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Clinical real-life case sharing
AuthorGlucocorticoids
are a hormone secreted by the human body itself, which is an important hormone
needed for our survival and stress response.
Various recently released new crown diagnosis and treatment guidelines have affirmed the status of
glucocorticoids in early treatment.
The "Diagnosis and Treatment Plan for Novel Coronavirus Infection (Trial Tenth Edition)" [1] states that "for severe and critical cases with progressive deterioration of oxygenation indicators, rapid imaging progression, and excessive activation of the body's inflammatory response, short-term (not more than 10 days) as appropriate.
" use of glucocorticoids"
.
Shanghai's primary COVID treatment guidelines [2] also mention that for patients with high-risk factors for progression to severe and critical disease, low-dose glucocorticoids
can be applied early in the early stages of progression.
Foreign clinical trials have shown that glucocorticoids reduce the mortality rate of hospitalized patients with new coronary pneumonia by exerting their anti-inflammatory effects [3].
The therapeutic effect of glucocorticoids and their many adverse reactions, which are "double-edged sword" characteristics, have always been a common problem in clinical practice
.
Endocrinologists need to note that glucocorticoids can induce the occurrence
of hyperglycemia by stimulating liver glucose output, fat tissue decomposition, increasing insulin resistance, and damaging the ability of pancreatic β cells to produce and secrete insulin.
As the use of glucocorticoids increases, endocrinologists receive more and more consultations for hyperglycemia
.
One of these cases caught the author's attention
.
Case Profile
A 75-year-old man was admitted to hospital
with "severe pneumonia".
Anamnesis: history of Alzheimer's disease for more than 2 years, cognitive dysfunction, denial of "hypertension" and "diabetes"
.
Admission examination: body temperature 36.
2 °C, heart rate 76 times/min, breathing: 20 times/min, blood pressure: 164/101mmHg, confusion, poor energy, slightly cold limbs, dry and wet rales in both lungs, negative pathological signs, lack of cooperation in residual examination
.
Admission aid: chest CT: diffuse multiple interstitial pneumonia in both lungs, considered virally related
.
Blood routine: white blood cells 13.
72×10 9/L, hemoglobin 134g/L, platelets 40×109/L, procalcitonin: 1.
38ng/ml
.
C-reactive protein: 186.
05mg/L
.
Biochemistry: albumin 33.
8g/L, creatinine 438umol/L, urea 37.
27mmol/L, cystatin C7.
33 mg/L, bicarbonate 18mmol/L, K+5.
3mmol/L, Na+154mmol/L, anion gap 18.
8
.
Treatment process: symptomatic supportive therapy such as antiviral, hormonal and oxygen therapy
.
Creatinine and urea nitrogen levels were monitored for continuous elevation and CRRT was treated
.
After more than 10 days of treatment, he suddenly became irritable, his blood pressure dropped, and the high blood
glucose value of his fingertips was measured.
8 hours ago, urine routine urine ketone body negative, urine sugar 3+
.
At that time, blood gas: pH 7.
29 (in CRRT), electrolyte: K+5.
2 mmol/L, Na+146 mmol/L, CL-100mmol/L, bicarbonate 17 mmol/L.
Physical examination: dry skin and mucous membrane, bilateral pupils and other large equal circles, diameter of about 3.
5mm, slow light reflex, soft abdomen, negative pathological signs, neck obstruction body does not cooperate
.
There is no doubt that there should be a hyperglycemic crisis in this case, what does a hyperglycemic crisis include? Does it have to be diabetic ketoacidosis?
Elderly new crown patients have elevated blood sugar, what should I pay attention to?
Hyperglycemic crises [4] include diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS
).
Common triggers are inadequate insulin therapy and infection, and other triggers include acute pancreatitis, myocardial infarction, and cerebrovascular accident
.
Drugs that induce hyperglycemic crises include glucocorticoids, thiazide diuretics, sympathomimetic drugs, and second-generation antipsychotics
.
Common clinical manifestations may include polyuria, thirst, and
polydipsia.
DKA occurs rapidly, can be accompanied by obvious clinical symptoms such as nausea, vomiting, abdominal pain, etc.
, and is easier to identify
than HHS.
However, the new crown infection is more than a large number of elderly patients, accompanied by a variety of underlying diseases, thirst center is insensitive, and the response to dehydration is poor, so timely identification of HHS is crucial
.
Identification of DKA from HHS
Plasma effective osmolality calculation formula: 2[(Na+)+(K+)] + blood glucose (both mmol/L).
The patient was well examined, venous blood glucose was 39.
7mmol/L, urine ketone was negative, serum hydroxybutyric acid 0.
53mmol/L, K+4.
1 mmol/L, Na+147mmol/L
。 Acidosis suggested by blood gas analysis and bicarbonate in patients should be considered metabolic acidosis due to renal insufficiency and acid expulsion disorders rather than DKA, so HHS
should be considered.
Treatment of HHS
The overall principle of treatment: replace fluids as soon as possible to restore blood volume, correct dehydration, reduce blood sugar, correct electrolyte and acid-base imbalance, and actively seek and eliminate triggers, prevent complications, and reduce mortality
.
The specific treatment measures will not be repeated in this article, but only a few details
that need to be paid attention to in treatment.
