ʻO nā hopena hoʻopiʻi o ka maʻi diabetes ma ka hana o kahi kauka

KA MANOLOKO, EʻOLIOLI ME KA ʻHlelo

Ka hoʻēmi o ka huehue, ka momona, ka hoʻohuihui protein, me ka hoʻāla ʻana o ka wai-electrolyte a me ka pāpaʻi ʻana o ka acid-base, me ka hyperglycemia, hyperketonemia, ketonuria a me ka metabolic acidosis e hopena ana mai ka pilikia nui o ka insulin a me ka nui. ʻO kahi hiʻohiʻona ka hele ʻana o nā kino ketone i loko o ka serum koko a me ka urine. Hiki ia i nā wā o kēlā me kēia ʻano mellitus o ka maʻi mellitus, ʻoi aku ka pinepine o ka hōʻike mua o ka maʻi type 1. Ma muli o ka nele o ka insulin, aia ka hana nui i ka glucose i loko o ka ate ma ka hopena o ka gluconeogenesis, a me ka hoʻonui ʻia ka lipolysis me ka hoʻokumu ʻana o nā kino ketone. ʻO ka hopena o kēia: hyperglycemia, nalowale o ka glucose i loko o ka pāʻai, osmotic diuresis, dehydration, hoʻopiʻi ka electrolyte (ʻoi aku hoʻi ka hyperkalemia me ka huina hoʻopiʻi intracellular concomitant) a me ka metabolic acidosis. Nā mea hoʻowahāwahā: ke kīnā o ka maʻi insulin (e.g. ma muli o kahi maʻi o ka ʻōpū gastrointestinal, hōʻemi ka mea maʻi mai ka ʻai) a i ʻole ke hoʻohana ʻana i ka insulin, nā maʻi kūʻai (bacterial, viral, fungal), nā maʻi cardiovascular maʻi (myocardial infarction, stroke), ka hoʻomehana ʻana o ka hoʻōla o ke kō maʻi 'āpau 1, pancreatitis, inu wai inu, hapai, nā kūlana a pau e hopena ai i ka piʻi o ke koi ʻana i ka insulin. luna ma luna

1. Nā hōʻailona kumumanaʻo: make nui ka wai, ka maloʻo maloʻo, polyuria, nāwaliwali, nā luhi a me ka hiamoe, nā luhi me ka hōʻeha a me ka hōʻeha, ka ʻōpū a me ka hōʻeha, ka ʻōpū a me ka luaʻi, ka ʻeha o ka ʻōpū, ka ʻeha ʻeha. luna ma luna

2. Nā hōʻailona kikoʻī: hypotension, tachycardia, wikiwiki a hohonu loa, a laila hoʻi i ka hanu pāpaku, nā hōʻailona o ka hōʻemi (hōʻemi i ke kaupaona, hōʻemi ka ʻoki kino), hoʻoemi iho i nā tendon reflexes, ʻā o ka acetone mai ka waha, ʻulaʻula o ka maka, hoʻemi ka hōkū eyeball, hoʻonui i ka hakakā o ka pā o ka ʻōpū (e like me ka peritonitis)

Hoʻokumu ʻia ka maʻi maʻi i ka hopena o nā hoʻokolohua hoʻokolohua → papa. 13.3-1. I nā maʻi i mālama ʻia me kahi mea mālama SGLT-2, ʻoi aku ka haʻahaʻa o ka glycemia.

Ma ka maʻi Dioma Ketoacidotic (DKA)

ʻO ka DKA kahi hoʻopiʻi nui loa o ka maʻi mellitus o ka maʻi mellitus, ke ʻano o ka metabolic acidosis (pH ma kahi o 7.35 a i ʻole ka bicarbonate haʻahaʻa ma mua o 15 mmol / L), hoʻonui hoʻonui anionic, hyperglycemia ma mua o 14 mmol / L, ketonemia. Hoʻolālā pinepine ia me ka maʻi type 1. Nā DKA waihona no 5 a 20 mau hihia no kēlā me nā mea maʻi 1000 i hoʻokahi makahiki (2/100). ʻO ka make ma kēia hihia he 5-15%, no nā mea maʻi ma mua o 60 mau makahiki - 20%. ʻOi aku ma mua o 16% o nā mea maʻi me ka maʻi type kīpē 1 make mai ka como ketoacidotic. ʻO ke kumu no ka hoʻomohala ʻana o DKA i ka mea pono ʻole a i ʻole ka pau ʻana o ka insina o ka insulin ma muli o ka lawa ʻole o ka inehina i ʻole ka nui o ka insulin.

