Mortality and Morbidity Hypoglycemia

1
Mortality and MorbidityHypoglycemia

• 92/11/20
• ???

2
Case 1

• Chart NO
• Age77 y/o
• Gendermale
• PH liver cirrhosis related to the HBV, old
  CVA with left hemiplegia
• CC cons change due to hypoglycemia referred
  from the ?? hospital

3
Case 1

• PI(1)
• Type 2 DM with OHA control for 5-6 years
  (Diamicron 0.5 qd? Noted in the old chart since
  Sep 14,1999)
• Walk by walker by himself 2 months ago and poor
  appetite attack one month ago with the same dose
  of the OHA
• Cons change on 11/1 evening and then sent to ??
  hospital at first and the dextrostix was 19 with
  normal brain CT finding
• Transferred to our ER on 11/2(1004am)
• ?GCSE4M3V2,glucose 139, BP 86/56 mmhg, HR
  78bpm, RR 12 and pulse oximeter 98 on room air

4
Case 1

• PI(2)
• Neurologist consultation No recurrent CVA
  evidence
• Observation on ACU-36 with GCSE4M4V2 on 11/2
  with NS supply
• Glucose 59 on 11/3 (620am) and then D50W 2amp
  prescribed
• Transferred to endocrine ward on 11/3 evening
• Order on ward
• ?NG Dm diet with G5S 1000cc and silimarin
  1BID
• ?STAT G5W 500CC IVD
• Apnea and dextrostix 11 on 11/4 (640am ) ?CPR
  for one hour ?hopeless
• Lab data WNL (ammonia 53)

5
Case 2

• Chart NO
• Age56
• Gendermale
• PHCHF Fc II-III, HTN, alcoholic liver cirrhosis
  and alcoholism
• CC less urine amount for one week

6
Case 2

• PI(1)
• CV OPD medicine
• ?aldactone 1qd, imdur 1qd, capoten 0.5
  tid, Dilatrend 1bid
• ?plavix 1qd, silimarin 1tid, trental
  1tid, digoxin 0.5qod,
• ?hytrin 0.5hs, concor 0.5 qd,
  glibenclamide 1qd but DC on 9/22 due to drinking
  without eating and hypoglycemia attack
• Ward order on 10/29
• ?as the OPD medicine and add the HM 20-10 bid
  use
• 3. Liver and renal echo
• ?C/W DM nephropathy (chronic change)
• ?alcoholic liver cirrhosis with splenomegaly,
  hepatomegaly and little ascites

7
Case 2

• PI(2)
• Good activity from 10/29 to 11/6
• Apnea with pulseless and dextrostix 46 while CPR
• Transferred to MICU with GCSE1M1Vt now and the
  neurologist consulation report was hypoxic
  encephalopathy

8
Case 2

• Lab data
• 10/29
• glucose 485, GOT/GPT 16/11, amylase 27,
  BUN/Cr 65/3
• Na/K 129/4.1
• 11/1
• HBA1C 8.4, Alb 2.5, Uric acid 12.8,

9
Discussion
10
Hypoglycemia

• defined as a plasma glucose level lt2.5 to 2.8
  mmol/L (lt45 to 50 mg/dL).
• Whipple's triad (1) symptoms consistent with
  hypoglycemia, (2) a low plasma glucose
  concentration, (3) relief of symptoms after the
  plasma glucose level is raised.
• Hypoglycemia should be considered in any patient
  who presents with confusion, altered level of
  consciousness, or seizures.

11
Hypoglycemia (NEJM April27, 1995)

• S/S of hypoglycemia calssified into two major
  group
• 1.actions of autonomic nerve system
• ?sweating, trembling, feeling of warmth, anxiety
  and nausea
• 2.neuroglycopenia (related to the insufficient of
  glucose supply to the brain)
• ?dizziness, confusion, difficulty in speaking,
  headache and inability to concentrate

12
Hypoglycemia (NEJM December 28, 1995)

• Conclusions During hypoglycemia, patients with
  IDDM with nearly normal HBA1C? normal glucose
  uptake in the brain? preserves cerebral
  metabolism, ?reduces the responses of
  counterregulatory hormones, and causes an
  unawareness of hypoglycemia?increase the risk of
  seizure and coma

13
HypoglycemiaDecreased Epinephrine Responses to
Hypoglycemia during Sleep(NEJM June 4, 1998)

• Conclusions
• Sleep impairs counterregulatory-hormone
  responses to hypoglycemia in patients with
  diabetes and normal subjects(The patients' plasma
  norepinephrine responses were also reduced during
  sleep, whereas their plasma cortisol
  concentrations did not increase and their plasma
  growth hormone concentrations increased slightly.
  The patterns of counterregulatory-hormone
  responses in the normal subjects were similar.

14
HypoglycemiaUnawareness of Hypoglycemia NEJM
December 28, 1995

• The Diabetes Control and Complications Trial
  showed IDDM should be treated to make HBA1C
  approximately 7.0 percent? the risk of the onset
  or progression of microangiopathy.9
• However, in that study intensive treatment
  increased the rate of severe hypoglycemia
  approximately threefold.9 Recent European
  studies7,8 indicate that the risks of
  complications, unawareness of hypoglycemia, and
  severe hypoglycemia can all be minimized if the
  HBA1C is maintained at 6.5 percent to 7.5
  percent.

