DUONG HUYET TAI HO! SUC BS Pham Phan Phuong Phuong BM Hai strc Cap ctru Chéng déc Dai hoc Y Dug TP. Hé Chi Minh Dan bai * Nguyén nhan tang duéng huyét * Muc tiéu dung huyét tai ICU + Protocol InsulinTONG QUAN + Tang DH thuéng gap 90% BN HSTC. + Tang DH cap: o Truéc day: 2 200 mg/dL o ADA 2010: 2 140 mg/dL (7,8 mmol/L) ma khéng cé bénh PTD trudc do o Nguong can diéu tri 220 mg/dL (vincent JL 2017 7%) * Khéng cé guideline nao dinh nghia ré rang tang DH & ICU + Tang BH lién quan TV & BN khéng co DTD nhap ICU: NMCT, dot Uy, (Egi 2008, Worthley MI 2007, Fogelhoim R 2005) NGUYEN NHAN CUA TANG DH Glucocorticoids, catecholamines Insulin resistance, Destrose (endogenous and exogenous) 1 beta-cell dysfunction (enteral) Lipolsis Inflammation (Garcalls) cytokines Gluconeogenesis liver) rt Hyperglycemia ~] Circulation and Electrolytes Cellular Effects Molecular Effects Fluid depletion Mitochondrial injury Oxidant injury Hypoperfusion Neutrophil dysfunction rotein glyestion Electrolyte loss Endothelial dysfunction Complement inhibition Sepsis Impaired wound healing NeuromyopathyVOLUME 345 NovemBer 8, 2001 NUMBER 19 INTENSIVE INSULIN THERAPY IN CRITICALLY ILL PATIENTS GREET VAN DEN BERGHE, M.D., PH.D., PieTeR WoureRS, M.Sc., FRANK Weexers, M.D., CHARLES VERWAEST, M.D., FRANS BRUYNINCKX, M.D., Mier ScHETz, M.D., PH.D., Dink VLASSELAERS, M.D., PATRICK FERDINANDE, M.D., PH.D., Peter Lauwers, M.D., AND ROGER BOUILLON, M.D., PH.D. * Di tugng: 1548 bénh nhan surgical ICU, hau hét PT tim * Chia thanh 2 nhom: —Nhom 1: intensive insuline therapy voi DH 80-110 mg% —Nhom 2: conventional treament voi DH 180-200 mg% CoNvENTIONAL —_INTENSIVE TREATMENT TREATMENT Pp Variable (N=783) (N=765) — Vawuet Administration of insulin 307 (39.2) 755 (98.7) <0.001 —no. (%) Insulin dose — TU/dayt Median 33 a Interquartile range 17-56 48-100 <0.001 Duration of insulin use —% of ICU stay Median 67 100 <0.001 Interquartile range 40-100 Morning blood glucose — mg/dlg All patients 153433 03219 = <0.001 Patients re ing insulin 173£33 103+18 <0.001Taste 3. Monat. Conventional Inrensive ‘Theatwent Treatment Various (N=783) (N=765) P vauue® 0:04 adjusted) ‘During firs § days of intensive care 14/783 (18) 13/768 (1.7) 09 Among patients receiving intensive care for >5 days 49/243 (20.2) 22/208 (10.6) 0.005 Reason for intensive care ‘Cardiac surgery 25/493(5.1) 10/477 (2.1) Neurologic disease, cerebral trauma, or brain surgery 7/30 (233) 6/33. (18.2) ‘Thoracic surgery, respiratory insulfiiency, or both 10/36 (179) 5/66. (7.6) Abdominal surgery or pert 9/58 6/48 (133) Vascular surgery 2/32 2/30 (6.7) ‘Multiple trauma or severe burns 3/35 4/33 (12.1) Transplantation 1/44 2/46 (4A) Other 6738 0738 No history of diabetes 57/680 (84) 31/664 (4.7) No history of ciaberes and >5 days of intensive care 45/218 (20.6) 20/187 (10.7) History of diabetes 6/103 (5.8) 4/101 (4.0) History of diabetes and >5 days of intensive care 4/25 (160) 2/21 9.5) Cause of death — 0.02 ‘Muliple-organ failure with proven septic Focus 33 8 e-organ failure without detectable septic focus 8 “4 5 3 Acute cardiovascular collapse 7 10 n-hospital death — no./toral no, (%) “All patients 85/783 (109) 55/765(7.2) O01 Patients receiving intensive care for >5 days 64/243 (26.3) 35/208(16.8) 0.01 7 Nghién clu Leuven Belgium * Két luan: —Intensive insuline therapy dé duy