Nā mea hoʻolako: ʻaʻole lawa ka nui o ka insulin a i ʻole ke ʻoki ʻana i kahi inikini o ka insulin (a i ʻole lawe i nā papa o ka hypoglycemic agents), ka hoʻokaʻawale ʻole ʻana o ka hana hypoglycemic therapy, ka hana hewa ʻana i ke ʻano o nā hoʻomehana insulin, hoʻohui i kekahi mau maʻi (maʻi, ʻeha, trauma, ʻehaʻeha, hapai, myocardial infarction, stroke, hoʻāhu, etc.) , ka hānai o ka meaʻai (nui ka nui o nā kaona), ka hana kino me ka glycemia kiʻekiʻe, ka inuʻana i ka waiʻona, ka nele o ka pale ʻana i ka hana metabolism, e lawe i kekahi mau lāʻau lapaʻau. nnyh ai '(corticosteroids, calcitonin, saluretics, acetazolamide, β-blockers, diltiazem, isoniazid, phenytoin listen'ōlelo.).

ʻO ka pinepine, ʻike pinepine ka etiology o DKA. Pono e hoʻomanaʻo ʻia ma kahi o 25% o nā hihia, loaʻa ʻo DKA i nā mea maʻi me ka mellitus maʻi maʻi maʻi.

ʻEkolu mau hanana o ka ketoacidosis maʻi: ketoacidosis mau, precoma, a i ʻole decompensated ketoacidosis, coma.

ʻO ka hōʻeha o ka como ketoacidotic e pili ana i ka thrombosis vein hohonu, pulmonary embolism, thrombosis arterial (myocardial infarction, cerebral infarction, necrosis), aspirī pneumonia, cerebral edema, pulmonary edema, maʻi, jarang GLC a ischemic colitis, erosive gastritis, late hypoglycemia. Hoʻomaopopo ka pilikia o ka hanu ʻeha, oliguria a me ka hala ʻole o ka renal. ʻO nā ʻōhumu o nā maʻi he cerebral a me ka pulema o ka pulmonary, hypoglycemia, hypokalemia, hyponatremia, hypophosphatemia.

Nā hōʻike Diagnostic no DKA

• ʻO kahi hiʻohiʻona o ka DKA kahi hoʻolālā holomua, ma mua o kekahi mau lā.
• Nā hōʻailona o ka ketoacidosis (ka hiona o ka acetone i loko o ka hanu i ea, Kussmaul ka hanu, ka holo, ka luaʻi, ka anorexia, ʻeha o ka ʻōpū).
• ʻO ka hele ʻana o nā hōʻailona o ka dehydration (hoʻemi i ka turgor kiko, hoʻoneʻe i ka paʻi eyeball, ka pūlima ʻana o ka naʻau, ka puhī o tendon, ke ʻano o ke kino a me ke kahe koko).

I ka hoʻokūkūʻana o DKA i ka manawa prehospital, pono ia e ʻike inā e loaʻa ana ka mea maʻi i ka mellitus maʻi diabetes, inā paha he mōʻaukala o DKA, inā e loaʻa ana ka mea maʻi i ka ʻohi hypoglycemic therapy, a inā pēlā, he aha ka manawa hope i lawe ai ʻoe i ka lāʻau lapaʻau, ka manawa o ka ʻai hope loa, a i ʻole ka hana kino kino i hōʻike ʻia a i ʻole inu ka waiʻona, kahi maʻi i hala ma mua o kahi coma, he polyuria, polydipsia a me ka nāwaliwali.

ʻO ka hoʻokaumahaʻana o ka DKA ma ka manawa prehospital kūlana (ʻike papa 1) koi i ka nānā kūikawā e pale ai i nā hewa.

