Hyperglycemic ketoacidotic coma ho bana
Hyperglycemic coma (ICD-10 khoutu ea E14.0) ke eona ntho e boima ka ho fetesisa le e tebileng ea bokuli bo kang lefu la tsoekere. Boemo bona ba mokuli bo ka hlahisoa ke karolo ea ho qetela ea pherekano ea metabolic.
Coma e hlaha ka keketseho e kholo ea khatello ea tsoekere ea mali (ho fihla ho likhato tse 30 kapa ho feta). Boholo ba linyeoe li bonoa ho bakuli ba nang le lefu la tsoekere la mofuta oa 1. Mme palo ea batho ba shoang e fapana ho tloha ho karolo ea 5 ho isa ho 30%.
Ho na le mokhathala o ikhethileng oa com. Li fapana ho etiology le lisosa tsa kholo. Hyperglycemic coma e hlaha hangata ho bakuli ba mofuta oa bobeli oa lefu la tsoekere. Ho boetse ho na le coma ea hypoglycemic. Lebaka le ka sehloohong la tsoelo-pele ea lona ke ho fokotseha ho hoholo ha khatello ea glucose maling a mokuli.
Hyperglycemic ketoacidotic coma e tšoauoa ke ketoacidosis, nakong ea hyperosmolar state e seng ketoacidotic, ho na le tlolo ea phallo ea phallo ea mali 'meleng oa motho, ho bokellana ha lactic acid liseleng le mali a mmele ke mokhoa o tloaelehileng oa hyperlactacidemic coma.
Mabaka le mabaka
Pathogenesis ea hyperglycemic coma e ipapisitse le keketseho ea boemo ba tsoekere 'meleng le tlolong ea lits'ebetso tsa metabolic. Haeba mokuli a hlahisa insulin e lekaneng, komisi e ke ke ea hlaha.
Maemong moo tsoekere e fetisang li-unit tse 10, e se e kene ka har'a moroto oa mokuli. Ka lebaka leo, mathata a eketseha.
Ka nako e tšoanang, lisosa tse latelang tsa nts'etsopele ea hyperglycemic coma li ka khetholloa:
- Tekanyetso e sa nepahalang ea insulin, ente e sa jeleng.
- Boemo bo sithabetsang, khatello ea methapo.
- Pheko e sa feleng ea lefu lena.
- Nalane ea myocardial infarction kapa stroke.
- Mafu a tšoaetsanoang a tsamaiso ea phefumoloho, boko le lits'ebetso tse ling tsa ts'ehetso ea bophelo ba 'mele.
- Tlolo ea phepo e ntle, tlhekefetso ea joala.
- Boimana
- Ho fetoha ha moriana o mong oa hypoglycemic ho o mong.
Nakong ea kemolo, 'mele oa mosali o sebetsa ka mojaro o habeli. Maemong ha 'm'a moimana a e-na le mofuta o patehileng oa pathology, joale phello e bolaeang ha e qheleloe ka thoko.
Boemong boo lefu la tsoekere le fumanoang pele ho ima, ho hlokahala ho laola boemo ba tsoekere 'meleng, mme ka matšoao afe kapa afe a fosahetseng, etela ngaka ea hau.
Maemong a mangata, ho kula ho fumanoa ke "hypoglycemic coma" ho bakuli ba nang le lefu la tsoekere ba hlahisang litekanyetso tse kholo haholo tsa insulin kapa moemeli oa hypoglycemic.
Hypoglycemia e ka ba lebaka la ho ikoetlisa ka matla kapa ho bolaoa ke tlala.
Setšoantšo sa Clinical
Hyperglycemic coma e ka hlaha ho tloha ho letsatsi le leng ho isa ho matsatsi a mararo, empa ho hlaha ha eona ka mor'a lihora tse 'maloa ha ho qheleloe ka thoko. Leha ho le joalo, maemong a 99%, likhetho tsa pelekano li bonoa matsatsi a 'maloa pele ho nts'etsopele.