tri DH < 110 mg% thi lam giam duoc bién chtrng va tty vong so voi nhém conventional treatment voi mirc DH 180-200 mg% & bénh nhan ICU PTBENEFITS AND RISKS OF TIGHT GLUCOSE CONTROL IN CRITICALLY ILL ADULTS: A META-ANALYSIS + Renda Soylemez Wiener, Danie! C Wiener, Robin J Larson JAMA 2009 + 29 RCT: 8432 patients + Hospital mortality did not differ between tight glucose control and usual care + No significant difference in mortality when stratified by glucose goal ([1] very tight: < or = 110 mg/dL; 23% vs 25.2%; RR, 0.90; 95% Cl, 0.77-1.04; or [2] moderately tight: < 150 mg/dL; 17.3% vs 18.0%; RR, 0.99; 95% Cl, 0.83-1.18) THU’ NGHIEM NICE-SUGAR 2009 * Déi tugng nghién ctru: 6104 bénh nhan 42 ICU * Chia thanh 2 nhom: —Nhom 1: intensive insulin therapy myc dich DH 81-108 mg% —Nhom 2: conventional treament muc tiéu DH 144-180 mg%de a we com are ccocoet Cusseta poy Satie Fae uth fatal 6) agate cion an ‘mopmogrs) mypo es) Leena oo ey 2 oypoi0(23) eani2g08) 1099612) wv remaeasinrgrarentnind 96914) 7692) LEHI) aptemecen OH ‘cso m Unie ecweedethuinmret SALSA) 69/70619) L2ASTIIH on Witiewieawerstapopiae 2916768) N0]Y. a3 WLI ost Peer et THM6RH TAA] CAT OAALAD) Lgeiempmnin 0a ‘spo soe cams) ter ow ung petal eng reine mon 08) ino) Cedanelaedardaiastock NARS AE) 0H) ote ctr msa.4) 931072) Newlpe pa2spa.n 941633) era wines ps0) 7751 4) oe aja) ys. 948) cet det ftp oy SMenna(659) e751 683) evborienpd sansa) 497051 4a) sms 55105) Seechpaens—ropsetnsl FDRG) SOUS) IBAA Lacepenon 20 psn median 18) ean) eae) . seme oak Darina — rein 198) yaw a5) . wernt 986 veiaton rm efptens| 2054014 2821453) A7E-OSLOLI| —asonstet O17 ep 10. c . 2 os & a ; é 07; Intensive glucose control eo —__,___,___,___,___,______,__, o 1 0 3 © so 6 7 80 90 Days after Randomization No. at Risk Conventional control 3014 2379 2308 2261 Intensive control 3016 2337 mr 2gTHU NGHIEM NICE-SUGAR 2009 + Két cuc phu: + Severe hypoglycemia (BG s40 mg%): 6.8% intensive control vs 0.5% conventional control (odds ratio, 14.7; 95% Cl, 9.0 to 25.9; P<0.001) + Két luan: + Intensive glucose control increased mortality among adults in the ICU: a blood glucose target $180 mg% resulted in lower mortality than did a target of 81 - 108 mg%. MUC TIEU DUO'NG HUYET ‘Table 1. Guidelines from Professional Organizations on the Management of Glucose Levels in the ICU.* Organization 2003 American Association of Clinical Endocrinologists and American Diabetes Association 2008 2005 2008 Surviving Sepsis Campaign Institute for Healthcare Improvement ‘American Heart Association 2001 European Society of Cardiology and European Association for the Study of Diabetes Target | Definition of Glucose Level | Hypoglycemia mg/dl Patient Population ICU patients 140-180 <1 ICU patients 150 Not stated ICU patients <180 <40 ICU patients with acute 90-140 | Not stated coronary syndromes ICU patients with cardiac “stict't | Not stated disorders Updated since NICE-SUGAR Trial, 2009 YesTable 1 Glycemic range recommendations Study Glycemic range Ref. Comments College of 140.200 mg/L Physicians: Recommend « Seteoltoayend Diabetes Intensive insuilin therapy 140-180 mg/a isa, Association! ‘cause severe hypoglycomia Jacobi et alll, | Recommend the use of moderate use of 2012 trol 150-180 mg/l Annane et af COTS study Standards of ae Saude tack ad eee a 2 oeae eae MGC: Mode ove