Hiki i nā hewa i ka hopena a me ka hoʻomohala ʻana ma ka manawa mua

• Pre-hospital therapy therapy me ka mālama ʻole o ka glycemic control.
• ʻO ke kau nei i ka mālamaʻana ma ke kau ʻana i kahi inikini Insulene me kaʻole o ka rehydration pono.
• ʻAʻohe plae nui ka waiwai.
• ʻO ka hoʻokomoʻana i nā hoʻonā hypotonic, ma mua o ka hoʻomaka ʻana o ka mālama ʻana.
• ʻO ka hoʻohana ʻana i ka diuresis koi ma kahi o ka rehydration. ʻO ka hoʻohana ʻana o ka diuretics me ka hoʻopuka o nā wai, e hoʻolōʻihi wale i ka hoʻihoʻi ʻana i ka kaulike o ka wai, a me ko comos hyperosmolar, ʻo ke koho ʻana o ka diuretics e hoʻopili paʻa ʻia.
• ʻO ka hoʻomaka ʻana me ka sodium bicarbonate hiki i ka momona. Ua hōʻike ʻia ʻo ka lawa ʻana o ka insulin i ka hapanui ke kōkua i ka hoʻopau ʻana i ka waihā. ʻO ka hoʻoponopono ʻana i nā waikawa me ka sodium bicarbonate e pili ana me ka nui loa o ka loaʻa ʻole o nā hoʻopiʻi. Hoʻonui ka hoʻonui ʻana i ka alkalis i ka hypokalemia, hōʻole i ka wehe ʻana o ka oxyhemoglobin, ka carbon dioxide i kūkulu ʻia i ka wā o ka hoʻomehana ʻana o ka sodium bicarbonate, hoʻomaikaʻi i ka acidosis intracellular (ʻoiai ke hoʻonui ʻia ka pH koko i loko o kēia hihia), ka waila paradoxical e nānā ʻia ana i ka wai o cerebrospinal, e kōkua ai i ka edema cerebral, e hoʻōla ʻole ʻia ka hoʻomohala. rebal alkalosis. ʻO ka hana wikiwiki o ka sodium bicarbonate (jet) hiki i ka make ke hopena ma muli o ka hiki ke hoʻololi i ka hypokalemia.
• ʻO ka hoʻomakaʻana o ka hoʻonā o ka sodium bicarbonate me ka ʻole o ka hoʻonā ʻana i ka paʻakai.
• ʻO ka hoʻoneʻe ʻana a i ʻole ʻole hoʻokele ʻana o ka insulin i nā mea maʻi me DKA i kahi mea maʻi ʻaʻole hiki ke ʻai.
• ʻO ka hoʻokele jet intravenous i ka insulin. ʻO nā minuke 15 wale nō ka mea, ʻo ka mālama ʻana i ke koko e mālama ʻia i kahi pae maʻa, no laila ʻaʻole maikaʻi kēia huakaʻi o ka hoʻokele.
• ʻEkolu a ʻehā mau manawa i ka hoʻokele ʻana o ka insulin hana pōkole (ICD) subcutaneously. Maʻa ʻo ICD no 4-5 mau hola, ka nui o nā kūlana ketoacidosis, no laila e kuhikuhi ʻia i ʻelima a hiki i ʻeono mau manawa i ka lā me kahi po ʻole ʻole o ka pō.
• ʻO ka hoʻohana ʻana i nā lāʻau sympathotonic e hakakā i ka hāʻule ʻana, ka mea, ʻo ka mea mua, he mau contrainsulin hormone, a, ka lua, i nā mea maʻi maʻi maʻi, i ko lākou hopena hōʻeuʻeu ʻana i ka hana kūlima glucagon e ʻoi aku ka ikaika ma mua o nā mea olakino.
• Ka noi ʻana o ka DKA. Ma DKA, ka mea i kapa ʻia ka "pseudoperitonitis diabetes", ʻike pinepine ʻia i ka hōʻailona o kahi "ʻōpūʻeha" a me ke kani ʻana a me ka ʻeha o ka paia ʻōpū, kahi e hoʻoneʻe ana a mau ana paha i nā murmurs peristaltic, i kekahi manawa he hoʻonui ma ka serum amylase. Ka hiki i ka wehe 'ana o ka leukocytosis ke alakaʻi i kahi hala i ka hoʻomohala ʻana, ma ke ʻano he mea komo i ka mea maʻi i ka' infectious ("intestinal infection") a i ʻole i nā mea maʻi ("abdomin abdomen") ʻena. I nā kūlana a pau o ka "ʻeha ʻeha" a i ʻole nā ​​maʻi dyspeptic i ka mea maʻi me ka maʻi mellitus o ka maʻi maʻi, kahi hopena o ka glycemia a me ke ketotonuria pono.
• ʻO kahi ana ʻana i nele i ka glycemia no kēlā me kēia mea i loko o ka naʻaupō ʻole, ka mea e hoʻopiʻi ʻia i ka hana ʻana o nā hopena hewa - "kuhihewa cerebrovascular", "coma a eamology kūlohelohe", aʻo ka mea maʻi me ka hoʻōla o ka maʻi metabolic maʻa.