Mokhoa oa ho amohela li-pathology? Matšoao a tšoaetsitsoeng a komello ea hyperglycemic ke ho felloa ke takatso ea lijo, ho nyekeloa le pelo le ho hlatsa, molomo o omileng, letsoalo le sa feleng la lenyora.
Karolo e boetse ke hore mokuli a ka ba le ho hema hanyane, bofokoli, ho hloka thahasello, ho khathatsoa ke boroko (hangata ho otsela) le ho fokotseha ha khatello ea mali. Hangata, boemo bona bo fetoha butle butle, ka hona, mehato ea ho hlahloba le ho hlokomela pelehi hangata e etsoa ka tšohanyetso.
Hyperglycemic diabetesic coma e kotsi ka hore ho bonolo haholo ho ferekanya chefo e tloaelehileng ea lijo, ka lebaka leo boemo bo ntseng bo tsoela pele, mme mokuli o ikutloa a mpefala le ho feta. Mohlomong nts'etsopele ea litlamorao tse mpe tse ngata, ho isa lefung.
Hypo le hyperglycemic coma li na le phapang e kholo matšoao. Hypa-hypoglycemic coma e lula e tšoauoa ka ho qaleha ho matla. Pathology e ka tšoauoa ka matšoao a latelang:
- Bofokoli bo ntseng bo hola ka potlako.
- Ho otla ha pelo ka potlako.
- Boiketsi bo se nang mohopolo le bo matla ba tšabo.
- Ho utloa tlala, chores, ho tsekela.
- Ho rohakana.
Haeba bonyane ho na le a mang a matšoao a ho qhekella ho joalo, o lokela ho hlahloba tsoekere e maling a hao hang-hang. Ha e bapisoa le coma ea hyperglycemic, hypoglycemia e hola ka potlako. Boemo bona bo kotsi hape bophelong ba mokuli.
Nts'etsopele ea komello ho ngoana
Hangata, bakuli ba fokolang ba ba le komello ea ketoacidotic, e hlokang kalafo feela sepetlele.
Lisosa tsa hyperglycemic ketoacidotic coma ha li tšoane. Leha ho le joalo, ho eketsoa ka maikutlo a ho hlakaha ha lihormone le kelello, e leng tšobotsi e khethollang bana le bacha.
Hyperglycemic diabetesic coma ho ngoana e hola butle butle ka matsatsi a 'maloa. Haeba ho fanoa ka insulin e nyane, tlolo ea ts'ebetso ea ts'ebeliso ea tsoekere e bonoa.
Matšoao bongoaneng a qala ka bokuli bo bobe mme a qetelle ka ho senyeha ho hoholo. Matšoao a komello ea hyperglycemic:
- Pele, ho na le matšoao a malaise ka kakaretso, bofokoli le mokhathala, ho otsela. Ka linako tse ling bana ba tletleba ka tlolo ea molao oa ho utloa, ho nyekeloa le maikutlo a ho lula ba nyoriloe.
- Ho feta moo, ho nyekeloa ke pelo ho fetoha ho hlatsa, mme ho sitoa ho fana ka liphallelo ho lebisa ho bohloko ka mpeng, karabelo e sa thijoeng le bohloko pelong.
- Mokhahlelong oa ho qetela, ngoana o bua ka mokhoa o sa hlatheng, a ka 'na a se ke a araba lipotso, a hema ka thata le ka lerata, monko oa acetone o fumanoa bokong ba molomo. Ntlha ea ho qetela ke ho lahleheloa ke kelello. Ha ho feta liteko, acetone maling e bonoa.
Hyperglycemic diabetesic coma e hloka tlhokomelo ea bongaka hanghang, kaha phepelo ea eona e sa lebelloang e ka lebisa lefung.
