Ketoacidosis ndi ketoacidotic chikomokere

KULIMBIKITSA, KULAMBIRA KWAULERE NDI PATHOGENESIS

Pachimake kuwonongeka kwa chakudya, mafuta, mapuloteni kagayidwe, komanso madzi-electrolyte bwino ndi acid-base bwino, ndi hyperglycemia, hyperketonemia, ketonuria ndi metabolic acidosis chifukwa cha kusowa kwadzidzidzi komanso kwakukulu kwa insulin. Chowoneka ndi kupezeka kwa matupi a ketone mu seramu yamagazi ndi mkodzo. Itha kuchitika nthawi iliyonse yamatenda a shuga, nthawi zambiri imakhala chiwonetsero cha matenda ashuga amtundu woyamba. Chifukwa cha kuchepa kwa insulin, pali kupangika kwakukulu kwa chiwindi mu chiwindi chifukwa cha gluconeogeneis, komanso kuchuluka kwa lipolysis ndikupanga matupi a ketone. Zotsatira zake ndi izi: hyperglycemia, kuchepa kwa shuga mkodzo, osmotic diuresis, kuchepa kwa madzi, kusokonezeka kwa ma electrolyte (makamaka hyperkalemia yokhala ndi kuchepa kwa potaziyamu wa potaziyamu) komanso metabolic acidosis. Zomwe zimayambitsa: kusiya kwa insulin mankhwala (mwachitsanzo chifukwa cha matenda am'mimba, wodwalayo amapewa kudya) kapena kugwiritsa ntchito molakwika mankhwala a insulin, matenda (bakiteriya, fungal), matenda amtundu wamtima mtundu 1 shuga, kapamba, uchidakwa, pakati, zinthu zonse zomwe zimapangitsa kuchuluka kw insulini mwadzidzidzi. kumtunda

1. Zizindikiro zake: ludzu kwambiri, pakamwa pouma, kupindika, kufooka, kugona, kusokonezeka kwa chikumbumtima, chizungulire komanso kupweteka mutu, nseru ndi kusanza, kupweteka m'mimba, kupweteka pachifuwa. kumtunda

2. Zizindikiro zakumaso: hypotension, tachycardia, kuthamanga komanso mwakuya, kenako kupuma kosaya, zizindikiro za kutopa (kuchepa thupi, kuchepa kwa khungu), kuchepa kwa tendon, kununkhira kwa acetone mkamwa, redness la nkhope, kuchepa kwa ma eye turgor, kuwonjezeka kwa khoma lam'mimba. (monga ndi peritonitis)

Kuzindikira kumakhazikitsidwa potsatira zotsatira za mayeso a labotale → tebulo. 13.3-1. Odwala omwe amathandizidwa ndi SGLT-2 inhibitor, glycemia ikhoza kukhala yotsika.

A Diabetes Ketoacidotic Coma (DKA)

DKA ndi zovuta kwambiri za matenda osokoneza bongo a shuga, omwe amadziwika ndi metabolic acidosis (pH ochepera 7.35 kapena bicarbonate ndende ochepera 15 mmol / L), kusiyana kwa anionic, hyperglycemia pamwamba pa 14 mmol / L, ketonemia. Nthawi zambiri amakula ndi matenda amtundu 1 shuga. DKA imakhala ndi milandu 5 mpaka 20 pa odwala 1000 pachaka (2/100). Imfa pamilandu iyi ndi 5-15%, kwa odwala omwe ali ndi zaka zopitilira 60 - 20%. Oposa 16% ya odwala matenda a shuga 1 amwalira ndi ketoacidotic chikomokere. Zomwe zimapangidwira DKA ndizosowa kwathunthu kapena kutchulidwa kwa insulin chifukwa chosakwanira insulin kapena chifukwa chokulimbitsa insulini.

Zopatsa: kuchuluka kosakwanira kwa insulini kapena kudumpha jakisoni wa insulin (kapena kumwa mapiritsi a hypoglycemic othandizira), kuchotsedwa kosavomerezeka kwa hypoglycemic therapy, kuphwanya njira ya insulin yoyendetsera, kuwonjezera matenda ena (matenda, kuvulala, opaleshoni, kutenga pakati, kuponderezedwa kwa myocardial, stroko, nkhawa, ndi zina). , zovuta zamagulu olimbitsa thupi (chakudya chochuluka), kuchita masewera olimbitsa thupi wokhala ndi glycemia wambiri, kumwa mowa kwambiri, kusadziletsa kokwanira kwa kagayidwe kachakudya, kumwa mankhwala ena mankhwala nnyh (corticosteroids, calcitonin, saluretics, acetazolamide, β-blockers, diltiazem, isoniazid, phenytoin neri Al.).

