Health Worlds

Medical HEALTH "> Pharmacy subjects of drugs and medicines Summary of Australia warned that the risk of lactic acidosis metformin reRecommended online full collection of paper," Journal of rational drug use "2010 No. 2 fast-food prizes Report Summary: Recently, Australian Medical Products Agency (TGA) in the new issue of "adverse reactions in Australia Bulletin" published in metformin lactic acidosis risk. Metformin lactic acidosis is a rare occurrence, but the most serious metabolic complications. For drugs with metformin, the relevant departments have in the product information (PI) 2 copies of the document issued bulletins and 1 black box warning. Metformin can cause a fatal accumulation of lactic acidosis. The main risk factor is renal failure; Pages: Page 1 Page Range :111-111 Key words: lactic acidosis metformin metabolic complications of medical products in Australia the risk of renal failure adverse subject classification: R977.15 [Medicine, he Phar D Drug metabolism affect the growth Ster insulin and hypoglycemic drugs] R587.1 [medicine, HEALTH "within SCIENCES" endocrine diseases and metabolic dise pancreatic disease,> diabetes] Related articles: subject
ThinkingLactic acidosis is a serious complication of diabetes. Because diabetes glucose oxidation blocked, increased glycolysis, resulting in a large number of lactic acid, lactic acid synthesis and excretion of lead greater than the degradation induced by in vivo accumulation of lactic acid acidosis. Ince