Hyperglycemic Coma Emergency Algorithm
Litho tsa lefu la tsoekere tse haufi li hloka ho tseba hantle hore na tleliniki le tlhokomelo ea tšohanyetso ea lefu la tsoekere ke eng. Hoa hlokahala ho khona ho khetholla pakeng tsa maemo a hypo- le hyperglycemic.
Ke eng e lokelang ho etsoa pele ambulense e fihla? Ho thusa ka mokokotlo oa hyperglycemic ho kenyelletsa ho tsamaisoa ha insulin ka mokhoa o ikhethileng ka linako tse ling tsa lihora tse 2-3. Litekanyetso li ntlafatsoa ho latela boleng ba glucose 'meleng. Glycemia e lokela ho lekanngoa hora e 'ngoe le e' ngoe.
Ho fokotsa tšebeliso ea lik'habohaedreite. Ha ho phekoloa coma ea hyperglycemic, lithethefatsi li sebelisoa tse kenyelletsang potasiamo le magnesium sebopeho sa tsona, hobane li thusa ho thibela hyperacidosis.
Maemong ha litekanyetso tse peli tsa insulin ka nako e lekanang ea nako li ne li se na phello e lakatsehang ea kalafo, matšoao ha a fetoha, 'me boemo ba mokuli ha boa tsitsa, ho hlokahala ho letsetsa ambulense.
Boemong boo lefu la lefu la tsoekere le lengata haholo 'me le le haufi le ho lahleheloa ke kelello, ho tla hlokahala tlhokomelo ea tšohanyetso. Leha ho le joalo, kalafo e matla ea komello e etsahala sepetlele.
Thuso ea pele ea thuso ea "hyperglycemic coma" e na le liketso tse latelang:
- Mokuli o beoa ka lehlakoreng la hae hore a se ke a bipetsa ka ho hlatsa. Boemo bona bo boetse bo felisa leleme le leng hape.
- Mokuli o koaheloa ka likobo tse 'maloa tse futhumetseng.
- Ho bohlokoa ho laola ho otla le ho phefumoloha.
Haeba mokuli a se a phefumoloha, ho hlokahala hore hang hang u qale ho tsosa, ho phefumoloha ka matsoho le ho ikoetlisa ka pelo.
Mefuta eohle ea mahlaba a tebileng ke mathata a tebileng, ho letsa ambulense ka tšohanyetso le ka nako ho tla thusa ho eketsa menyetla ea sephetho se setle. Haeba litho tsa lelapa li na le lefu la tsoekere, lelapa le leng le le leng la batho ba baholo le tlameha ho utloisisa hore thuso e lekaneng e ka thibela koluoa, 'me ea boloka mokuli.
Bohlokoa: o tlameha ho tseba ho khetholla pakeng tsa hyperglycemia le hypoglycemia. Khetlong la pele, insulin e ea tsamaisoa, 'me ka hypoglycemic coma glucose e tsamaisoa.
Thibelo
Hyperglycemic diabetesic coma ke bothata bo tebileng, empa bo ka qojoa haeba u latela litlhahiso tsohle tsa ngaka mme u phela bophelo bo botle. Ka linako tse ling boemo bona bo hlaha ho batho ba sa belaeleng ho ba teng ha lefu la tsoekere. Ka hona, ho bohlokoa haholo ha matšoao a rarahaneng a autoimmune pathology a bonahala a e-na le tlhahlobo e felletseng ea phapang.
Tlhahlobo ea hemoglobin ea glycated, ho hlahloba tsoekere ea mali (ka mpeng e se nang letho), tlhahlobo ea mamello ea tsoekere, ultrasound ea manyeme, urinalysis bakeng sa tsoekere e tla lumella ho fumanoa ka nako ea mofuta oa 1 kapa mofuta oa 2 oa lefu la tsoekere mme o fane ka maqheka a loketseng a kalafo.
