Hyperosmolar coma: lisosa, matšoao, tlhahlobo ea mali, kalafo

• Khotso
• Pherekano
• Ho sitisoa ke puo
• Ho hloka kelello
• Ho holofala
• Ho eketsa takatso ea lijo
• Mocheso o tlase
• Khatello ea mali e tlase
• Lenyora le matla
• Bofokoli
• Ho fokotsa boima ba 'mele
• Maqhubu
• Letlalo le omeletseng
• Li-membrane tse omileng tsa mucous
• Ho shoa litho ka tsela e itseng

Hyperosmolar coma ke motsoako oa lefu la tsoekere, le tšoauoang ke hyperglycemia, hyperosmolarity ea mali. E bontšoa ka ho omella (dehydration) le ho ba sieo ha ketoacidosis. E bonoa ho bakuli ba lilemo tse kaholimo ho tse 50 ba nang le mofuta oa insulin o itšetlehileng ka lefu la tsoekere, ba ka kopanngoa le botenya. Hangata ho hlaha bathong ka lebaka la kalafo e mpe ea lefu lena kapa ho ba sieo ha lona.

Setšoantšo sa tliliniki se ka ba teng ka matsatsi a 'maloa ho fihlela ho felloa ke matla ka ho fokotseha le ho se arabele ho susumetsoang ka ntle.

E fumanoa ka mekhoa ea tlhahlobo ea laboratori le e sebetsang. Phekolo e reretsoe ho theola tsoekere ea mali, ho khutlisetsa tekanyo ea metsi le ho tlosa motho setlamong. Pherekano ena ha e mpe: ho 50% ea linyeoe tse teng li etsahala.

Hyperosmolar coma ho lefu la tsoekere mellitus ke ntho e etsahalang khafetsa 'me e bonoa ho 70-80% ea bakuli. Hyperosmolarity ke boemo bo amanang le ntho e kaholimo le lintho tse ngata tse kang tsoekere le sodium maling a motho, e lebisang khaellong ea kelello, kamora 'mele kaofela.

Bolwetse bo hlaha ka lebaka la ho ba teng ha lefu la tsoekere ho motho kapa ke lebaka la tlolo ea metabolism ea carbohydrate, mme sena se baka ho theoha ha insulin le ho eketseha ha khatello ea tsoekere le 'mele oa ketone.

Tsoekere ea mali ea mokuli e nyoloha ka mabaka a latelang:

• ho felloa ke metsi 'meleng ka mor'a ho hlatsa haholo, letšollo, ho ja metsi a mangata, ho hlekefetsa methapo ea mmele,
• tsoekere e eketsehileng ea sebete e hlahisoang ke ho bola kapa kalafo e sa lokelang,
• Khatello ea tsoekere e ngata ka mor'a ho tsamaisoa ha tharollo ea methapo.

Kamora sena, ts'ebetso ea liphio ea senyeha, e amang ho ntsooa ha tsoekere moriring, mme ho fetella ha eona ho kotsi ho 'mele oohle. Sena se thibela tlhahiso ea insulin le tšebeliso ea tsoekere ke linama tse ling. Ka lebaka leo, boemo ba mokuli bo mpefala, phallo ea mali ea fokotseha, ho senyeha ha sele ea boko ho bonoa, khatello ea fokotseha, ho ferekana hoa tsebahala, hemorrhages lia khonahala, litšitiso tsamaisong ea tšehetso ea bophelo mme motho o oela sethaleng.

Hyperosmolar diabetesic coma ke boemo ba tahlehelo ea kelello ka ho se sebetse hantle hoa lits'ebetso tsohle tsa 'mele, ha matla a kelello a fokotseha, ts'ebetso ea pelo e fela, le ho fokotseha hoa matla. Boemong bona, ho na le kotsi e kholo ea lefu.

