Case conference Karnmanee - PowerPoint Presentation

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Case conference

Karnmanee Thina 570710159Group G

Slide2

Objective

1

เพื่อให้ทราบถึงภาวะ

Metformin

-associated lactic

aciosis

2

3

4

เพื่อให้ทราบแนวทางการรักษาภาวะ

Metformin

-associated lactic

aciosis

เพื่อให้ทราบข้อบ่งชี้ในการทำ

Urgent

hemodialysis

ในผู้ป่วยที่มีภาวะ

acute kidney injury

เพื่อให้ทราบการปรับใช้ยา

Metformin

ในผู้ป่วยที่มีการทำงานของไตบกพร่อง

Slide3

A 50-year-old female

อาชีพ: รับจ้างภูมิลำเนา:

ต.แม่ยาว อ.เมือง จ.เชียงราย

Chief complaint:

สับสน

5hrPTA

Slide4

Primary 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

Slide5

Primary 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

Slide6

Primary survey

E

T 36.3 c

Completely undress

- Keep warm with blanket

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Adjunct to

Primary survey

Investigate

Monitoring

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Secondary 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

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Secondary survey

Personal/Social historyNo alcohol drinking

No smoking

No food/drug allergyNo herbal use

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Secondary 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

Slide12

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

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Adjunct to

Secondary survey

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CBC and

Coagulogram

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BUN, Cr, Electrolyte and Glucose

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LFT and lactate

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Urinalysis

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ABG

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

Slide19

Problem list

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Differential diagnosis

Provisional

diagnosis

Slide21

Progression 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

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Progression 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

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Progression 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

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Progression 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

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Progression 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

Slide28

Metformin

-

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.

Slide29

Metformin

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 

Slide30

Pathophysiology

Slide31

Pathophysiology

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Predisposing factor

MALA

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Diagnosis

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

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Treatment

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

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EXTRIP indications for dialysis

Main indicationsLactate >15-20 mMpH <7.0-7.1Failure to improve despite standard supportive measures

Slide38

Metformin

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!!

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Reference

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Thank youAny question?