Nthawi zambiri, etiology ya DKA imakhala yosadziwika. Tiyenera kukumbukira kuti pafupifupi 25% ya milandu, DKA imapezeka mwa odwala omwe akupezeka ndi matenda a shuga.

Pali magawo atatu a matenda ashuga a ketoacidosis: ketoacidosis wolimbitsa, precoma, kapena kuwonongeka ketoacidosis, chikomokere.

Mavuto obwera chifukwa cha ketoacidotic coma akuphatikizapo vein thrombosis, pulmonary embolism, ochepa thrombosis (myocardial infarction, ubongo infarction, necrosis), kufunafuna chibayo, matenda a edema, pulmonary edema, matenda, kawirikawiri GLC ndi ischemic colitis, erosive gastritis. Kulephera kupuma kwakukulu, oliguria ndi kulephera kwa impso zimadziwika. Mavuto azachipatala ndi matenda am'mimba ndi m'mapapo edema, hypoglycemia, hypokalemia, hyponatremia, hypophosphatemia.

Zizindikiro za DKA

Gawo la DKA ndikutukuka pang'onopang'ono, nthawi zambiri pamasiku angapo.
Zizindikiro za ketoacidosis (kununkhira kwa acetone kupuma kwambiri, kupuma kwa Kussmaul, nseru, kusanza, kupweteka kwa m'mimba, kupweteka kwam'mimba).
Kukhalapo kwa zizindikiro za kuchepa mphamvu kwa thupi (kuchepa kwa minofu turgor, kamvekedwe ka maso, kutulutsa minofu, kupendekera kwa thupi, kutentha kwa thupi ndi kuthamanga kwa magazi).

Mukazindikira DKA panthawi yoyamba, muyenera kudziwa ngati wodwalayo akudwala matenda a shuga, ngati panali mbiri ya DKA, ngati wodwalayo amalandila chithandizo cha hypoglycemic, ndipo ngati ndi choncho, inali nthawi yanji yomaliza kumwa mankhwalawo, nthawi yakudya yomaliza, kapena zochitika zolimbitsa thupi kwambiri adadziwika kapena kudya mowa, zomwe matenda aposachedwa amisala, anali polyuria, polydipsia ndi kufooka.

Chithandizo cha DKA pa prehospital gawo (onani tebulo 1) imafuna chisamaliro chapadera kuti tipewe zolakwa.