ʻO ka coma Hyperosmolar non-ketoacidotic coma

Kuhi i kahi coma hyperosmolar non-ketoacidotic coma e ka maʻi dehydration koʻikoʻi, hyperglycemia nui (pinepine ʻia ma luna o 33 mmol / L), hyperosmolarity (ʻoi aku ma mua o 340 mau mau mākaʻi / L), hypernatremia ma luna o 150 mmol / L, a me ka waiho ʻole o ka ketoacidosis (nui ketonuria (+)). Hoʻonui pinepine ia i nā mea maʻi me nā maʻi diabetes type 2. ʻO 10 mau hola i hōʻemi ma mua o DKA. Hōʻano ʻia ia e ke kiʻekiʻe make nui (15-60%). ʻO nā kumu no ka hoʻomohala ʻana o ka comos hyperosmolar ka hemahema o ka insulin a me nā mea e hoʻonāukiuki i ka loaʻa ʻana o kahi wai.

Nā mea e hoʻolako ai: ʻaʻole lawa ka nui o ka insulin a i ʻole ke kala ʻana i ka inikini o ka insulin (a i ʻole lawe i nā papa o nā ʻaina hypoglycemic), ka hoʻokaʻawale ʻole ʻana o ka hypoglycemic therapy, ka hana hewa ʻana i ke ʻano o ka lawelawe ʻana i ka insulin, ka hoʻohui o nā maʻi ʻē aʻe (maʻi), pancreatitis aʻeha, trauma, ʻeha, hapai, myocardial infarction, stroke, ʻeha a me nā ʻeha. A laila.), ke kī ʻana o ka papaʻai (he nui loa i nā kālaiā), ka lawe ʻana i kekahi mau lāʻau lapaʻau (diuretics, corticosteroids, beta-blockers, etc.), hoʻomehana, hiki ʻole i ka haʻalele i ka makewai. kuni, puhi a i ʻole ka lolo, hemodialysis a i ʻole peritoneal dialysis.

Pono e hoʻomanaʻo ʻia o kahi hapakolu o nā poʻe maʻi me ka hyperosmolar coma, ʻaʻole i loaʻa he mua o ka maʻi maʻi.

Nā kiʻi haukapila

Ka makewai ikaika, polyuria, dehydration koʻikoʻi, arterial hypotension, tachycardia, iʻikeʻike nui ʻole i nā mea kiaʻi e ulu ana no nā lā a i hoʻokahi pule paha. Inā me DKA, hele mai nā pilikia o ka ʻōnaehana o ka Central a me nā ʻōnaehana hoʻoneʻe peripheral ma ke ʻano o ka hala o ka noʻonoʻo a me ka pale ʻana o nā tendon reflexes, a laila ua hui pū ʻia ka comosmolar coma e nā ʻano like ʻole o ka noʻonoʻo a me ka neurological. I ka hoʻohui i ke kūlana soporotic, ka nānā pinepine ʻia i ke coma hyperosmolar, hele pinepine ka maʻi noʻonoʻo ma o ka delirium, maʻi hallucinatory psychosis, a me catotonic syndrome. Hōʻike ʻia nā maʻi neurological e nā hōʻailona neʻokeʻo focal (aphasia, hemiparesis, tetraparesis, polymorphic sensory disturbance, pathological tendon reflexes, etc.).