Litsebi tsa lefu la tsoekere ho qoba tlhoko ea kelello:
- Ha ho fumanoa hore o na le mofuta oa 1 mellitus oa lefu la tsoekere, lekola boemo ba hau pele le ka mor'a ente ea insulin. Haeba, kamora tsamaiso ea lihormone, boemo ba glycemia bo feta letšoao la 10-15 mmol / l, joale mofuta oa kalafo o tla hloka ho fetoloa. Mohlokomeli oa hau oa bophelo bo botle a ka u fa mofuta o mong oa insulin. Tse sebetsang ka ho fetisisa le tse sireletsehileng ka ho fetisisa ke insulin ea motho.
- Ka lefu la tsoekere la mofuta oa 2, mokuli o lokela ho latela lijo ka tieo. Ha ho na le botenya, ho bontšoa phepelo ea nama e tlase ea carb.
- E phela bophelo bo mafolofolo. Ho ikoetlisa ka mokhoa o itekanetseng ho tla eketsa ho senyeha ha lisele tsa mmele ho ea ho insulin, le ho ntlafatsa maemo a akaretsang a mokuli.
- Nka lithethefatsi tsa hypoglycemic (tse nang le lefu la tsoekere la mofuta oa 2), 'me u se ke oa etsa phetoho e ikemetseng ea litekanyetso.
Hape, bakuli ba eletsoa hore ba ee tlhahlobong e thibelang pele. Lingaka li khothaletsa ho lekola boemo ba lefu la glycemic le matla ka kakaretso a lefu lena. Bakeng sa litekanyo lapeng, o hloka ho sebelisa gluroeter ea electrochemical.
Ho bohlokoa hape ka tsela e tšoanang ho lekola boemo ba hemoglobin ea glycated. Tafole e ka tlase e bonts'a khokahano ea hemoglobin e tsoang glycated ho palo e tloaelehileng ea tsoekere letsatsi le letsatsi.
Boleng ba HbA1c (%) | Boleng ba HbA1 (%) | Tsoekere e mahareng (mmol / L) |
---|---|---|
4,0 | 4,8 | 2,6 |
4,5 | 5,4 | 3,6 |
5,0 | 6,0 | 4,4 |
5,5 | 6,6 | 5,4 |
6,0 | 7,2 | 6,3 |
6,5 | 7,8 | 7,2 |
7,0 | 8,4 | 8,2 |
7,5 | 9,0 | 9,1 |
8,0 | 9,6 | 10,0 |
8,5 | 10,2 | 11,0 |
9,0 | 10,8 | 11,9 |
9,5 | 11,4 | 12,8 |
10,0 | 12,0 | 13,7 |
10,5 | 12,6 | 14,7 |
11,0 | 13,2 | 15,5 |
11,5 | 13,8 | 16,0 |
12,0 | 14,4 | 16,7 |
12,5 | 15,0 | 17,5 |
13,0 | 15,6 | 18,5 |
13,5 | 16,2 | 19,0 |
14,0 | 16,9 | 20,0 |
Multivitamin complexes, e kenyeletsang chromium, zinki le thioctic acid, e tla thusa ho thibela lefu la tsoekere le nts'etsopele ea mathata a lefu la tsoekere. Le haeba e le ka mabaka a thusang, u ka sebelisa litlhare tsa setso. Sebetsa ke li-decoctions tse thehiloeng litlamong tsa linaoa, viburnum, lemongrass, calendula.
Tlhahlobo ea bongaka
Ho hola butle-butle ha ketoacidosis ho ngoana ea kulang ho bonahala ka matsatsi a mangata kapa libeke. Matšoao a pele a bontšang ho fokotseha hoa lefu la tsoekere ke: ho theola boima ba 'mele takatso e ntle ea lenyora, ho otsela hangata, ho fokola le ho tepella hangata, ho hlohlona khafetsa, mafu a tšoaetsanoang khafetsa le a maiketsetso.