Tlhomamiso

Hyperosmolar coma e na le mefuta e 'maloa:

• Hyperglycemic coma. E bonoa ka keketseho ea tsoekere ea mali, e lebisang ho taoleng le ho ferekaneng kelellong, e kanna ea tsamaisana le keketseho ea khatello ea lactic acid.
• Hyperglycemic hyperosmolar coma ke mofuta o tsoakaneng oa boemo ba kelello ha letsoalo le fokolang le hlaha ka lebaka la tsoekere e feteletseng le likhomphutha tsa osmotic haholo tse nang le metabolism ea khase e senyehileng. Ha ho hlahlojoa, ho hlokahala hore u hlahlobe mokuli hore na o na le mafu a tšoaetsanoang lipelong, ka mpeng ea nko, ho hlahloba lera le ka mpeng, kaha ha ho na ketoacidosis ka mefuta ena.
• Ketoacidotic coma. E amana le ho haella ha insulin ka lebaka la kalafo e khethiloeng ka nepo, e tlatsetsang khaellong ea phepelo ea tsoekere ho lisele le ho fokotseha ha ts'ebeliso ea eona. Matšoao a ntse a eketseha ka potlako, phello ea kalafo e monate: ho hlaphoheloa ho hlaha ho 85% ea linyeoe. Mokuli a ka ba le lenyora le matla, bohloko ba ka mpeng, mokuli a phefumoloha ka matla le monko oa acetone, pherekano e hlaha kelellong.
• Hyperosmolar e seng ketoacidotic coma. E tšoauoa ka bothata bo hlobaetsang ba metabolic bo nang le matla a tebileng a ho omella le exsicosis. Ha ho na pokello ea litopo tsa ketone, ho na le seoelo. Lebaka ke ho haella ha insulin le ho omella. Ts'ebetso ea nts'etsopele e ea lieha - hoo e ka bang libeke tse peli le matšoao a ntseng a eketseha butle butle.

E 'ngoe le e' ngoe ea mefuta e hokahantsoe ke sesosa se ka sehloohong - lefu la tsoekere. Hyperosmolar coma e hola kamora libeke tse peli ho isa ho tse tharo.

Matšoao a matšoao

Hyperosmolar coma e na le matšoao a latelang a akaretsang, a tlang pele ho tlolo ea kelello:

• lenyora le matla
• letlalo le omeletseng le membrane ea mucous,
• boima ba 'mele boa fokotseha
• bofokoli bo akaretsang le phokolo ea mali.

Khatello ea mali ea mokuli ea fokotseha, mocheso oa 'mele oa theoha,' me le tsona lia hlokomeloa:

Maemong a matla, ho bona lipono, ho ferekanya kelello, ho holofala le mathata a ho bua, hoa khoneha. Haeba tlhokomelo ea bongaka e sa fanoe, kotsi ea lefu e eketseha haholo.

Ha motho a e-na le lefu la tsoekere ho bana, ho lahleheloa ke boima ba 'mele haholo, takatso e eketsehileng ea lijo le ho bola hoa phello ea mathata le tsamaiso ea pelo. Ka nako e tšoanang, monko o tsoang molomong o tšoana le monko o monate.

Ts'oaetso

Maemong a mangata, mokuli ea nang le lefu la hyperosmolar non-ketoacidotic coma hang-hang o ea tlhokomelong e matla, moo sesosa sa boemo bona bo fumanehang ka potlako. Mokuli o fuoa tlhokomelo ea mantlha, empa ntle le ho hlakisa setšoantšo kaofela, ha e sebetse ka ho lekana mme o lumella feela ho tiisa boemo ba mokuli.

• Teko ea mali bakeng sa insulin le tsoekere, hammoho le acid e lactic,
• tlhatlhobo ea kantle ea mokuli ea etsoa, ​​ho hlahlojoa maikutlo ho a hlahlojoa.

Haeba mokuli a oela pele ho bokuli ba ho tseba, o fuoa tlhahlobo ea mali, tlhahlobo ea moroto bakeng sa tsoekere, insulin, bakeng sa boteng ba sodium.

