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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5537_Библиотеки_им_академика_М_И_Перельмана.pdf
Hyperglycemia is associated with worse outcomes in the critically ill,
and may be more deleterious in those without pre-existing diabetes.
2
There are some populations wherein intravenous (IV) insulin reduces
blood glucose (BG) and appears to be beneficial in reducing mortality
and/or infection: diabetics undergoing cardiothoracic surgery,
3,4
diabet-
ics with myocardial infarction,
5
and non-diabetics undergoing cardio-
thoracic and general surgery.
6
Based on large, randomized control trials, the optimal glucose range
for improving outcomes in the critically ill is unknown and remains a
moving target. In the NICE-SUGAR trial, surgical and medical critically
ill patients suffered increased mortality and hypoglycemia when glucose
targets of 80–110 mg/dL were applied.
7
Furthermore, the optimal glucose
target may vary depending on the population type, i.e. medical versus
surgical, diabetic versus non-diabetic. Current recommendations by the
ADA/AACE are BG goal of 140–180 mg/dL in critically ill patients,
using an IV insulin protocol with demonstrated efficacy and safety.
8
There are published insulin drip protocols using the lower glucose goal
of 80–110 mg/dL,
9–11
and the newer goal of 140–180 mg/dL.
12
Glucose Goals
• Glucose goals in the critically ill patient: 140–180 mg/dL.
• Consider initiating IV insulin infusion when glucose >180 mg/dL.
Insulin IV Infusion
A validated IV insulin drip protocol should be used, incorporating current
glucose, rate of glucose change, and current insulin infusion rate into adjustments of the insulin infusion. A hypoglycemia protocol should be used.
• Insulin IV infusion: 100% bioavailable, immediate onset, duration of
insulin action ∼1 hour
• Insulin infusions come in different concentrations.
Regular insulin 100 units mixed in 1000 mL of 0.9% NaCl (normal
saline) → 1 unit insulin per 10 mL.
394
M. Skamagas
Regular insulin 100 units mixed in 100 mL of 0.9% NaCl (normal
saline) → 1 unit insulin per 1 mL.
This concentration requires an infusion pump that can dispense
≤ 1mL/hour.
Glucose Monitoring
• Measure blood glucose (BG) every 1 hour.
• When BG is stable and no change in clinical status, nutrition, steroids,
etc., consider reducing BG measurements to every 2 hours.
• Obtain blood from capillary/fingerstick and use bedside glucometer,
OR obtain blood from venous/arterial source/catheter and measure
BG on blood gas.
• Caveat: capillary BG measurements may be inaccurate in hypotensive/
hypoperfused patients, severe edema, and patients receiving
pressors.
• Check HbA1c to determine if patient has pre-existing diabetes or
stress hyperglycemia.
Converting IV to Subcutaneous (SC) Insulin
in Critically Ill
13
• Convert to SC insulin when patient is clinically stable, off pressors,
BG is stable, patient is ready to resume eating.
• Check BG before meals and at bedtime.
• If patient is not eating or is receiving tube feeds, check BG every
6 hours.
• Not to be used for diabetic emergencies (diabetic ketoacdosis and
hyperglycemic hyperosmolar state).
Patients who do not have a prior diagnosis of insulin-requiring diabetes and who are receiving ≤ 1.5 units/hour of IV insulin, may not
require transition to SC basal insulin. Consider starting correction insulin
scale only, monitor BG, and initiate basal insulin if BG is not at goal.
395
Glycemic Management in Critically Ill Patients
These patients may require correction scale only, basal insulin only, or
basal and mealtime insulin.
Calculation of SC Insulin Doses
1. Total Daily Insulin Requirement
Determine the average hourly rate of IV insulin over last 6 hours and
multiple rate × 20 hours
Ex: 2 Units/hr × 20 hr = 40 Units = Total Daily Insulin
2. Convert Total Daily Insulin to SC insulin: 50% basal, 50% mealtime
in divided doses.
