TCNCYH Phu truxyng 80 (3) - 2012 control level was observed in patients who complied strictly with the therapy regimen than those who didn't with significant difference (p < 0.001). The longer duration of disease was the worse glycemic control level (p < 0.05). In conclusion, almost elderiy outpatients had good and ac- ceptable glycemic control level. The cholesterol control was better than triglyceride control ob- served in these patients. Only a small number of patients had a good blood pressure control.
Related factors that influence glycemic control are the compliance of therapy regimen and dura- tion of suffering from the disease.
Key words: Diabetes, glycemic control, elderly
AP DUNG PHAC D 6 CHUYEN INSULIN TRUYEN TTNH MACH SANG DU'DNG TIEM DU'QI DA O CAC BENH NHAN
DAI THAO DU'DNG CO BIEN CHU'NG CAP TJNH
Nguyin Khoa Dieu Van, Trinh Nggc Anh Truing Dai hoc Y Ha Noi Cic phic dd chuyin insulin truyin tTnh mach sang tiem dudi da da du^c nghien c&u nhiiu trin thi gidi. Nghiin cuv nhim dinh gii hieu qua cOa phic do chuyin insulin truyin tTnh mach sang tiim dudi da trong kiim soit glucose miu 6 benh nhan dai thao duung cd biin chiing cip tinh va phan tich cac yiu td inh hi^ng tdi hiiu qui cua phic dd Kit qua cho thiy, hiiu qua kiim soil glucose mau sau chuyin tiim dirdi da: gli tri glucose miu trung binh sau chuyin tiem difdi da tir 12,12 - 12,38mmolA: muc dao ddng glucose miu li 3.57— 4,05 mmoiA, ty le glucose mau duac kiim soat theo muc tieu la 36 - 38%, ty le ha glucose miu li 0.83%. Cic yiu tdanh huung cic benh nhin HbAlc < 10.0% vi duv/c truyin insulin tinh mach liiu trung binh < 3.0 Ul/gid cd ty 1$ kiim soat glucose mau cao han nhdm binh nhin cd HbAlc >
10,0% vi truyin insulin ^3,0 Ul/gid. Kit luan phac dd chuyin insulin truyin tinh mach sang tiem dwdi da giOp kiim soit tdt va it gay ha glucose, die biet d nhdm benh nhin HbAlc £ 10.0% va duac truyin insu- lin < 3,0 Ul/gia.
TIP khoa: dai thao duvng, insulin truyin tinh mach, Insulin tiem du>di da
' I. BAT V A N D £ benh [3]. Tuy nhien khi cac benh nhan nay da Hien nay, dai thao du-dng da va dang trd on dinh tinh trang d p cdu, dilu tn chuyin 1 thanh mot v l n d l sdc khoe toan c l u vdi s i sang dung insulin theo dudng tiem du-di da lu'p'ng benh nhan ngay cang gia tang [1, 2]. la can thilt nham giam bdt chi phi, giam i Tang glucose mau va cac biln chung cap ganh nang d l i vdi nhan vien y t l , tao dilu 1 tinh la nhung ly do chinh khiln cho benh kien cho benh nhan du-gc xuat vien dilu tri I nhan dai thao du-dng phai nhap vipn. Cac ngoai tru [5], Tren t h i gidi hien da co nhilu
; nghidn cuu g i n day d l u chdng minh rang nghien cdu xoay quanh v l n d l chuyin I kiem soat glucose mau chat che blng truyin insulin truyin tTnh machsang du-dng tiem (insulin du-dng tTnh mach tren cac benh nhan dudi da nhung d Viet Nam cac nghien cuu unay da dem lai nhilu Ip-i ich d l i vdi ngu'di d l cap tdi khia canh nay con it. Do do, d l tai 63
TCNCYH Phu truxyng 80 (3) - 2012 dup-c nghien cdu vdi muc tieu sau:
1. Deinh gia hi$u qui cua phac dd chuyen insulin truyen tTnh m^ch sang duung tidm du^i da trong kiem so^t glucose mdu sau giai do^n cap cii'u a b^nh nhSn dai thdo dw&ng c6 biin chirng cip tinh.
