Regional ICM teaching - Metabolic
Facilitators: Alex Belcher and Pete McQuillan
Venue: QA Hospital, Portsmouth
Edited by: Steve Mathieu
Endocrine Emergencies Quiz
Revisited the UK guidelines on DKA management, discussion around ketone monitoring, speed of fluid resuscitation/reduction of glucose and risk of cerebral oedema. Note the same organisation (Joint British Diabetics Societies) also provides guidelines on HHS (previously HONK) and perioperative management of diabetes: http://www.diabetologists-abcd.org.uk/JBDS/JBDS.htm
Also discussed management of Addisonian crisis and perioperative management of the steroid-dependent patient. Again, specific guidelines found at http://www.addisons.org.uk/topics/2005/10/0021.html
Control of glucose in ICU - Tom Pratt
Review of the major papers including the Leuven papers (Van den Bergh 2001 NEJM 345 1359) that suggested major mortality benefit of tight control, but not replicated since. Criticisms include one small centre, almost all cardiac surgery patients and had high nursing intensity.
Other major trials to note are:
VISEP (NEJM 2008 354 449) halted early as evidence of harm in tight control
Leuven 2 (Van den Bergh NEJM 2006 354 449) no sig difference
Glucontrol (Inten Care Med 2009 35 1738) too many trial violations so halted
NICE SUGAR (NEJM 2009 360 1283) higher mortality with tight control
So, no convincing evidence yet for tight control, and maybe harm with more hypos. ?role of continuous glucose monitors (once calibrated!)
Case summary of hyponatraemia/Mx of hypoadrenalism - Adam Stokes
Overview of presentation/aetiology/diagnosis and management of hypoadrenalism by Adam Stokes
Often vague, long history, but crisis may be profound. Don’t delay treatment for investigations, but dexamethasone may be preferable to not confound the short synacthen test. If primary need both glucocorticoid and mineralocorticoid replacement; secondary/tertiary only the glucocorticoid.
Endocrine changes in ICU
Description of the (patho)physiological changes that occur in the critically unwell, specifically stress hyperglycaemia (critical-illness induced hyperglycaemia), relative adrenal insufficiency and sick euthyroid syndrome.
Discussion around the potential adaptive benefits of these changes versus the maladaptive changes. In general, there does not seem to be any evidence of mortality benefit in treating these changes per se. No need to perform short synacthen tests or TFTs unless evidence of specific disease.