Ex: 40 units × 50% = 20 units
BASAL: 20 Units glargine SC once daily
Can also use detemir divided twice daily, or NPH divided twice
daily (more hypoglycemia with the latter)
MEALTIME: 20 ÷ 3 ≈ 6 Units rapid-acting insulin SC before meals
Use only if patient is eating
Use aspart, lispro, or glulisine
If PO intake variable/poor, give less than this calculated dose
Ex: Give 25–50% = 2–3 units after patient has eaten >25–50% meal
CORRECTION INSULIN SCALE: Use before meals or every 6 hours
Use aspart, lispro, or glulisine
See Table 4 in Chapter 46 “Management of Diabetes and
Hyperglycemia in Hospitalized Patients”
ENTERAL NUTRITION (TUBE FEEDS): For patients on continuous
tube feeds and insulin drip:
Convert Total Daily Insulin to NPH insulin SC divided every
8 hours
Ex: Total daily insulin of 40 units ÷ 3 ≈ NPH 13 units every
8 hours, give if tube feeds are infusing
If tube feeds are inadvertently stopped, start IV Dextrose 10% and
hold NPH.
396
M. Skamagas
3. Discontinue IV insulin drip 2 hours after 1st dose of SC Basal
Insulin
4. Hypoglycemia Orders — See “Hypoglycemia” section in Chapter 46
“Management of Diabetes and Hyperglycemia in Hospitalized
Patients.”
References
1. Kavanagh BP, McCowen KC. (2010) Clinical practice. Glycemic
control in the ICU. N Engl J Med 363: 2540–6.
2. Egi M, Bellomo R, Stachowski E, et al. (2008) Blood glucose concentration and outcome of critical illness: The impact of diabetes. Crit
Care Med 36: 2249–55.
3. Furnary AP, Zerr KJ, Grunkemeier GL and Starr A. (1999)
Continuous intravenous insulin infusion reduces the incidence of deep
sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 67: 352–60.
4. Furnary AP, Gao G, Grunkemeier GL, et al. (2003) Continuous insulin
infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 125: 1007–21.
5. Malmberg K. (1997) Prospective randomised study of intensive
insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus,
Insulin Glucose Infusion in Acute Myocardial Infarction) Study
Group. BMJ 314: 1512–5.
6. Van den Berghe G, Wouters P, Weekers F, et al. (2001) Intensive
insulin therapy in the critically ill patients. N Engl J Med 345:
1359–67.
7. The NICE-SUGAR Study Investigators. (2009) Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360:
1283–97.
8. Moghissi ES, Korytkowski MT, DiNardo M, et al. (2009) American
Association of Clinical Endocrinologists and American Diabetes
397
Glycemic Management in Critically Ill Patients
Association consensus statement on inpatient glycemic control.
Endocr Pract 15: 353–69.
9. Goldberg PA, Siegel MD, Sherwin RS, et al. (2004) Implementation
of a safe and effective insulin infusion protocol in a medical intensive
care unit. Diabetes Care 27: 461–7.
10. Wilson M, Weinreb J and Hoo GW. (2007) Intensive insulin therapy in
critical care: A review of 12 protocols. Diabetes Care 30: 1005–1011.
11. Portland: Portland Protocol. Providence Health Systems. Available from
http://www.providence.org/oregon/programs_and_services/heart/
portlandprotocol/e05protocol.htm
12. The NICE-SUGAR Study. Protocol available from https://studies.thegeorgeinstitute.org/nice/
13. Bode BW, Brathwaite SS, Steed RD, et al. (2004) ACE inpatient dia-
betes and metabolic control consensus conference. Intravenous insulin
infusion therapy: Indications, methods, and transition to subcutaneous
insulin therapy. Endocr Pract 10: 71–80.
398
M. Skamagas
Renal
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Management of Hospitalized Patients
with End-Stage Renal Disease
Anand C. Reddy,* Sridhar R. Allam* and Brian D. Radbill*
Key Pearls
• Intradialytic hypotension is often secondary to excessive volume
removal but may be a sign of an infected dialysis access, myocardial
ischemia, or a significant pericardial effusion.
• Hemodialysis patients who present with a thrombosed AV access may
be treated by an interventional radiologist or vascular surgeon in the
outpatient setting and avoid hospital admission if they do not have an
acute indication for dialysis.
• Hospitalized patients with advanced CKD should be educated about
the risk of progression to ESRD and ideally seen by a nephrologist or
CKD educator during their admission so that they may make early
arrangements for future renal replacement therapy.
• Blood transfusions should be avoided in ESRD patients who are potential transplant candidates because of the risk of developing antibodies
and rejecting a donor kidney in the future, but should be administered, if
necessary, while the patient receives dialysis to avoid volume overload.