Cardiogram e laetsoe, ho hlahlojoa ha pelo ka sefuba, ka ha lefu la tsoekere le ka baka stroke kapa ho otla ha pelo.

Ngaka e tlameha ho khetholla methapo ea methapo ea methapo le lefu la ho ruruha, hore a se ke a mpefatsa boemo ka ho fana ka diuretics. Ho qaptjoa ha tomoso ea hlooho e entsoeng.

Ha ts'oaetso e nepahetseng e thehiloe, mokuli o kena sepetlele mme kalafo e laetsoe.

Tlhokomelo ea maemo a tšohanyetso e na le liketso tse latelang:

• ambulense e bitsoa,
• Ho otla ha pelo le khatello ea mali li hlahlojoa pele ngaka e fihla,
• lisebelisoa tsa ho bua tsa mokuli li hlahlojoe, li-earlobes li lokela ho pikitloa, li hloibiloe marameng hore mokuli a se ke a akheha.
• haeba mokuli a le ho insulin, joale insulin e kenngoa ka tšohanyetso 'me ho fanoa ka seno se sengata ka metsi a brackish.

Kamora ho kena sepetlele ho mokuli le ho fumana mabaka, kalafo e nepahetseng e fanoa ho latela mofuta oa ho akheha.

Hyperosmolar coma e kenyelletsa liketso tse latelang tsa kalafo:

• Ho felisoa ha metsi le ho tsitsipana,
• Ho khutlisoa ha chelete ea electrolyte,
• Hyperosmolarity e felisoa,
• haeba lactic acidosis e bonoa, ho etsoa qeto le ho tloaela boemo ba acid ea lactic.

Mokuli o kenngoa sepetlele, mpa ea hlatsuoa, ho kenngoa cuseter ea moroto, ho phekoloa oksijene.

Ka mofuta ona oa komello, ho laetsoe 'mele o mongata ka bongata: e phahame haholo ho feta ho ketoacidotic coma, eo ho eona ho phetisetsoang mmele, hammoho le kalafo ea insulin.

Boloetse bona bo phekoloa ka ho khutlisetsa bophahamo ba mokelikeli 'meleng, bo ka bang le glucose le sodium. Leha ho le joalo, ntlheng ena, ho na le kotsi e kholo ea lefu.

Ka komello ea hyperglycemic, insulin e eketsehileng ea bonoa, ka hona ha e laetsoe, mme ho fanoa ka palo e kholo ea potasiamo. Ts'ebeliso ea alkalis le sopho ea ho baka ha e etsoe ka ketoacidosis kapa ka hyperosmolar coma.

Litlhahiso tsa kalafo kamora ho tlosa mokuli komeng le ho etsa hore mesebetsi e meng le e 'ngoe' meleng e etsoe ka tsela e latelang:

• nka lithethefatsi tse fanoeng ka nako,
• se ke oa feta tekanyetso e boletsoeng,
• laola tsoekere ea mali, ho etsa liteko hangata,
• laola khatello ea mali, sebelisa lithethefatsi tse tlatselletsang ho tloaelehileng.

Se ke oa sebetsa haholo, phomola haholoanyane, haholo-holo nakong ea bocha.

Mathata a ka bang teng

Mathata a atisang ho hlaha a hyperosmolar coma ke:

Pontšong ea pele ea matšoao a kliniki, mokuli o hloka ho fana ka tlhokomelo ea bongaka, tlhahlobo le ho fana ka kalafo.

Coma ho bana e tloaelehile haholo ho feta ho batho ba baholo mme e tsebahala ka liphatlalatso tse mpe haholo. Ka hona, batsoali ba hloka ho hlokomela bophelo bo botle ba lesea, 'me matšoao a pele a batle thuso ea bongaka.