2. Ph§n tich ciic yiu td inh huxjrng tOi hi0u qui cua phic dd tr&n cic b$nh nhin dii thio duxrng co bien chimg cip tinh.
II. D 6 | TU-aNG VA PHU'aNG PHAP 1. Ddi tu'O'ng nghien cdu
50 bpnh nhan dup-c dilu trj tgl khoa Npl tilt - Dai thao dudng b^nh vi^n B^ch Mai tu thang
11/2010 den 09/2011 co du cac tieu chuin sau:
- Tuoi t d 18 trd len, khong co thai, - Dup-c chan doan nhilm toan xeton ho^c tang ap luc thIm t h i u theo tieu chuan cua ADA 2008 [3].
- Benh nhan khong phai dung cac thuoc anh hudng tdi glucose mau;
- Benh nhan khong bj thilu mau, suy chuc nang gan than nang;
2. Phu'ang phap nghien cdu 2.1. Thiit ke nghien cuv nghien cuu t i l n cdu can thiep.
2.2. Co miu: l l y m l u thuan tien 2.3. Phuxyng phap tien hanh:
S i lieu dup-c thu th^p theo so- d l nghien cdu vdi mau benh an thong nhat.
Cac benh nhan tham gia nghien cuu dugc kham, dilu tri theo mpt phac do chung bao gIm:
Budc 1- benh nhan nhap vien du-o-c kham lam sang, lam xet nghiem,
- Budc 2: cac benh nhan du-cc dilu trj nhlem toan xeton hoac tang ap ly-c thIm thIu
64
theo phac d l ADA 2008 [3] gom: b l i phi, djch, truyin insulin du'dng tTnh mach, bu Kal song song vdi d i l u tn y i u to khdi phSt dp, theo doi glucose m^u mao mach 8 - 12 llrv ngay
- Budc 3: Chuyin insulin truyin tTnh mgch sang du-dng TDD.
Tieu chuin chuyin sang insulin TDD [3,5]:
Benh nhan ti'nh, Sn u i n g du-p'c du-dng mi0ng, huylt dpng 6n djnh
- Glucose mau du-p-c kiem soat I n djnh ti>
7,8 - 10,0 mmol/l trong it nhlt 4 gid vdi lilu truyen insulin TM ti> 0,02 - 0,05 Ul/kg/gid.
pH => 7,3, HCOs' =* 18mmol/l, khoang trlng anion < 14, ap lu-c tham thau m^u hi$u dgng 280 - 300mOsmol/kg.
- Cac y i u to khdi phat cap (nhilm khuln, m i t nude) da du-p-c kilm soat
Cach thiK chuyen insulin truyin TM sang dux/ng tiem duxiri da.
Du-a theo phac do cua tac gia Lilian F 2011 vdi 3 bu'dcsau[5]:
- Tinh t i n g lilu insulin da truyin tTnh mgch trong 24 gid cull cung.
Tinh tong lieu insulin tiem du-di da trong ngay d l u tien bang 80% tong luang insulin truyen tTnh mgch trong 24 gid cuoi.
- Chia tong lilu insulin thanh 4 mui tiem su dung k i t hp-p insulin regular (03 mOI chiem 75% t i n g lilu ti6m dudi da) va NPH (01 mui chilm 25% t i n g lilu tiem dudi da).
Mgc tieu kiem soat glucose mau: glucose mau doi va trudc an ti> 3,9 - 7,8 mmol/l, glucose mau sau an £ 10 mmol/l [3]. Benh nhan du-cc theo doi glucose mau mao mach 6 lln/ngay-
* Budc 4: Danh gia hieu qua cua ph^cm va cac yeu t l anh hudng
- Hieu qua cua phac do du-p-c danh fli^ i
TCNCYH Phu truxyng 80 (3) - 2012 theo gia tri glucose mau trung binh, muc dao qua kilm soat glucose mau bang each chia dpng glucose mau va so phln tram gia tri
GMMM nam trong gidi hgn mgc tieu.
- Ty le huylt glucose mau la so lan glu- cose mau mao m^ch < 3,9 mmol/l tren tong s i lan thu.
nhom;
+ HbAlc: HbAlc < 10% va HbAlc a 10%.