Zolakwika zomwe zingatheke pazochita zamankhwala ndi kuzindikira koyambira

Pre-chipatala insulin mankhwala popanda glycemic control.
Kugogomezera kwamankhwala kumathandizira pakulimbitsa insulin pokhapokha ngati munthu asamatulutsenso madzi m'thupi.
Osakwanira madzimadzi akumwa.
Kukhazikitsidwa kwa njira za hypotonic, makamaka kumayambiriro kwa chithandizo.
Kugwiritsa ntchito kukakamiza diuresis m'malo moperekanso madzi m'thupi. Kugwiritsira ntchito okodzetsa limodzi ndi kuyambitsa kwamadzimadzi kumangolepheretsa kubwezeretsanso kwa kuchuluka kwa madzi, ndipo ndi hyperosmolar coma, kusankha ma diuretics kumatsutsana kwambiri.
Kuyamba kuchiza ndi sodium bicarbonate kumatha kupha. Zimatsimikiziridwa kuti chithandizo chokwanira cha insulin nthawi zambiri chimathandizira kuthetsa acidosis. Kuwongolera acidosis ndi sodium bicarbonate kumalumikizidwa ndi chiwopsezo chachikulu cha zovuta. Kukhazikitsa alkalis kumathandizira hypokalemia, kusokoneza kudzipatula kwa oxyhemoglobin, kaboni dayoksoni wopangidwa pakayendetsedwe ka sodium bicarbonate, kumalimbitsa intracellular acidosis (ngakhale magazi a pH akhoza kuchuluka pamenepa), paradoxical acidosis imawonedwanso m'magazi a cerebrospinal, omwe amatha kupangitsa kuti ziwonetsedwe m'magazi rebound alkalosis. Kuwongolera mwachangu kwa sodium bicarbonate (ndege) kungayambitse kufa chifukwa chakuchepa kwa hypokalemia.
Kukhazikitsidwa kwa yankho la sodium bicarbonate popanda mankhwala ena a potaziyamu.
Kuchotsa kapena kusayang'anira insulin odwala omwe ali ndi DKA kwa wodwala yemwe sangathe kudya.
Intravenous ndege kuperekera insulin. Mphindi 15 mpaka 15 zoyambirira zokha, kutsitsa kwake m'magazi kumakhalabe kokwanira, kotero njira iyi yoyendetsera siyothandiza.
Katatu kapena kanayi kapangidwe ka insulin (ICD) kosakhalitsa. ICD imagwira ntchito kwa maola 4-5, makamaka pamikhalidwe ya ketoacidosis, choncho iyenera kukhazikitsidwa osachepera kasanu ndi kamodzi patsiku popanda yopuma usiku.
Kugwiritsa ntchito mankhwala a sympathotonic kuthana ndi kugwa, komwe, choyamba, ndi ma contrainsulin mahomoni, ndipo, chachiwiri, mwa odwala matenda ashuga, mphamvu yawo yolimbikitsira katulutsidwe ka glucagon imakhala yamphamvu kwambiri kuposa mwa anthu athanzi.
Kuzindikira kolakwika kwa DKA. Ku DKA, omwe amadziwika kuti "diabetesic pseudoperitonitis" amapezeka kawirikawiri, omwe amayimira zizindikiro za "pamimba pamimba" - kusokonezeka ndi kuwawa kwa khoma lam'mimba, kuchepa kapena kutha kwa madandaulo a peristaltic, nthawi zina kuwonjezeka kwa serum amylase. Kupezeka kwa munthawi yomweyo kumayambitsa leukocytosis kumatha kudzetsa vuto linalake, chifukwa chomwe wodwalayo amalowa m'dipatimenti yopanda matenda ("m'mimba") kapena opaleshoni ("yamimba yam'mimba"). Muzochitika zonse "zam'mimba zam'mimba" kapena zizindikiro za dyspeptic mwa wodwala yemwe ali ndi matenda osokoneza bongo, kutsimikiza kwa glycemia ndi ketotonuria ndikofunikira.
Kuyeza kwa glycemia kosawerengeka kwa wodwala aliyense amene ali ndi vuto losazindikira, lomwe nthawi zambiri limakhala ndi kupezeka kwa matenda olakwika - "vuto la ubongo", "kukomoka kwa matenda osamveka", pomwe wodwalayo ali ndi vuto lalikulu la matenda a shuga.

Hyperosmolar non-ketoacidotic chikomokere

Hyperosmolar non-ketoacidotic coma imadziwika ndi kuchepa mphamvu kwa madzi m'thupi, kwambiri hyperglycemia (nthawi zambiri pamwamba pa 33 mmol / L), hyperosmolarity (kupitirira 340 mOsm / L), hypernatremia pamwamba pa 150 mmol / L, ndi kusowa kwa ketoacidosis (maximum ketonuria (+)). Nthawi zambiri amakula mwa odwala okalamba omwe ali ndi matenda ashuga a 2. Ndiwocheperako maulendo 10 kuposa DKA. Amadziwika ndi chiwopsezo chachikulu cha kufa (15-60%). Zomwe zimayambitsa kukula kwa hyperosmolar coma ndizosowa insulin komanso zomwe zimapangitsa kupezeka kwamadzi.

Zopatsa: osakwanira insulin mlingo kapena kudumphira jakisoni wa insulini (kapena kumwa mapiritsi a hypoglycemic othandizira), kuchotsedwa kosavomerezeka kwa hypoglycemic mankhwala, kuphwanya njira yoyendetsera insulin, kuphatikiza kwa matenda ena (matenda, kupweteka kwapakhosi, kuvulala, kuperewera, kutenga pakati, kupweteka kwa m'mimba etc.), mavuto azakudya (chakudya chochuluka), akumamwa mankhwala ena (okodzetsa, corticosteroids, beta-blockers, ndi zina), kuziziritsa, kulephera kuthetsa ludzu kuwotcha, kusanza kapena kutsegula m'mimba, hemodialysis kapena peritoneal dialysis.

Tiyenera kukumbukira kuti gawo limodzi mwa magawo atatu a odwala omwe ali ndi hyperosmolar coma alibe kale matenda a shuga.