ntives, including diet, exercise, infection and drug treatment inappropriate. Most of the literature report the incidence of diabetes and lactic acidosis related to drug taking biguanides (eg phenformin, metformin, etc.). Biguanide antidiabetic drugs can increase lactic acid, such as liver and muscle inhibited tissue uptake of lactic acid, and inhibition of liver cells to the glucose into pyruvate, the pyruvate and lactate were increased. Especially those with decreased renal function, biguanide drugs excreted by the kidneys slow down the increase in blood lead concentration of lactic acidosis. But there are also studies that diabetes, a variety of lactic acidosis is the result of common risk factors.
Fasting and postprandial blood glucose of the patients were significantly increased, hemoglobin also increased significantly, suggesting that poor glycemic control in patients with recently. Patients have a history of long-term strenuous exercise may also lead to acute lactic acidosis. In addition, this case clearly before the onset of gastrointestinal tract infections, frequent vomiting, and did not receive timely and effective rehydration treatment, and ultimately dehydration, effectively reduced blood volume, leading to impaired renal function, the accumulation of lactic acid increased. Thus, poor glycemic control, vigorous exercise and frequent vomiting, hypovolemia is the cause of diabetes patients, mainly due to lactic acidosis. The lactic acidosis itself can increase the vomiting and other gastrointestinal symptoms, so a vicious cycle in which acidosis is increasing.
As the body caused by accumulation of lactic acid decreased myocardial contractility, and peripheral catecholamine reactivity of small arteries cause decreased blood pressure decreased or disappeared, the patient, shock, the body corresponding reduction in blood flow in vital organs, causing multiple organ damage.
Lactic acidosis in critical condition, high mortality, studies have reported case fatality rate was 30%, and early, aggressive treatment is the key to successful treatment.Patients in critical condition, in a timely manner to the anti-shock, treatment and other measures.1. Anti-shock, to correct acidosis monitoring of blood pressure immediately after admission, to dopamine (12 mg / h) norepinephrine (1 mg / h) to maintain mean arterial blood pressure is not lower than 60 mmHg. Added crystal, plasma and albumin, and adjust the dose according to blood pressure. Gradually stable mean arterial blood pressure ( 70 mmHg), 7 hours after the disabled norepinephrine, dopamine disabled after 10 hours (Figure 1). Crystals were added 3500 ml, gel 500 ml. Anti-shock also quick to add sodium bicarbonate, and to patients with high-volume continuous veno - venous hemofiltration (CVVH). 24 hours after admission of patients to correct the acidosis, pH, and lactate returned to normal (A12 map 2).2. Control of upper gastrointestinal bleeding fast, be pantoprazole, octreotide control gastrointestinal bleeding, patients with vomiting and bleeding stopped. Anti-shock and coagulation function after correction of acidosis improved 24 hours after admission PT, APTT returned to normal.
3. Control of blood glucose intravenous infusion of insulin (6 ~ 12 U / h) to maintain blood glucose <10 mmol / L. Normally be long after eating, short-acting insulin combined with control of blood sugar.
4. The treatment of acute respiratory distress syndrome, 7 hours after admission in patients with shortness of breath (40 beats / min), PO2 decreased to Oxygen Mask (10 L / min), adjustment of fluid balance for the surplus, no better. Switch to bi-level positive airway pressure (BiPAP) ventilator-assisted breathing, oxygen saturation (SaO2) after a brief improvement in the sexual decline. Consider the blood volume lead to heart failure, pulmonary edema. However, dehydration, increased after the oxygen concentration has not improved, and no left heart failure performance. 12 hours after admission, PO2 70 mmHg, SaO2 volatility at 90% ~ 94%, the oxygenation index was only 120, chest radiograph shows diffuse patchy lung shadow, consistent with acute respiratory distress syndrome. Then to tracheal intubation and ventilator assisted breathing, the patient gradually improved lung function. The next day Charles oxygenation index 386 mmHg, PO2 193 mmHg, chest X-ray showed diffuse patchy lung shadow was absorbed, so the change extubation BiPAP ventilator-assisted breathing, oxygen masks after the change and stop getting oxygen.5. Renal replacement therapy after admission to blood purification, urine volume increased after 4 days, azotemia improvement, followed by daytime blood purification. Scr decreased urine output increased to 4000 ml / d, 7 days after admission stop blood purification therapy (Figure 3).
6. Other fasting, symptomatic treatment of blood amylase and lipase decreased. Blood purification and during ventilator-assisted breathing, be parenteral nutrition.
1 week after admission check Scr 150 mol / L, urine output 3000 ml / d, blood pressure, blood sugar normal, 11 days after the patient was discharged. After 1 month follow-up, renal function was normal.High-volume continuous blood purificationFor patients with severe acidosis (pH <7.0) should be sodium bicarbonate, sodium bicarbonate, but large doses can cause high blood sodium, blood osmotic pressure, volume load increased, but increased lactate. Who are more vulnerable to heart and lung function to reduce carbon dioxide accumulation and increased hypoxia. Studies suggest that regular intermittent hemodialysis treatment can not improve the prognosis of lactic acidosis, but the continuous blood purification therapy (such as CVVH) can improve patients with severe lactic acidosis within the environment, clear the lactic acid role in improving the prognosis is better than intermittent hemodialysis treatment.
The patients had hypotension on admission of patients, no urine, and other risk factors for hemodynamic instability. In the treatment process, high-volume continuous blood purification therapy (replacement fluid 6000 ml / h) play an important role. As more severe acidosis associated with significant hypotension, acidosis is not difficult to correct blood pressure rise, and continuous blood purification therapy on hemodynamics and consequently instability of blood pressure in critically ill patients may consider the application. CVVH compared with the traditional, high-volume continuous blood purification therapy by increasing the amount of fluid replacement increases for large and middle molecular solute removal effect can be more improved hemodynamics and reduce the amount of vasoactive drugs. High-volume continuous blood purification therapy, according to clinical need of liquid intake and output can be adjusted quickly leaving hemodynamic stability, which is other treatments can not be replaced.
Continuous blood purification therapy to the patients blood volume increased rapidly (within 6 hours of rehydration nearly 4000 ml), and provide a lot of bicarbonate to correct acidosis, the gradual reduction of the pressor agent, anti-shock treatment success. Acidosis and hypotension in patients with a large number of inflammatory mediators in vivo, high-volume continuous blood purification to remove these inflammatory mediators, reduced inflammation, thereby reducing the inflammatory damage to the body. In addition, the stability of the environment after treatment for the treatment of the other complications (such as acute respiratory distress syndrome, acute renal failure) to create the conditions.
Note that, because of accumulation of lactic acid, to provide bicarbonate to correct acidosis than lactate. In addition, due to lack of oxygen in vivo tissue margin citrate salt metabolism, and acidosis will increase, so should be used anticoagulant low molecular weight heparin instead of citrate salt edge.Monitoring of respiratory function in critically ill patientsHypotension, shock and severe acidosis can cause alveolar capillary damage, increased permeability, leading to acute lung injury. Therefore, these patients need close monitoring of respiratory function. To be implemented found that early intervention in acute lung injury.
Early tracheal intubation, the establishment of mechanical ventilation not only to improve oxygen supply of tissues and organs, and the use of PEEP (PEEP) can collapse the alveoli expand, reduce pulmonary edema, improving lung compliance, as soon as possible in favor of lung function recovery. Therefore, mechanical ventilation, respiratory support for the rescue treatment of severe patients with active, not passive, life-saving method.
In this case, acute respiratory distress syndrome patients, the timely intubation and mechanical ventilation, respiratory function of patients returned to normal within 30 hours. However, intubation may also cause complications such as ventilator-associated pneumonia, and therefore improve lung function in time after extubation and the use of noninvasive ventilation.The patients with severe lactic acidosis due cause shock, the kidney, lung and gastrointestinal tract and other organ dysfunction, and ultimately rescued. High-volume continuous blood purification treatment by removing lactic acid and other acidic substances, removal of inflammatory factors and stabilize the environment so that the rescue work carried out smoothly. Course of treatment, close monitoring will enable the clinician to detect lung function in acute respiratory distress syndrome and to take therapy, respiratory function in patients with rapid recovery in a short time. Therefore, the positive line of high-volume continuous blood purification therapy, timely use of mechanical ventilation is the key to successful treatment in this case.




Friends Links:Automation Control Blog
Automation Products Order Numbers