+ Toe dp truyin Insulin trung binh insulin truyin tTnh mach < 3,0UI/h va a 3,0UI/h
3. Phu'O'ng phap XIP ly s6 li^u Theo chu-o-ng trinh toan thing kd SPSS - Danh gia cac y i u t l anh hu-dng tdi hipu 16,0.
III. K^T QUA
1. Hi#u qua k i l m soat glucose mau sau c h u y i n insulin tiem du-di da 1.1 Glucose miu trung binh vi mux: dao dong
Gia trj glucose mau trung binh sau khi chuyin tiem dudi da sau ngay thd 1 vangaythd2 cua nhom b$nh nhan nghien cdu lln lupt 1^ 12,12 ± 3,569 mmol/l va 12,38 ± 4,05 mmol/l thap hon mpt each co y nghTa so vdi thdi d i l m 24 gid c u l i cung truyen insulin tTnh mach la 14,14 ± 3,409 mmol/l (T-test, T = 3,951 va 2,941, p < 0,005).
Glucose mau doi va tru-dc an trung binh sau chuyin tiem dudi da co gia tn 11,37 - 11,6 mmol/I, glucose mau sau an trung binh ta 13,03 - 13,17 mmol/l.
1
i M 1
N-.,^ , i i l . . r i T M
GMti-iiitshmli (iMtiiioc .iii HM smi .iii
B i l u dd 1. So sanh gia t n glucose mau trung binh tai 3 thdi diem 1.2 Tyle kiem scat glucose mau theo muc tieu
Chung toi thu dup'c 600 gia tri glucose mau mao mach cua 50 benh nhan trong 48 gid dau sau chuyin insulin tiem du-di da Ty le kilm soat glucose mau dup-c tinh bang so phln tram gia tri glucose mau mao mach nam trong gidi han muc tieu so vdi tong so l l n thu glucose mau mao mach.
Ty le glucose mau mao mach dat muc tieu trong ngay thd nhat la 36,33% va ngay thd hai la 38,33%, sy khac biet ty le trong 2 ngay khong co y nghTa thing ke x^ = 0,256 vdi p > 0,05
65
TCNCYH Phil tnmng 80 (3) - 2012
3.5 2.5 1.5 1 0,5
Bi4u dd 2. Mi>c dao dpng glucose mdu t^i thai dilm tni'd'c - sau chuyin tiem duvi da 13 T^leha glucose miu
Trong 600 gia tri glucose mau mao mach thu cJup'c co 05 gid tr| < 3.9 mmol/l, chilm ty 1$
5/600 (0,83%) s6 \hn thu glucose mau mao mach gap tren 03 benh nhan (chiem ty 10 6%). Gia trj gluccse mau th4p nhlt la 3.0 mmol/l Khong co benh nhan nao bj hon me hay co giet do huylt glucose mau khi chuyin sang tiem du-oi da
2. Cac yiu to anh hu'vng to*! hieu qua liilm soat glucose mau cua phac dd 2.1. Anh huang cua HbA 1c len ty le HSGM
r v,.tft5
|, ^U UU1
. Ddi muc Iia
Bilu d6 3. Anh hu'dng ciia HbAlc len hieu qua l<ilm scat glucose mau Cac benh nhan du'o'c chia lam 2 nhom HbAlc s 10,0% (14 benh nhsln) va nhom HbAlc>
10,0% (36 benh nhan). Ty le glucose mau dat muc tieu a nhom HbAlc s 10,0% la 47,02% cao hen nhom c6 HbAlc > 10,0% (vol 33,56%) co y nghTa thong l^e (x^ = 9,365; p < 0,001). Ngoai ra. nhom benh nhan HbAlc s 10.0% co tong lilu insulin tiem dual da trong 1 ngay (33,571 10,93 UI/24 glCT) va dao dpng glucose mau (3,56 mmol/l) cung t h i p han so vol nhom HbAlO 10,0% (voi cac gia trj lan lupl la 46,00 ± 13,28 UI/24 gio va 4,40 mmol/l).