control; TGC: Tight glucose control Citation: Casillas S, Jauregui E, Surani S, Varon 3. Blood glucose control in the intensive care unit: Fe erat end URL: bites://www.w DOH: hitns://dx.dol.ore/10.13105/wima.y7.l8.399 INSULIN + Regular insulin + TTM bat ké tién can DTD + Khéng qua 20 Ul/h TTM + Khéng str dung thuéc ha DH uéng © Khéng thé dr doan hép thu, bai tiét, chuyén hoa o SU gay ha DH nang o Metformin gay TCH o Ue ché SGLT-2 gay mat nuéc va DKA DH binh thuongINSULIN + Kiém tra Glucose méi gid’ cho dén khi dat duc muc tiéu thi thtr méi 2 - 4 gid * Duy tri tiép Insulin regular TTM 2 — 3 gio’ sau liéu Insulin tiém duoi da dau tién PROTOCOL INSULIN + Khoi dau: —Pha 50 UI insulin véi 50 mi NaCl 0,9 % —Truyén tinh mach hay qua bom tiém dién + DH/70 va lam tran cé dugc sé don vj insulin can thiét: —Vd: DH 250 > 250/70 =3.57 > lwong insulin la 4 UI + Néu DH > 180 mg% thi can bolus trudc —Bolus 4 UI (theo vd) — Sau dé truyén TM véi téc dé trong mét gi’ bang liéu bolus (vd: 4 Ul/h) + Néu DH < 180 mg% thi khong can bolus -Vd: DH 150 > 150/70 = 2.15 > BTD 2UI/hTHEO DOI DU'O'NG HUYET * Theo dédi DH (mao mach, DM, TM, loc mau) + MAu mau khéng cé dich truyén * DHMM cé thé khéng chinh xac 20%: o Phu: mé mém o Gidm tuéi mau, nhiét do thap o Thiéu mau (Hct<34%: sai sé lam tang gia tri POC DH tai givéng) THEO DOI DUONG HUYET * Quay tré lai DH theo 1h khi DH > 70 mg% va co thém bat ki mét trong nhivng diém sau: —Thay ddi liéu truyén insulin —Khdéi déng hay ngung str dung corticoid hay vasopressin —Tinh trang lam sang thay déi dang ké —Thay ddi ché d6 dinh duéngThoi gian bat Thoi gian kéo Cac Log ineutin | They | Bin oat Bigt duge Insulin tic dung shank (Rapid - acting insulin) inulin aspart analog 70-iSphk | +2 oe 3=59@ | Now Rapid insulin glusisine nalog | 10-15 phat | 1-2 gio 3-500 -piara insulin topo analog 10-15phit | 12 90 3-59@ Huralog Insulin tée dng ng (short — acting insuin) Regular insulin 05-198 2598 4-890 ‘Retrapid Insuman insulin te dng tang binh (intermediate - acing) INPH insulin 7-3 9@ Hi0ge 70-189] insvatard Insulin tc dyng Kéo dong — acting) insulin detemir analog 19 Binh 249i Levemir Insulin glargine analog 2-300 | | Ihde 249 Lantus _| hoa kong insulin Degludoe 30-80 phat ‘inh 90 Tresiba Insulin hn hop (Premixed insulin combinations) 70% NPH30% regular 05-t9o | 21080 | 10-1890 | Mixtard30 70% protamine suspension | 10-20 phit | 14g | 10-16 gio | NowoMix30 aspart 30% aspart 76% tsp protamine; 25% | 10-t8phat | 13g | 10-16 glo | Humalog 7625 lspro Acting (Glargine or Detemir) Insulin Dose ll . The average hourly insulin drip rate for the last 6 hours is ___units per hour. Multiply by 24 to give a daily usage rate: __units per day. . Multiply by 70% to 85% to estimate the first day’s total insulin dose: __units. . All can be administered in divided doses twice daily; glargine and detemir can be given once daily. Dose adjustment may be necessary after first dose given. Review daily thereafter. 3 rCHUYEN SANG INSULIN TIEM DUO! DA + Tiém dui da: - Nén: NPH = 2/3 téng liéu insulin truyén trong ngay TDD 1 hay 2 lan cach 12 gid - Theo doi dong huyét mai 4 — 6 gid + Néu DH cao cé thé thém insulin Regular TDD - Néu BH 2 [an > 200 mg% hay liéu TDD > 20 don vi, nén truyén insulin tré lai KET LUAN * Khong khuyén cao kiém soat DH qua chat ché * Gia tri DH: 150-180 mg% la con sé thich hop