
• Glic. Capilar c/20 min• 25 mL de dextrosa al 50% si glic <60
mg/dL• Reiniciar infusión si glic >70 mg/dL
Adaptado de: Trence et al. The racionale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-7
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Manejo de Endocrinología• Cambio de glucemia > 100 mg/dL/h• Glucemia > 360 mg/dL• Hipoglucemia que no mejora en 20
min con 50 mL de Dextrosa al 50%
Adaptado de: Trence et al. The racionale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-7
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Insulinoterapia Subcutánea• Monitorización de la glucemia:
• Antes de las comidas y HS• 2 horas después de las comidas• 2 a 3 am
• Meta de glucemia prepandial: 80 – 150 mg/dL
Adaptado de: Trence et al. The racionale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-87
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Orden de
Insulina
Desayuno
Almuerzo
Cena Hora Sueño
Prandial Dar ___ U de: Lispro Asparto Regular
Dar ___ U de: Lispro Asparto Regular
Dar ___ U de: Lispro Asparto Regular
Dar ___ U de: Lispro Asparto Regular
Basal Dar ___ U de: NPH Glargina Lenta Ultralenta
Dar ___ U de: NPH Glargina Lenta Ultralenta
Dar ___ U de: NPH Glargina Lenta Ultralenta
• Aspart/Lispro: 0 – 15 min antes•Regular: 30 min antes
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Insulinoterapia Subcutánea• Si glucemia < 60 mg/dL:
• Tolera VO• 15 g de carbohidratos de acción rápida
• 4 oz de judo de frutas, 8 oz leche descremada, 3 tab de glucosa
• No tolera VO• 25 mL de Sol. Dextrosa al 50%
• Monitorizar c/15 min y repetir si gluc. < 80 mg/dL
Adaptado de: Trence et al. The racionale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-87
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Glucemia
U Adiciona
l
150-199 1
200-149 2
250-299 3
300-349 4
>349 5Glucemia
U Adiciona
l
150-199 1
200-149 3
250-299 5
300-349 7
>349 8Glucemia
U Adiciona
l
150-199 2
200-149 4
250-299 7
300-349 10
>349 12
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Recomendaciones GeneralesDM tipo 1
(Incluso si esta en ayuna mantener Insulina Basal)
• Continuar Dosis Ambulatoria• Ajuste según requerimientos• Preferiblemente uso IV
• Nuevo Diagnóstico: 0,5 – 0,7 U/kg/d• 50% Insulina Basal/50%Insulina PrandialAdaptado de: Trence et al. The racionale and management of
hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-87
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Recomendaciones GeneralesDM tipo 2
• Continuar Dosis Ambulatoria• Ajuste según requerimientos
• Nuevo Diagnóstico: 0,4 – 1 U/kg/d
Adaptado de: Trence et al. The racionale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-87
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Paciente femenina de 53 años con asma y neumonia de focos múltiples ingresada con insuficiencia respiratoria aguda. Amerita intubación y tratamiento con antibioticos, broncodilatadores (sulbutamol) y glucocorticoides (metilprednisolona). Glicemia de ingreso de 183 mg/dL. Despues de 3 horas en la Unidad de Terapia Intensiva tiene una glucemia capilar de 264 mg/dL. No tiene antecedente de diabetes. Deberia su hiperglicemia ser tratada, y si es asi, como?
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• Moghissi et al. Hospital Management of Diabetes. Endocrinol Metab Clin N Am. 2005; 34:99-116
• American college of endocrinology. Position statement on inpatient diabetes and metabolic control. Endocr Pract 2004;10:77-82
• Inzucchi. Management of Hyperglycemia in the Hospital Setting. N Engl J Med. 2006; 355:1903-1911
• Van den Berghe et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359-67
• Norhammar et al. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet 2002;359:2140-4
• Malberg et al. Glycometabolic state at admisison: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the diabetes and insulin-glucose infusion in acute myocardial infarction (DIGAMI) study. Circulation 1999;99:2626-32
• Capes et al. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke. Oct 2001;32(10):2426-32
• Pomposelli et al. Early postoperatory glucose control predicts nosocomial infectons rates in diabetics patients. JPEN, 1998;22:77-81
• Funary. Clinical efects of hyperglycemia in the cardiac surgery population: the Porlant diabetic project. Endocr pract. 2006;34:612-616
• Trence et al. The racionale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. J Clin Endocrinol Metab 2003;88:2430-7
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