TCNCYH Phu tnjcmg 80 (3) - 2012 2.2 Anh hurang cua toe dg truyen insu-
lin TM trung binh lin hi^u qua KSGM Cac BN du'p'c chia thSnh 2 nh6m vd'i t i c 3d truyin insulin TM trung binh < 3,0 Ul/h vi 2 3,0 Ul/h. TJ IS KSGM theo mgc tiSu cua 2 nhlm lan lu'gl la 39,71 vi 32,29%, 2 ty le niy khac bi$t c6 y nghTa thing ke (x^ = 3,967, p <
0,05).
IV. BAN LU^N
1. Hieu qua Itilm soat glucose m i u sau chuyen insulin TDD
1.1 Glucose miu trung binh (TB) va mire dao dgng
Khi chuyen insulin truyin TM sang du-d'ng TDD thu'd'ng cd sg' biln d^ng ve glucose mau, a l trSnh nguy cc HGM, cSc tSc gia thudrng chpn 80% t i n g lilu Insulin truyin TM trong 24 gid' cuoi \i tong lilu TDD trong 24 gid' dau tien. Su' Ig'a chpn nay lam giam nguy co HGM nhu'ng lai cd the Idm cho glucose mau d l tang cao sau khi k i t thuc truyin insu- lin TM [3]. Trong nghiSn ofl'u nay, chung tdi nhan thay gia tri glucose mau TB trong ng^y thu nhlt va thu hai sau TDD thip hon cd y nghTa thong kg so vd'i gia tri glucose tniu TB ngay cull cDng khi truyin TM. Han nura, khdng cd BN nSo trong nghien cuu khi chuyin TDD cd glucose m i u tang Idn qui 25 mmol/l, khdng cd tru'dng hp'p nao bj til phdt biln chirng d p tinh. K i t quS niy cho thiy viec si> dgng phic do chuyin insulin truyin TM sang dudng TDD cd hidu qua thg'c sg'.
Tuy nhidn g l i tn glucose mau TB n i y cdn thap khi so sinh vdi cac t i c gia nude ngoii nhu Rick Carlson 2006 [8] l i 6,9 mmol/l v i Lowel Schmeltz [6] la 8,52 mmol/l.
Khi chuyen tir insulin truyin TM vd'i uu dilm kilm soit mire dao dOng glucose m i u r l t t i t sang insulin TDD, sg' dao djng glu- cose m i u se tang cd the g i y ra TGM q u i
cao hay HGM q u i thip g i y i n h hudng khdng t i t tdi c i c BN. Tuy nhign, k i t q u i thu dup'c tir nghidn ciiu cDa chiing tdi cho thay mO'c dao d$ng glucose m i u d ngiy thir 1 v i 2 sau TDD khdng cd sg' khic bi^t cd j nghTa so vdi mi>c dao dOng glucose m i u ngiy culi truyin TM. B i l u n i y d i chu'ng td vigc i p dgng phic d l chuyin tir insulin truyin TM sang dudng TDD cua chCing tdi khlng nhO'ng l i m he glucose m i u TB d c i c BN m i mire dao d|ng glucose m i u cQng thay d l i khlng ding k l so vdi giai do?n truyin TM.
1.2 T;^ l# k i l m s o i t glucose m i u theo m^c tieu
Ty le KSGM la thdng so dup'c nhilu t i c g i i nude ngoii lira chpn khi dinh g i i hieu qua phic d l chuyin insulin truyen TM sang TDD: nhu Olansky L 2009 [7] c6 ty Ip KSGM l i 70%, Lovrell Schmeltz [6] nim 2010 cd t^ Ip KSGM dao dpng tu- 44 - 67%. K i t q u i thu dupe tir nghien ciru ciia chung t l i l i 37,33%
cd thip hon so vdi c i c t i c g i i tren chu y i u do sg' khic biet v l mau nghien cii'u, each thirc, loai insulin du'p'c sd dgng v i mgc tieg KSGM.
1.3 Ty /e A? glucose miu
l i 10 HGM l i mpt thing s i quan trpng dinh g i i tinh an toin khi sd dgng mOt phic d l dilu trj cd Insulin. T^ 10 HGM trcng nghidn cuu cua chiing tdi l i 0,83% thip ho'n khi so sinh vdi mpt s i t i c g i i nude ngoai nhu Yel- dandi 2006 [10] l i 2,2% v i Kyle A nim 2009 [4] l i 2,2 - 4,2%. Mit khio, trong c i c BN bj HGM tir nghidn cdu cOa chOng tdi, khdng cd BN n i o cd bilu hl0n hdn me hay co giit.