Lisosa tsa hyperosmolar coma

Hyperosmolar coma e ka hlaha ka lebaka la:

• ho omella haholo (ka ho hlatsa, lets'ollo, ho chesa, kalafo ea nako e telele ka diuretics),
• ho haella kapa ho se be teng ha insulin kapa "kapa" insulin "(mohlala, ka lebaka la kalafo e sa lekaneng ea insulin kapa ho ba sieo ha eona),
• tlhokahalo e eketsehileng ea insulin (ka tlheketso e kholo ea lijo kapa ho hlahisoa ha tharollo ea tsoekere e akaretsang, hammoho le mafu a tšoaetsanoang, haholo-holo pneumonia le ts'oaetso ea pampitšana ea urinary, mafu a mang a tebileng, likotsi le lingaka, kalafo ea lithethefatsi ka thepa ea bahanyetsi ba insulin, glucocorticosteroids, litokisetso tsa li-hormone tsa thobalano, jj.).

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Pathogenesis ea hyperosmolar coma ha e utloisisoe ka botlalo. Hyperglycemia e kholo e hlaha ka lebaka la ho kenella ha tsoekere e ngata 'meleng. Ho hlahisa tsoekere ea glucose ke sebete, chefo ea tsoekere, khatello ea "insulin secretion" le ts'ebeliso ea tsoekere ea glucose ka litho tsa mmele. Ho ne ho lumeloa hore boteng ba insulin ea endo native e kena-kenana le lipolysis le ketogenesis, empa ha ho a lekana ho hatella sebopeho sa tsoekere ke sebete.

Kahoo, gluconeogenesis le glycogenolysis li lebisa ho hyperglycemia e matla. Leha ho le joalo, khatello ea "insulin" maling le lefu la tsoekere la ketoacidosis le hyperosmolar coma le eona e batla e tšoana.

Ho latela khopolo e 'ngoe, ka hyperosmolar coma, litekanyetso tsa "hormone ea somatotropic" le "cortisol" li tlase haholo ho feta ka lefu la tsoekere la ketoacidosis, ho ekelletsa moo, ka hyperosmolar coma, tekanyo ea "insulin" ea glucagon e phahame ho feta ka lefu la tsoekere. Plasma hyperosmolarity e lebisa ho khatello ea tokollo ea FFA ho tsoa lisele tsa adipose le inhibits lipolysis le ketogeneis.

Mochine oa hyperosmolarity ea plasma o kenyelletsa tlhahiso e eketsehileng ea aldosterone le cortisol ho arabela ho qoelisoa ke hypovolemia, ka lebaka leo hypernatremia e tsoelang pele. Hyperglycemia e phahameng le hypernatremia e lebisa ho plasma hyperosmolarity, eo le eona e lebisang ho khaello ea metsi a tsoang ka hare ho mali. Ka nako e ts'oanang, lihlahisoa tsa sodium le tsona lia phahama ka har'a mokelikeli oa "cerebrospinal". Ho senyeha ha metsi le ho leka-lekana ha electrolyte liseleng tsa boko ho lebisa ho holiseng matšoao a methapo, mokokotlo oa mokokotlo le mokoka.

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Matšoao a coma ea hyperosmolar

Hyperosmolar coma e mela matsatsing a 'maloa kapa libeke.

Mokuli o ba le matšoao a lefu la tsoekere le fetotsoeng, ho kenyeletsa:

• polyuria
• lenyora
• letlalo le omeletseng le membrane ea mucous,
• ho theola boima ba 'mele
• bofokoli, adynamia.

Ntle le moo, ho na le matšoao a ho felloa ke metsi 'meleng,

• ho fokotsa letlalo,
• tonus e fokotsehileng ea liso tsa mahlo,
• ho fokotseha ha khatello ea mali le mocheso oa 'mele.

Matšoao a methapo ea kutlo ke tšobotsi:

• hemiparesis,
• hyperreflexia kapa areflexia,
• ho akheha
• ho tsitsipana (ho 5% ea bakuli).