Chithunzi cha kuchipatala

Ludzu lamphamvu, polyuria, kuchepa mphamvu kwa madzi m'thupi, kuchepa kwa thumu, tachycardia, kugunda kwamphamvu kapena kosasinthika komwe kumakula masiku angapo kapena masabata. Ngati ndi DKA, kusokonezeka kwa chapakati mantha dongosolo ndi zotumphukira mantha dongosolo kumachitika ngati pang'onopang'ono kutha kwa chikumbumtima ndi chotupa cha tendon, ndiye hyperosmolar chikomokoma limodzi ndi zovuta zamisala ndi mitsempha. Kuphatikiza pa soporotic state, yomwe nthawi zambiri imawonedwa ndi hyperosmolar coma, matenda amisala nthawi zambiri amakhala ngati delirium, pachimake hallucinatory psychosis, komanso catotonic syndrome. Matenda a mitsempha amawonetsedwa ndi oyang'ana amanjenje zizindikiro (aphasia, hemiparesis, tetraparesis, kusokonezeka kwa mphamvu ya polymorphic, pathological tendon reflexes, etc.).

Hypoglycemic chikomokere

Hypoglycemic coma imayamba chifukwa cha kuchepa kwambiri kwa shuga m'magazi (m'munsimu 3-3.5 mmol / l) komanso kutayika kwa mphamvu mu ubongo.

Zopereka: kuchuluka kwa insulin ndi TSS, kudumphadumpha kapena kudya chakudya chokwanira, kuchuluka kwa masewera olimbitsa thupi, kumwa kwambiri mowa, kumwa mankhwala (β-blockers, salicylates, sulfonamides, etc.).

Zotheka kupeza zolondola pakuzindikira komanso zochizira

Kuyesera kukhazikitsa zophatikiza zama carbohydrate (shuga, ndi zina) m'mkamwa mwa wodwala wosazindikira. Izi nthawi zambiri zimabweretsa chilimbikitso ndi kukondwerera.
Ntchito yoletsa hypoglycemia yazinthu zosayenera izi (buledi, chokoleti, ndi zina). Zogulitsazi sizikhala ndi mphamvu yokwanira yowonjezera shuga kapena kuwonjezera kuchuluka kwa shuga m'magazi, koma pang'onopang'ono kwambiri.
Kuzindikira kolakwika kwa hypoglycemia. Zizindikiro zina za hypoglycemia zitha kutengedwa molakwika ngati kugwidwa, khunyu, "zovuta zamasamba", ndi zina. Wodwala akalandira chithandizo cha hypoglycemic, ndikukayikira koyenera kwa hypoglycemia, iyenera kuyimitsidwa nthawi yomweyo, ngakhale asanakalandire mayankho a labotale.
Pambuyo pochotsa wodwala ku vuto la hypoglycemia, chiopsezo chobwereranso nthawi zambiri sichingaganiziridwe.

Odwala omwe ali ndi vuto losadziwika, nthawi zonse pamafunika kuganiza za kukhalapo kwa glycemia. Ngati zili zodziwika kuti wodwalayo ali ndi matenda osokoneza bongo ndipo nthawi yomweyo zimakhala zovuta kusiyanitsa mtundu wa hypo- kapena hyperglycemic wa chikomokere, kulowetsedwa kwa shuga m'magawo a 20- 40-60 ml yankho la 40% ndikulimbikitsidwa kuti mupatsidwe matenda mosiyanasiyana ndi chisamaliro chadzidzidzi cha hypoglycemic. chikomokere. Pankhani ya hypoglycemia, izi zimachepetsa kwambiri kuwopsa kwa zizindikiro ndipo, motero, zitha kusiyanitsa zinthu ziwiri izi. Ndi hyperglycemic coma, kuchuluka kwa shuga kotereku sikungakhudze mkhalidwe wa wodwalayo.

Munthawi zonse pomwe muyeso wa glucose sungatheke nthawi yomweyo, shuga wambiri amayenera kuperekedwa mothandizidwa. Ngati hypoglycemia siyimitsidwa mwadzidzidzi, imatha kupha.

Thiamine 100 mg iv, shuga 40% 60 ml ndi naloxone 0,4-22 mg iv amadziwika kuti ndiwo mankhwala oyenera odwala omwe ali ndi chikomokere, pakalibe mwayi wofotokozera za matenda komanso kuchipatala. Kuchita bwino komanso chitetezo cha kuphatikiza uku kwatsimikiziridwa mobwerezabwereza pochita.

Kh. M. Torshkhoeva, Woyankhidwa wa Sayansi ya Zamankhwala
A. L. Vertkin, Doctor of Medical Science, Pulofesa
V.V. Gorodetsky, Woyankha wa Sayansi ya Zachipatala, Pulofesa Wothandizira
Ambulansi ya NNGO, MSMSU