Dilu n i y cho t h i y vl0c sd dgng phic do chgyin insglin truyin TM sang dudng TDD cDa chCing t l i l i an toin cho c i c BN.
2.Cic yeu td anh hudng t d i hipu qua KSGM cua phac d l
67
TCNCYH Phv truong 80 (3) - 2012 2.1 Anh huimg cOa HbAlc lin tf 1$
HSGM
HbAlc tir 10,0% l i dilm c l t dting d l x i c djnh b0nh nhin d i i thio dudng tjp 2 c i n dupe dilu trj insulin theo ADA 2008 [3]. D i y cOng l i dilm c l t d l chia nhdm cOa chCing tdi, vdi nhdm HbAlc £ 10,0% (14 b0nh nhin) v i nhdm HbAlc > 10,0% (36 b0nh nhin). TJ 10 glucose m i u d?t mgc tilu d nhdm HbAlc s 10.0% l i 47,02% cao hpn nhdm cd HbAlc >
10,0% (vdi 33,56%) cd •} nghTa thing k0 (x' = 9,365; p < 0,001). K i t q u i thu duvc n i y cho thiy cd t h i su dgng HbAlc dilm c l t 10,0%
trong vi0c tidn lupng hi0u q u i kilm soit glu- cose m i u sau khi chuyin tu insulin truyin tTnh m^ch sang du'dng t i i m dudi da.
2.2 Anh huimg ciia t6c d^ truyin insu- lin tinh m^ch trung binh len hi^u qui kiem soat glucose miu
Cic b0nh nhin dup'c chia thinh 2 nhdm vdi toe d0 truyen insulin tTnh mech trung binh < 3,0 Ul/h v i i 3,0 Ul/h. T^ 10 kiem soit glucose m i u thep mgc tieu cda 2 nhdm lln lupt l i 39,71 v i 32,29%, 2 t j 10 niy khic bi0t cd y nghTa thing k0 (x^ = 3,967; p < 0,05).
T i c d0 tmyin insulin ITnh m?oh trung binh d c i c BN n l u cing cao thi mCrc d0 thilu hgt hoic d l khing vdi insulin cOa b0nh nhin cing nhilu v i do dd hi0u q u i kilm soit glu- cose m i u cung se thip. B i l u n i y dup'c ghi nhin tir k i t q u i nghidn cuu cua chCing t l i vdi nhdm truyen insulin tTnh msich i 3,0 Ul/gid kilm soit glucose m i u thip hon so vdi nhdm tnjyln insulin tTnh mgch < 3,0 Ul/gid (p < 0,0001).
K i t q u i n i y cdn cho thiy vi0o udc tinh lilu lupng insulin truyin tTnh mach khlng ohi gldp udc lupng sa b$ lieu t i i m insulin dudi da m i cdn l i thdng s i quan trpng giup dif doin k h i nang kilm soit glucose m i u khi chuyin qua tiem dudi da.
V. KfeT LUAN
Qua nghidn cdu t r i n 50 b0nh nhin bj dii thio dudng cd biln chdng d p tinh, sau khi d i l u trj dup'c chuyin t u insulin truyin tTnh m?ch sang dudng ti6m dudi da chiing tli nhin t h i y :
- G l i trj glucose m i u trung binh sau tiim dudi da t h i p ho'n cd •ji nghTa so vdi glucose m i u trung binh ngiy c u l i truyin tTnh mech trong khi mdc dao dOng glucose miu ting khlng ding k l .
- Jj 10 kilm soit glucose m i u theo m^c tilu d^t 38,33%.
Ti^ 10 huylt glucose m i u d muc thip \i 0,83%.
- Cic b0nh nhin cd HbAlc > 10% ty 10 kilm soit glucose m i u thip hon so vdi nhdm b0nli n h i n c d H b A 1 c s l 0 % .
