Thina 570710159 Group G Objective 1 เพอใหทราบถงภาวะ Metformin associated lactic aciosis 2 3 4 เพอใหทราบแนวทางการรกษาภาวะ ID: 935078
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Slide1
Case conference
Karnmanee Thina 570710159Group G
Slide2Objective
1
เพื่อให้ทราบถึงภาวะ
Metformin
-associated lactic
aciosis
2
3
4
เพื่อให้ทราบแนวทางการรักษาภาวะ
Metformin
-associated lactic
aciosis
เพื่อให้ทราบข้อบ่งชี้ในการทำ
Urgent
hemodialysis
ในผู้ป่วยที่มีภาวะ
acute kidney injury
เพื่อให้ทราบการปรับใช้ยา
Metformin
ในผู้ป่วยที่มีการทำงานของไตบกพร่อง
Slide3A 50-year-old female
อาชีพ: รับจ้างภูมิลำเนา:
ต.แม่ยาว อ.เมือง จ.เชียงราย
Chief complaint:
สับสน
5hrPTA
Slide4Primary survey
A
Triage:
B
Can talk, no
stridor
, no secretion
Pass
RR 22/min SpO2 98%(RA)
Lung: clear and equal breath sound both
lungs
Pass
Emergency
Slide5Primary survey
C
D
BP 138/83 mmHg PR 120
bpm
CRT <2 sec
E3V4M6 pupil 2
mmRTLBE
DTX 13 mg%
Pass
- 50% glucose 50 ml iv push
- 10%DN/2 1000ml iv drip rate 60 ml/
hr
Slide6Primary survey
E
T 36.3 c
Completely undress
- Keep warm with blanket
Slide7Adjunct to
Primary survey
Investigate
Monitoring
Slide8Slide9Secondary survey
Present illnessPast history
4dPTA
มีไข้ ทานได้น้อย อาเจียนเป็นเศษอาหาร ปวดท้อง รู้สึกอ่อนเพลีย
1dPTA ไม่มีไข้ แต่อาเจียนมากขึ้น ญาติสังเกตว่าผู้ป่วยดูซึมลง ถามตอบช้าลง
5hrPTA
ผู้ป่วยพูดจาสับสน อ่อนเพลีย ไม่มีแรงมากขึ้น จึงพามาโรงพยาบาล
U/D:
T2DM(HbA1C 8), HT, DLP, old CVA(28/9/60
)Statusเดิม: เดินได้ ช่วยเหลือตัวเองได้ พูดคุยรู้เรื่องCurrent medication: Aspirin(81) 1x1 po OD Glipizide(5) 2x2 po ac Metformin(500) 2.5x2 po pc Simvastatin(20) 1x1
po
hs
No traumaPrevious surgery: ทำหมัน last 23 years
IV
V
V
V
Slide10Secondary survey
Personal/Social historyNo alcohol drinking
No smoking
No food/drug allergyNo herbal use
Slide11Secondary survey
Physical examinationVital signs: T 35.9 c RR 20 /min PR 20 bpm
BP 142/83 mmHg
SpO2 98%(RA)GA: A woman looks drowsiness and fati
gue
HEENT: no pale conjunctivae, no icteric sclerae, dry lips
Lymph node:
not palpable
Skin:
normal skin turgor, no skin lesion
Chest & lung:
normal breathing pattern, clear and equal breath sound both lungs
CVS: no neck vein engorgement, regular rhythm, normal S1S2, no murmur, pulse 2+ all limbs, CRT<2secs
Secondary survey
Physical examinationAbdomen: normal contour,
normoactive
bowel sound, soft, no tenderness, liver and spleen can’t be palpated, liver span 7 cmGU: no CVA tenderness
Extremities: no pitting edema, no deformity
Neurology: E4V4M6, pupil 2 mmRTLBE
,
stiffneck
-
ve
Adjunct to
Secondary survey
Slide14CBC and
Coagulogram
Slide15BUN, Cr, Electrolyte and Glucose
Slide16LFT and lactate
Slide17Urinalysis
Slide18ABG
pH 6.845pCO222.5 mmHg
pO2
122.0 mmHgcHCO3
3.9 mmol/L
cSO293.9%
Lactate
18.88
mmol
/L
Na
129
mmol
/LK
4.3
mmol/L
Cl
97
mmol
/L
CO2
<5
mmol
/L
Slide19Problem list
Slide20Differential diagnosis
Provisional
diagnosis
Slide21Progression at
ObserveABG: high AG metabolic acidosis
(pH 6.845)
#Symptomatic hypoglycemia
-> R/O sepsis