• Oral sodium phosphate solution bowel preps should never be used in
patients with renal disease as these can cause acute phosphate
nephropathy in patients with CKD, and severe hyperphosphatemia
and hypocalcemia in patients with ESRD.
401
34
Chapter
*Mount Sinai School of Medicine, New York NY, USA.
Introduction
Patients with end-stage renal disease (ESRD) are frequently hospitalized for
conditions directly and indirectly related to their chronic kidney disease
(CKD) or renal replacement therapy (i.e. hemodialysis, peritoneal dialysis,
kidney transplantation). With an average of nearly two hospital admissions
per patient-year, the adjusted ESRD hospitalization rate is four times higher
than that of the general Medicare population.
1
As the number of patients
with ESRD continues to grow in the United States, hospitalists can expect
to see an increase in the number of ESRD-related admissions and must
understand the specific care needs associated with this patient population.
Common Reasons for ESRD-related Hospitalization
Infections
ESRD patients are more susceptible to infections because of the
adverse effects of uremia on the immune system; CKD/ESRD patients
have a 3–4-fold higher risk of major infections and sepsis as compared to
the general population.
2
In this section, we will limit our discussion to the
management of dialysis access-associated infections. Other infections
commonly seen in ESRD patients, such as pneumonia, are covered in
other chapters.
Catheter-related Bacteremia
The overwhelming majority of vascular access-associated bloodstream
infections in ESRD patients on hemodialysis (HD) are catheter-related
bacteremias (CRBs). Patients typically present with fever and chills,
often while receiving dialysis treatment through the infected catheres.
Diagnosis of dialysis CRBs requires concurrent positive blood cultures
from the dialysis catheter and a peripheral vein. In practice, obtaining
blood cultures from the periphery is rarely done as ESRD patients have
notoriously poor venous access. Empirical antibiotic therapy consists of
vancomycin and an aminoglycoside or third-generation cephalosporin
402
A. Reddy, S. R Allam and B. Radbill
(see Table 1). In addition, management of a dialysis CRB typically
involves catheter removal or catheter replacement via guidewire
exchange because the risk of recurrence after antibiotic treatment alone
is too high to attempt catheter salvage in most settings. If the patient is
stable, most nephrologists prefer guidewire exchange over catheter
removal because the results are similar and guidewire exchange preserves access sites which may otherwise be lost.
3
403
Management of Hospitalized Patients with End-Stage Renal Disease
Table 1. Commonly Used Empiric Antibiotic Regimens for Catheter-related
Bacteremia in HD Patients* and Catheter-associated Peritonitis in PD Patients**
Mode of Dialysis Gram Positive Coverage Gram Negative Coverage
IHD (intermittent Vancomycin 20 mg/kg IV Gentamicin or 1 tobramycin
hemodialysis) during last hr of dialysis 1 mg/kg IV (not exceeding
followed by 10 mg/kg IV 100 mg), or ceftazidime 1 g IV
during last 30 min of each after each dialysis session.
subsequent dialysis session.
(Cefazolin 20 mg/kg IV after
each dialysis can be used
alternatively in units with
low prevalence of MRSA)
CAPD (continuous Vancomycin 15–30 mg/kg IP Gentamicin or tobramycin 0.6
ambulatory every 5–7 days. mg/kg IP daily, or
peritoneal (Cefazolin 15 mg/kg IP daily cefepime 1g IP daily
dialysis done can be used alternatively in
manually) units with low prevalence
of MRSA)
APD (automated Vancomycin 30 mg/kg IP, Tobramycin 1.5 mg/kg IP once,
peritoneal followed by 15 mg/kg IP then 0.5 mg/kg IP daily, or
dialysis using every 3–5 days. cefepime 1g IP daily
cycler) (Cefazolin 20 mg/kg IP daily
can be used alternatively in
units with low prevalence
of MRSA)
*Adapted from 2009 guidelines published by IDSA (Infectious Diseases Society of America).
**Adapted from 2010 guidelines published by ISPD (International Society of Peritoneal
Dialysis); for patients with residual renal function (urine output >100 ml/day), dose should be
increased by 25%. All antibiotics administered by intraperitoneal (IP) route should be used with
long dwell of PD.