- C i c b0nh nhin cd t i c d l truyin insulin tTnh mech trung binh £ 3 Ul/gid se KSGM theo mgc t i i g k i m hen so vdi nhdm truyin insulin tTnh m^ch < 3,0 Ul/gid.
TAI LI|U THAM KHAO 1. Nguyin D^t Anh (2004). Nghiin ohi d i e d i l m l i m s i n g - hda sinh v i dinh g/i hl0u q u i phic d l insulin lilu chia nhd d b0nh nhin d p cdu bj t i n g dudng h u y l t Luin in tiln STY hpc. H i NOI.
2. T f V i n Binh v i c$ng SM'(2a03). Djdi t l hoc b0nh d i i t h i o dudng, c i c y i u t l nguy ca t?i khu vi,pc n0i thinh b&n thinh p h i liin 4 Vi0t Nam. N h i x u l t b i n Y hpc.
3. KitabchI AE, Umplerrez GE, Murphy MB (2008). Thirsty years of personal experience in hyperglycemic crisises: Diabelic ketoacidosis and Hyperglycemic Hyperosmolar state. J Clin Endocrinol Metab. 93 (5): 1641 • 1552.
68
TCNCYH Phu tmxmg 80 (3) - 2012 4. Kyle A Weant, Alim L, (2009). Conver- col. J Diabetes Sci Technol; 478 - 486.
sion from continous insulin infusion to subcu- ^ RJ^.^ C, Jame F, et al, (2006). Transi- taneous insulin in critically ill patients. The tion from a continous intravenous infusion to Annals of pharmacotherapy. 3 (4): 629 - 634. g subcutaneous insulin regimen in critically ill
5. Lilian F, et al, (2011). Glycemic control patients. Chest J; 149S.
in the hospitalized patients - A comprehen- 9. Shornali E, Daniel L, Peter C, (2011).
sive clinical guide. Springer: 23 - 27. Conversion from intravenous insulin to sub- cutaneous insulin after cardiac surgery: tran- 6. Lowell R Schmeltz, Anthony J, et ai,
(2010). Conversion of intravenous insulin in- fusions to subcutaneously administered insu- lin glargine in patients with hyperglycemia. 12 (6), 641 - 650.
sition to target study Diabetes Technol &
Ther; 13(2): 121 -126.
10. Yeldandi RR, Lurle A, Baldwin F, (2006). Comparison of once-daily glargine insulin with twice daily NPH/regular insulin for 7. Olansky L, Sam S, Lober 0, et al, control li hyperglycemia in inpatients after (2009). Cleveriand clinic cardiovascular cardiovascular surgery. Diabetes Technol intensive care unit insulin conversion proto- Ther; 8(6): 609-616.
Summary
APPLICATION OF INSULIN INTRAVENOUS TO SUBCUTANEOUS TRANSITION PROTO- COL IN DIABETIC PATIENTS SUFFERING FROM ACUTE COMPLICATIONS Studies on the protocol of conversion from intravenous to subcutaneous insulin have been carried out around the world. The study was to evaluate the glycemic control efficacy of intrave- nous to subcutaneous insulin conversion protocol in diabetic patients suffering from acute com- plications and to analyze factors which might have influence on the efficacy of this protocol. The results indicated that efficacy of glycemic control: the mean capillary blood glucose levels after insulin transition were 12.12 - 12.38 mmol/l; glucose variability levels after transition were 3.57 - 4.05 mmol/l; the percentage of capillary blood glucose measured (CBGM) values in the prede- fined study target range were 36% to 38%; the incidence of hypoglycemic episode was 0.83%.
Factors which might have influence on the efficacy of the protocol, patients having HbAlc <
10.0% and intravenous insulin infusion rate < 3,0 Ul/h had higher percentage of CBGM values in the target range in comparison to those having HbAlc >10.0% or intravenous Insulin infusion rate s 3.0 Ul/h. In conclusion, using intravenous - subcutaneous insulin transition protocol in diabetic patients with acute complications helped control effectively the CBGM within target range with low incidence of hypoglycemia, especially In groups with HbAlc < 10.0% and insulin infusion rate ^ 3 0 Ul/h.
Keywords: diabetes, intravenous insulin, subcutaneous insulin injection
69