Boemong bo matla, bo sa hlophiswang ba hyperosmolar, stupor le coma lia ntšoa. Mathata a tloaelehileng haholo a komello ea hyperosmolar a kenyelletsa:

• lefu la sethoathoa
• vein thrombosis,
• pancreatitis
• ho hloleha ha rems.

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Tlhahlobo e fapaneng

Hyperosmolar coma e khetholloa le lisosa tse ling tsa ho hloka kelello.

Ka lebaka la botsofe ba bakuli, hangata tlhahlobo e khethollang e etsoa ka tlolo ea ho potoloha ha litho tsa khoele le hematoma e ka tlasana.

Mosebetsi oa bohlokoahali ke ho khetholla ho hlaka ha hyperosmolar coma ka lefu la tsoekere le ketoacidotic mme haholoholo hypoglycemic coma.

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Kalafo ea hyperosmolar coma

Bakuli ba nang le hypa ea hyperosmolar coma ba tlameha ho sepetlele ka setsing sa tlhokomelo e matla ea tlhokomelo. Kamora hore ho fumanoe hore na lefu ke mang mme kalafo e qalile, bakuli ba hloka ho lekola boemo ba bona ka linako tsohle, ho kenyelletsa le ho hlahloba likarolo tse kholo tsa hemodynamic, mocheso oa 'mele le li-paramente tsa laboratori.

Haeba ho hlokahala, bakuli ba kenella ka hare ho mochine, ho hlatsoa lesapo la mokokotlo, ho kenngoa khubung ea venous catheter le phepo e ntle ea botsoali. Setsing sa tlhokomelo e matla / tlhokomelo e matla e etsa:

• Tlhatlhobo e potlakileng ea tsoekere ea mali nako e le 'ngoe ka hora e nang le tsoekere e kenang kapa 1 nako ea lihora tse 3 ha e fetoha ho tsamaiso ea subcutaneous,
• boikemisetso ba 'mele ea ketone ho serum maling maling makhetlo a 2 ka letsatsi (haeba ho sa khonehe - boikemisetso ba' mele ea ketone mochine oa 2 r / ka letsatsi,
• boikemisetso ba boemo ba K, Na maling maling makhetlo a 3-4 ka letsatsi,
• ho ithuta ka acid-base state makhetlo a 2-3 ka letsatsi ho fihlela phetiso e phehellang ea pH,
• taolo ea hora ea ho ntša moroto ho fihlela metsi a felisoa,
• Tlhahlobo ea ECG
• taolo ea khatello ea mali, lebelo la pelo, mocheso oa 'mele lihora tse ling le tse ling tse peli,
• radiography ea matšoafo
• Tlhahlobo e akaretsang ea mali, moroto nako e le 1 ka matsatsi a 2-3.

Joalo ka lefu la tsoekere la ketoacidosis, litsela tsa mantlha tsa kalafo ho bakuli ba nang le hyperosmolar coma ke ho khutlisetsa metsi 'meleng, kalafo ea insulin (ho fokotsa glycemia le hyperosmolarity), tokiso ea likhathatso tsa electrolyte le mathata a acid-base).

Motsoalle o mong hape

Sodium chloride, tharollo ea 0,45 kapa 0,9%, e hula kahare ho 1-1.5 L nakong ea 1 ea ts'ebetso, 0.5-1 L nakong ea 2 le ea 3, 300-500 ml ho lihora tse latelang. Khatello ea tharollo ea sodium chloride e khethoa ke boemo ba sodium maling. Boemong ba Na + 145-165 meq / l, tharollo ea sodium chloride ka bongata ba 0.45% e fanoa, ka tekanyo ea Na + +> 165 meq / l, ho hlahisoa ha tharollo ea letsoai ho hanyetsoa, ​​ho bakuli ba joalo ho sebelisoa tharollo ea glucose bakeng sa phepelo ea mmele.