Matšoao a komello e sa tloaelehang le e fumanehang ka ketoapidotic:
- ho tepella, ho otsela ho fihlela sopor,
- lenyora le matla le polyuria,
- eketseha ka mpeng ketoacidosis, e bonahatsoang ke ho nyekeloa, ho hlatsa, bohloko bo ka mpeng, ho tsitsipana ha mesifa leboteng la ka mpeng (kliniki ea "mpa ea ka mpeng") e nang le hyperleukocytosis ea laboratori, neutrophilia, stab shift,
- Letlalo le omile, le boreleli, 'mala o moputsoa, "lefu la tsoekere" sefahlehong, le "tishu"
- tachycardia, molumo oa pelo o tetemang, khatello ea mali e fokotsehile,
- monko oa acetone moeeng o tsoang,
- glucose maling a kaholimo ho 15 mmol / l,
- ka moroto, ho ekelletsa ho bongata bo boholo ba glucose, acetone e ikemiselitse.
Haeba u sa fane ka tlhokomelo ea bongaka ka nako, ho ba le komello e tebileng:
- ho lahleheloa ke tsebo ka thibelo ea letlalo le maikutlo a bulbar,
- ho felloa ke metsi haholo ka ho ferekana ho hoholo ha hemodynamic ho fihlela ho tsitsipano ea hypovolemic: lifahleho tsa sefahleho, ho omella le cyanosis ea letlalo le li-membrane tsa mucous, mahlo a bonolo, ho putlama ha khatello ea mali, ho fokotseha ha tlhahiso ea moroto ho anuria,
- Ho phefumoloha ha Kussmaul: khafetsa, ho teba, lerata, ka monko oa acetone moeeng o tsoang,
- laboratori: glycemia e phahameng (20-30 mmol / l), glucosuria, acetonuria, urea e eketsehileng, creatinine, lactate ea mali, hyponatremia, hypokalemia (ka anuria ho ka ba le keketseho e nyane), CBS e tšoauoa ka metabolic acidosis e nang le phello e ntle ea ho phefumoloha: boemo pH 7.3-6.8; BE = - 3-20 le tlase.
Tlhahlobo e khethollang ea ketoacidotic coma e etsoa haholo ka hypoglycemic le li-comas tse ling tsa lefu la tsoekere - hyperosmolar non-ketoacidotic le hyperlactatacidemic. Lefu la tsoekere le lefu la tsoekere le ka hloka tlhahlobo e arohanang le mafu a tsoang ka mpeng a lefu la ka mpeng, pneumonia, encephalitis, jj. Bakeng sa tlhahlobo e fumanehang ea ketoacidosis maemong a joalo, ho a hlokahala ho tseba boemo ba "glucose" le 'mele oa ketone maling le moroto.
Tlhokomelo ea maemo a tšohanyetso
1. Hlophisa ho kena sepetlele ka tšohanyetso lefapheng la ho tsosa kapa ho khetha lefapha le ikhethang la endocrinology.
2. Etsa bonnete ba patency ea phepelo e phahameng ea phefumoloho, kalafo ea oksijene.
3. Fana ka monyetla oa ho kena betheng ea venous bakeng sa ho futhumatsa mmele:
- ka nako ea hora e le ngoe, hlahisa tharollo ea methapo ea methapo ea 0,9% sodium chloride ka tekanyo ea 20 ml / kg, eketsa 50-200 mg ea cocarboxylase tharollo, 5 ml ea tharollo ea acid ea 5%, maemong a tšohanyetso, ho eketsa palo ea tharollo ho 30 ml / kg
- lihoreng tse 24 tse latelang ho tsoela pele kalafo ea infusion ka tekanyo ea 50-150 ml / kg, kakaretso ea kakaretso ea letsatsi le letsatsi ho latela lilemo: ho fihlela ho selemo 1 - 1000 ml, lilemo tse 1-5 - 1500 ml, lilemo tse 5-10 - 2000 ml, 10-18 lilemo - 2000-2500 ml. Lihoreng tse 6 tsa pele kenya 50%, lihora tse 6 tse latelang - 25% le lihora tse 12 tse setseng - 25% ea mokelikeli.