15
Hypoglycemia (NEJM April27, 1995)

• The primary causes of hypoglycemia in patients
  without diabetes were renal insufficiency,
  chronic liver disease, infection, malnutrition
  and shock.

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Cause of hypoglycemia
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19
Hypoglycemia

• Plasma glucose levels within a narrow range
  between 3.3 and 8.3 mmol/L (60 and 150 mg/dL),
• serum glucose levels are maintained primarily by
  glycogenolysis in the liver and by
  gluconeogenesis .
• hepatic glycogen stores are sufficient to
  maintain plasma glucose levels for 8 to 12 h,
• it can be shorter if glucose demand is increased
  by exercise or if glycogen stores are depleted by
  illness or starvation.

20
Hypoglycemia

• Gluconeogenesis occurs primarily in the liver but
  also in the kidney.
• Gluconeogenesis requires precursors from liver,
  muscle, and adipose tissue.
• ? triglycerides in adipose tissue are broken down
  into glycerol and free fatty acids, which
  generate acetyl CoA for gluconeogenesis
• Muscle provides lactate, pyruvate, alanine, and
  other amino acids

21
Glucose metabolism and pathways
22
Hypoglycemia
23
Hypoglycemia(NEJM April 27,1995)
24
Hypoglycemia

• Ethanol blocks gluconeogenesis but not
  glycogenolysis.
• alcohol-induced hypoglycemia typically occurs
  after a several-day ethanol binge during eating
  little food?causing glycogen depletion.
• Hypoglycemia mortality rates as high as 10
• .

25
Hypoglycemia
26
Hypoglycemia

• Urgent Treatment
• Oral treatment with glucose tablets or
  glucose-containing fluids, candy, or food
• A reasonable initial dose is 20 g of glucose
• Intravenous glucose (25 g) should be given using
  a 50 solution followed by a constant infusion of
  5 or 10 dextrose.
• subcutaneous or intramuscular glucagon can be
  used, particularly in people with type 1 diabetes
  mellitus.
• it acts primarily by stimulating glycogenolysis,
  glucagon is ineffective in glycogen-depleted
  individuals (e.g., those with alcohol-induced
  hypoglycemia).
• These treatments raise plasma glucose
  concentrations only transiently

27
Hypoglycemia

• Three general mechanisms have been implicated.
• hypoglycemia can be induced by a single
  hypoglycemic agent such as a sulfonylurea.
• two or more hypoglycemic drugs can induce
  hypoglycemia.Specific include a sulfonylurea plus
  insulin,a sulfonylurea and salicylates, and a
  sulfonylurea or insulin mixed with alcohol.
• multiple drug-drug interactions to potentiate
  the effect of sulfonylureas. These include
  anti-inflammatory agents, sulfa
  antibiotics,bishydroxycoumarin, antidepressants
  and propranolol
• and tetracyclines have been reported to
  potentiate the hypoglycemic effects of insulin

DIABETES CARE, VOLUME 25, NUMBER 9, SEPTEMBER 2002
28
Hypoglycemia

• Various risk factors have been analyzed
  sulfonylurea induced hypoglycemia include
• gt60years, renal dysfunction, alcohol ingestion,
• sepsis, intentional overdose, liver cirrhosis.
  The most common cause sulfonylurea-induced
  hypoglycemia are glyburide and glipizide
• DIABETES CARE, VOLUME 25,
  NUMBER 9, SEPTEMBER 2002

29
Hypoglycemia

• clarithromycin should be cautiously prescribed
  to type 2 diabetic patients with mild renal
  impairment with sulfonylurea medications.
  (Mechanisms of drug-drug interactions include one
  drug binding another,displacement from protein
  binding sites,alteration of drug metabolism, or
  alteration of drug excretion. )
• DIABETES CARE, VOLUME
  25, NUMBER 9, SEPTEMBER 2002

30
Hypoglycemia

• Hypoglycemia as a Predictor of Mortality in
  Hospitalized Elderly Patients?
• From Archives of Internal Medicine.163(15)1825-18
  29, August 11/25,2003

31
Hypoglycemia Hypoglycemia as a Predictor of
Mortality in Hospitalized Elderly Patients

• 5404 Pts, gt70y/o
• 281 with hypoglycemia
• ?woman(58) gtman (40)sepsis was 10times
  Malignancy was 2.8times
• 70 hypoglycemic Pt with sulfonyuria or insulin
• Multivariate logistic analysis revealed that
  sepsis, albumin level, malignancy, sulfonylurea
  and insulin Tx, alkaline phosphatase level,
  female and creatinine were the independent
  predictors of hypoglycemia
• In-hospital mortality and 3-month mortality were
  2 as high in the hypoglycemic group?sepsis, low
  albumin level and malignancy were independent
  predictors
• From Archives of Internal Medicine.163(15)1825-18
  29, August 11/25,2003