ʻO ka piko hāpū pīhoihoi

Hoʻokomo ka com Hypoglycemic ma muli o ke kahe nui o ka glucose o ke koko (ma lalo o 3-3.5 mmol / l) a me kahi ke hoʻopuka ikaika ʻia i loko o ka lolo.

Hāʻawi i nā mea: he overdose o ka insulin a me TCC, skipping a i ʻole ke komo ʻana i ka meaʻai ʻai nui aʻe, hoʻonui i ke kino pilikino, nui ka inu ʻana i ka waiʻona, ka lawe ʻana i nā lāʻau lapaʻau (β-blockers, salicylates, sulfonamides, etc.).

Hiki i nā hewa diagnostic a me ka therapeutic hewa

• ʻO kahi hoʻāʻo e hoʻolauna i nā huahana me ka ʻai o ka kalawa (me ke kō, a me nā mea ʻē aʻe) i loko o ka waha o ka mea maʻi ʻole ʻike. Hōʻai pinepine pinepine kēia i ka noʻonoʻo a me ka aspalphia.
• Ke noi no ka hoʻokuʻu ʻana i ka hypoglycemia o nā huahana kūpono ʻole no kēia (berena, chocolate, etc.). ʻAʻole loaʻa kēia mau huahana i ka hopena e hoʻoulu ai i ke kōkolo a hoʻonui paha i ke kōpaʻa koko, akā lohi loa.
• ʻO ka nānā hewa ʻana o ka hypoglycemia. ʻO kekahi mau hōʻailona o ka hypoglycemia hiki ke hoʻomaopopo ʻia i ka lawaiʻa epileptic, stroke, "krisis kai", a me kekahi mea i kahi maʻi e loaʻa ana i kahi ʻano maʻi hypoglycemic, me kahi mākaʻi kūpono hypoglycemia, pono e hoʻokaʻawale koke ia, ʻoiai ma mua o ka loaʻa ʻana o kahi pane ʻalani.
• Ma hope o ka wehe ʻana i kahi maʻi mai kahi kūlana o ka hypoglycemia koʻikoʻi, ʻaʻole pinepine ka nui o ka hōʻemi o ka hoʻi hou ʻana.

I ka poʻe maʻi ma kahi coma o kahi kumu i ʻike ʻole ʻia, pono mau ia i ka hāpai ʻana i ka hōʻea i ka glycemia. Inā maopopo ia ka mea maʻi i ka maʻi mellitus a me ka manawa like ka paʻakikī i ka hoʻokaʻawale ʻana i nā maʻi hyp- a i ka hyperglycemic genesis o kahi coma, hoʻōlaʻike intravenous glucose i loko o kahi pae o 20-40-60 ml o kahi hopena 40% e ʻōlelo ʻia no ka maʻi ʻokoʻa a me ka mālama pōʻaiʻi ʻana no ka hypoglycemic koma. Ma ka hihia o ka hypoglycemia, e hoʻemi nui ana kēia i ka nui o nā hōʻailona a, no laila, e hoʻokaʻawale i kēia mau ʻano ʻelua. Me ka hyperglycemic coma, kahi nui o ka glucose e pono ai e hoʻopilikia i ke kūlana o ka mea maʻi.

I nā hihia a pau inā ʻaʻole hiki koke ke ana ʻana i ka glucose, ʻike paʻu ka ʻaila nui. Inā ʻaʻole kū ka hypoglycemia i kahi ulia, hiki iā ia ke hōʻeha.

Thiamine 100 mg iv, glucose 40% 60 ml a me naloxone 0.4–2 mg iv ka mea i manaʻo ʻia he mea nui ia no nā maʻi maʻi i kahi hōʻeha, me ka loaʻa ʻole o ka manaʻo e hoʻomaʻamaʻa i ka maʻi maʻi a me ka hoʻouka haukaʻi. Ua hōʻoia pinepine ʻia ka maikaʻi a me ka palekana o kēia hui ʻana i ka hoʻomaʻamaʻa.

Kh. M. Torshkhoeva, moho o nā lāʻau lapaʻau lāʻau
A. L. Vertkin, Kauka o Kauka Hema, Kauka
V.V. Gorodetsky, Kuhina no mau ʻOlelo Kauka, Kauka Pelekikena
ʻAmelika ʻO NNGO, MSMSU