Kenyelletso ea tharollo ea chloride ea 0,9% ea sodium e tsoela pele ho fihlela boemo ba tsoekere ea mali ba 14 mmol / L. Ebe u hokela tharollo ea glucose ea 5%, u e hlahisa ka mokhoa o fapaneng le tharollo ea 0,9% ea sodium chloride ka karolelano ea 1: 1. Taolo ea osmolarity e sebetsang e baloang ka foromo: 2 x (sodium ea mali ho mmol / l + mali a potasiamo ho mmol / l + glucose ea mali ho mmol / l). Ka tloaelo, letšoao lena ke 297 ± 2 mOsm / l. Boteng ba hyperosmolarity - tharollo ea sodium chloride e 0,9% e nkeloa sebaka ke tharollo ea hypotonic 0.45%.
4. Ka nako e ts'oanang le ho qala hoa ho ts'oaroa ha mmele hape, tsamaisa nako e khutšoane (!) Insulin (actrapid, humulin khafetsa, joalo-joalo) iv ka tekanyo ea 01. U / kg (e nang le lefu la tsoekere le lilemo tse fetang 1 - 0,2 U / kg) ka 100-150 ml ea tharollo ea chloride ea 0,9% ea sodium.
Litekanyetso tse latelang tsa insulin li lokela ho tsamaisoa ka vum ka tekanyo ea, le 1 LD / kg ka hora tlasa taolo ea tsoekere ea mali. Bophahamo ba glycemia ha boa lokela ho fokotsoa ke ho feta 2,8 mmol / hora.
Ka ho fokotseha ha tsoekere ea mali ho isa ho 12-14 mmol / l, chencha ts'ebetsong ea insulin ka mor'a lihora tse 4 ka tekanyo ea 0,1 U / kg.
5. Bakeng sa ho lefella khaello ea potasiamo kamora lihora tse 2-3 ho tloha ha ho qala kalafo ea IV, tharollo ea 1% ea chloride ea potasiamo e huleloa ka tekanyo ea 2 mmol / kg ka letsatsi (1/2 - - kahare le 1/2 - haeba ho se na ho hlatsa kahare) :
a) ka ho hloka ya data ka tekanyo ea potasiamo, kenella tharollo ea potasiamo ea 1% ea potasiamo ka tekanyo ea 1.5 g ka hora (100 ml ea tharollo ea 1% KCl e na le 1 g ea chloride ea potasiamo, le 1 g ea chloride ea potasiamo e tsamaellanang le 134 mmol ea potasiamo, 1 ml 7 , 5% KCl tharollo e na le 1 mmol ea potasiamo),
b) haeba ho na le matšoao a boemo ba potasiamo maling, tekanyo ea tsamaiso ea tharollo ea 1% ea chloride ea potasiamo e tjena:
- ho fihla ho 3 mmol / l - 3 g / hora,
- 3-4 mmol / l - 2 g / hora,
- 4-5 mmol / l - 1.5 g / hora,
- 6 mmol / l kapa ho feta - emisa ho tsamaisa.
Litokisetso tsa potasiamo ha lia lokela ho fanoa haeba ngoana a tšohile ebile a e-na le bothata ba ho opa!
6. Khalemelo ea metabolism ea metabolic:
- ha ho na taolo ea mali pH - enema e nang le tharollo e futhumetseng ea 4% ea sodium bicarbonate ka bongata ba 200-300 ml,
- ka / kenyelletsong ea tharollo ea sodium bicarbonate ea 4% e bonts'oa ho pH <7.0 feela ho tloha lipalo-palo tsa "drip" tsa 2,5- ml / kg bakeng sa lihora tse 1-3 ka tekanyo ea 50 mmol / hora (1 g NaHCO3 = 11 mmol), feela ho fihlela pH e fihla ho 7.1 kapa boholo ba 7.2.
7. Bakeng sa thibelo ea mathata a baktheria, fana ka kalafo e thibelang likokoana-hloko e pharaletseng.