Dextrose, tharollo ea 5%, o hohola kahare ho 1-1.5 L ka nako ea 1 ea ts'ebetso, 0.5-1 L nakong ea 2 le 3, 300-500 ml - ka lihora tse latelang. Osmolality ea litharollo tsa infusion:

• 0,9% ea sodium chloride - 308 mosm / kg,
• 0,45% ea sodium chloride - 154 mosm / kg,
• 5% dextrose - 250 mosm / kg.

Ho ikoetlisa ka ho lekaneng mmele ho thusa ho fokotsa hypoglycemia.

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Phekolo ea insulin

Lithethefatsi tse nkang nakoana li sebelisoa:

Soluble insulin (liphatsa tsa motho tsa lefutso kapa tsa maiketsetso) kahare ho tharollo ea sodium chloride / dextrose ka tekanyo ea 00.5-0.1 U / kg / h (ha boemo ba glucose maling bo lokela ho fokotseha ka se feteng 10 mosm / kg / h).

Tabeng ea motsoako oa ketoacidosis le hyperosmolar syndrome, kalafo e etsoa ho latela melao-motheo e akaretsang ea kalafo ea lefu la tsoekere ketoacidosis.

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Teko ea katleho ea kalafo

Matšoao a kalafo e sebetsang bakeng sa komello ea hyperosmolar a kenyelletsa ho khutlisa kelello, ho felisoa ha lipontšo tsa hyperglycemia, ho fihlella ha maemo a tsoekere ea mali le sepheo se tloaelehileng sa plasma, ho nyamela ha acidosis le mathata a electrolyte.

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Liphoso le likhetho tse sa utloahaleng

Ho futhumala ka potlako le ho fokotseha ho matla ha tsoekere ea mali ho ka lebisa ho fokotseha ho potlakileng ha osmolarity ea plasma le nts'etsopele ea edema ea "cerebral" (haholo-holo ho bana).

Ka lebaka la botsofe ba bakuli le ho ba teng hoa maloetse a tšoanang, leha ho ts'oaroa ka mokhoa o lekaneng hangata ho ka lebisa ho bola hoa ho nyekeloa ke pelo le edema ea pulmonary.

Ho fokotseha ka sekhahla ha tsoekere ea mali ho ka etsa hore mokelikeli oa kantle ho lisele o felle ka hare ho lisele mme o mpefatsa hypotension ea arterial le oliguria.

Tšebeliso ea potasiamo esita le hypokalemia e itekanetseng ho batho ba nang le oligo- kapa anuria e ka lebisa ho hyperkalemia e sokelang bophelo.

Ho khethoa ha phosphate ka ho se sebetse hantle ha motho a emetse ho phekoloa.

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Matšoao a Neurological

Ntle le moo, matšoao a ka boela a bonoa ho tsoa ho tsamaiso ea methapo:

• hallucinations
• hemiparesis (e nyenyefatsa metsamao ea boithatelo),
• bothata ba puo, bo entsoe hore bo thelle,
• ho tsitsisa ho phehella
• Areflexia (ho haella ha likhanyetsano, e le 'ngoe kapa ho feta) kapa hyperlefxia (Reflexes e eketsehang),
• khatello ea mesifa
• ho akheha.

Matšoao a hlaha matsatsi a 'maloa pele komello ea hyperosmolar e hlaha ho bana kapa ho bakuli ba baholo.

Thibelo ea mathata

Ts'ebetso ea pelo le pelo e boetse e hloka ho thibeloa, e leng, thibelo ea ho se sebetse ha pelo le pelo. Bakeng sa morero ona, "Cordiamin", "Strofantin", "Korglikon" li sebelisoa. Ka khatello e fokotsehileng, e maemong a sa khaotseng, ho khothalletsoa ho fana ka tharollo ea DOXA, hammoho le tsamaiso e kenelletseng ea plasma, hemodeis, albin ea motho le mali a felletseng.