#MALA
DTX 105mg%
T 38.4 c RR 20/min BP 142/83 mmHg
DTX
premeal
,
hs
(keep 80-180mg%) septic W/U Antibiotics : Cef-3 2 g IV OD 7.5%NaHCO3 100ml IV push then 100 ml IV drip in 1 hr#AKI
Cr1.3(23/8/62)-> 7.42
IV hydration
Slide22Progression at ward
#Symptomatic hypoglycemia
-> R/O sepsis
DTX 85-211 mg%
T 38.6 -> no feverH/C I:
Staphylococcus epidermidis
H/C II: No growth in 5 days
DTX q 6 hr (keep 80-180mg%)
continue Cef-3
ครบ
7 days
Slide23Progression at ward
#MALA
7.5%NaHCO3 100ml IV push
then100 ml IV drip
in 1 hr
7.5%NaHCO3 150 ml + 5%DW 850 ml IV drip 60ml/hr
Off NaHCO3 IV
(
เช้า
31/9/62)
Off
Metformin Plan start insulin sc
Slide24Progression at ward
#
AKI
Urgent
hemodialysis plan H/D until Cr≤3
Lab
30/9
31/8
1/9
2/9
3/9
4/9
5/9
9/911/913/9BUN24
49
60
6425
30
29
4434
30
Cr2.65
4.78
7.20
8.585.24
5.915.00
3.593.052.67eGFR2010
65989
141720I/O neg ตลอด
Slide25Slide26Slide27Progression at ward
Lab
18.50
31/8
1/9
2/9
3/9
4/9
5/9
BUN
24
49
60
64Cr2.654.78
7.20
8.58
Na
137
136
135136
K
3.6
3.7
3.5
3.3
Cl
89929094
CO220232725
eGFR20106
5
Slide28Metformin
-
Associated
Lactic
Acidosis
Definition
:
Patient
on
metformin
develops an acute
life- threatening illness (e.g. septic shock, cardiogenic shock). Metformin amplifies the degree of lactic acidosis, but it's not the sole cause of the illness.
Slide29Metformin
is an
antihyperglycemic agent
of the biguanide class, used for the management of type II diabetes
). Currently, metformin
is
the first drug of choice for the management of type II diabetes
is
not
metabolized
and is excreted unchanged in the urine, with a half-life of ~5 h
Slide30Pathophysiology
Slide31Pathophysiology
Slide32Slide33Predisposing factor
MALA
Slide34Diagnosis
History taking
S&S
Investigation
Metformin
use
Predisposing factors
symptoms of lactic acidosis
Blood sugar
ABG : high AG metabolic acidosis
Lactate : > 4-5 mEq/L Renal function work up other causes
Slide35Slide36Treatment
Correct acidosis
Supportive treatment
Renal replacement therapy
Correct cause
7.5%NaHCO3
if pH<7.0 or serum HCO3
≤ 6
mEq
/L
volume resuscitation
Respiratory support
Off
metformin
correct/control predisposing factors
-
if
dialysis is
performed:
continued
until the lactate <3
mM
and pH >7.35.
-
Hemodialysis
is
preferable
Slide37EXTRIP indications for dialysis
Main indicationsLactate >15-20 mMpH <7.0-7.1Failure to improve despite standard supportive measures
Slide38Metformin
useIn Renal insufficiency
The dosing recommendations suggested by the FDA target
eGFR as a more accurate representation of renal status than a single biomarker like serum
creatinine.
eGFR
≥60
mL
/min/1.73 m
2
no dose adjustments and are able to safely use
metformin
with annual
monitoringeGFR 45- 60 mL/min/1.73 m2continue treatment but require more frequent renal function monitoring every 3 to 6 monthseGFR 30-45
mL
/min/1.73 m2
50% dose reduction with renal function monitoring every 3 months
eGFR <30 mL
/min/1.73
m2
Contraindication!!
Slide39Reference
Slide40Thank youAny question?