1.
Since HHS is a hypertonic state, normal saline is considered a hypotonic fluid for it, so early rehydration does not have to be entangled in whether hypotonic fluid
must be supplemented.
Excessive replacement of hypotonic fluid, resulting in a sharp change in osmolality, may induce cerebral edema
.
2.
HHS is more common in the elderly, may be combined with cardiac and renal insufficiency, the speed and amount of fluid rehydration need to be determined according to the clinical situation, and vital signs and urine output
should be closely monitored.
Encourage drinking plenty of water, and warm water
can be fed through a gastric tube if there is a disturbance of consciousness.
3.
Hyperglycemia is an important factor in maintaining HHS blood volume, so the rate of blood sugar decline should not be too fast, and hypoglycemic treatment
is required under the premise of fluid replacement.
The rate of blood glucose decline is controlled at 2.
8-3.
9 mmol/L per hour [5].
4.
Due to the hyperosmolar state, it is easy to ignore the possibility of hypokalemia, and potassium supplementation should be started when the blood potassium < 5.
2 mmol/h and there is sufficient urine output (> 40 ml/h
).
Precautions for the use of glucocorticoids
1.Whether there is a history of diabetes, as long as glucocorticoids are used, routine monitoring of blood sugar
is required.
Corticosteroids have a greater effect on postprandial blood glucose, so fasting and postprandial blood glucose need to be monitored
.
2.
Oral hypoglycemic drugs are usually suitable for patients with mild glucocorticoid-induced hyperglycemia (fasting blood glucose concentration < 11.
1 mmol/L), no history of diabetes
, or well-controlled diabetes.
Glinide and α-glycosidase inhibitors can be used for postprandial hyperglycemia caused by glucocorticoid use, and in combination with metformin, can also improve glucocorticoid-induced insulin resistance [6].
Glucagon-like peptide-1 receptor agonists (GLP-1RA) and dipeptidyl peptidase 4 inhibitors (DPP4i) may be limited due to price and gastrointestinal adverse effects
。 Sodium-glucose co-transporter 2 inhibitors (SGLT-2i) require careful evaluation for clinical use in the immunosuppressed state of glucocorticoid use
, given their risk of urogenital infection.
3.
For patients with fasting blood glucose > 10mmol/L, when using glucocorticoids, it is recommended to use insulin to control blood sugar
.
Basal-meal insulin is recommended for hospitalized patients with severe or persistent hyperglycaemia due to high-dose glucocorticoids, multiple daily doses, or long-acting glucocorticoid use
.
Although glucocorticoids have many adverse reactions, people often talk about hormones and discoloration, and they still play an indispensable role
in the treatment of a variety of diseases.
When we use it, we select different types of hormones according to the focus of the disease, reasonably arrange the time of medication and discontinuation, and do a good job in monitoring adverse reactions to reduce the adverse effects
of hormones on patients.
References:
[1] "Diagnosis and Treatment Plan for Novel Coronavirus Infection (Trial Tenth Edition)" [2] "Shanghai Novel Coronavirus Infection Diagnosis and Treatment Standards and Graded Diagnosis and Treatment Procedures" [3] RECOVERY Collaborative Group et al.“Dexamethasone in Hospitalized.
Patients with Covid-19.
” The New England journal of medicine vol.
384,8 (2021): 693-704.
doi:10.
1056/NEJMoa2021436[4] Guidelines for the diagnosis and treatment of hyperglycemic crisis in China[J].
Chinese Journal of Diabetes, 2013, 5(8):13 [5] Endocrinology and Metabolism 3rd Edition - Section 234 - Hyperglycemic Hyperosmolar State [6] Ikeuchi, Hidekazu et al.
"Efficacy and safety of multi-target therapy using a.
combination of tacrolimus, mycophenolate mofetil and a steroid in patients with active lupus nephritis.
” Modern rheumatology vol.
24,4 (2014): 618-25.
doi:10.
3109/14397595.
2013.
844397
Looking back on 2022 is an extraordinary and wonderful year, under the background of the era of scientific and precise epidemic prevention, endocrinology colleagues at home and abroad are still persevering, unremitting struggle, deeply engaged in endocrine clinical scientific research, continuous breakthroughs and innovations, and achieved gratifying results
.
This time, the Endocrinology Channel of the Medical Profession joined hands with 5 experts from the Department of Endocrinology of the First Affiliated Hospital of Chongqing Medical University and 4 experts from the Endocrinology and Metabolism Center of Shanghai Tenth Hospital to explore the "secretion" forward - the annual inventory of endocrinology in 2022
.
Meeting Time:
January 13, 2022 ~ January 14, 2022 starts at 9:30 a.
m
How to participate: Scan the QR code of the poster to watch the live broadcast
The specific schedule of the meeting
The web version of the doctor's station is online
Please scan the QR code below or click to read the original article, you can browse more endocrine frontier information without downloading
Responsible editorTangerine
Call for Papers The Medical Endocrinology Channel welcomes your submissions! Click the link below or scan the QR code to submit: https://titan.
yishengzhan.
cn/#/public_contribution Please fill in the real information according to the call page*"The medical community" strives to publish the content professional and reliable, but does not promise the accuracy of the content; Relevant parties are requested to check
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