Ketoacidosis na ketoacidotic coma > Ọgwụgwọ na mgbochi

NKWUP ,TA, EKPERE NA PATHOGENESIS

Oké oriri na-adịghịzi mkpa nke carbohydrate, abụba, metabolism metabolism, yana mmiri-electrolyte balanta na acid-base balance, yana hyperglycemia, hyperketonemia, ketonuria na metabolic acidosis na-esite na insulin mberede na nnukwu ụkọ. Otu ihe e ji mara ya bụ ọnụnọ nke anụ ahụ ketone n'ime ọbara yana mmamịrị. Ọ nwere ike ime n'oge ụdị ọrịa shuga ọ bụla, ugboro ugboro ọ bụ ngosipụta mbụ nke ụdị shuga 1. N'ihi ụkọ insulin, enwere oke glucose na imeju n'ihi gluconeogenesis, yana ịba ụba lipolysis na usoro nke ketone ahụ. Nsonaazụ nke a bụ: hyperglycemia, mfu nke glucose na mmamịrị, osmotic diuresis, akpọnwụ akpọnwụ, ọgba aghara electrolyte (karịsịa hyperkalemia na ụkọ protein intracellular intracellular) na metabolic acidosis. Ihe ndị na - akpalite: kwụsịlata ọgwụgwọ insulin (dịka n'ihi ọrịa nke eriri afọ, onye ọrịa na - egbochi iri nri) ma ọ bụ insulin, n'ụzọ na - ekwesịghị ekwesị (nje, nje, fungal), ọrịa obi na-arịa nnukwu ọrịa (myocardial infarction, stroke), na-egbu oge nchọpụta shuga. ụdị 1 ọrịa shuga, ọrịa shuga, ị alcoholụbiga mmanya ókè, ịtụrụ ime, ọnọdụ niile na-akpata mmụba mberede na insulin chọrọ. n’elu ugwu

1. Akara ngosiputa okwu: akpịrị ịkpọ nkụ, akpịrị ịkpọ nkụ, polyuria, adịghị ike, ike ọgwụgwụ na ụra, isi ọwụwa ruo coma, akpịrị na isi ọwụwa, ọgbụgbọ na ọgbụgbọ, ọgbụgbọ, mgbu afọ. n’elu ugwu

2. Ihe mgbaàmà ebumnuche: hypotension, tachycardia, accelerated and miri, mgbe ahụ ume iku ume, ihe mgbaàmà nke akpịrị ịkpọ nkụ (mbelata anụ ahụ, mbelata ajị anụ ahụ), ọnya nke acetone site n’ọnụ, ọbara ọbara nke ihu, mgbada ihu bọọlụ, mụbara mgbatị nke mgbidi afọ. (dị ka peritonitis)

Emere nchọpụta a dabere na nsonaazụ nyocha ụlọ nyocha tebụl. 13.3-1. N'ime ndị ọrịa mesiri SGLT-2 inhibitor, glycemia nwere ike belata.

Ọrịa mamịrị Ketoacidotic Coma (DKA)

DKA bụ nsogbu siri ike nke ọrịa shuga mellitus, nke metabolos acidosis gosipụtara (pH na-erughị 7.35 ma ọ bụ itinye bicarbonate erughị 15 mmol / L), mmụba nke anionic, hyperglycemia karịa 14 mmol / L, ketonemia. Ọ na-amalitekarị ụdị ọrịa shuga 1. DKA na-ekwupụta afọ 5 ruo 20 n'ime ndị ọrịa 1000 kwa afọ (2/100). Ọnwụ dị na nke a bụ 5-15%, maka ndị ọrịa karịrị afọ 60 - 20%. Ihe karịrị 16% nke ndị ọrịa nwere ụdị shuga 1 na-anwụ site na ketoacidotic coma. Ihe kpatara mmepe DKA bụ erughi insulin zuru oke ma ọ bụ n'ihi insulin na-ezughị ezu ma ọ bụ nwee nnukwu insulin.

Ihe ndị na-enye aka: insulin ezughi oke ma ọ bụ na-egbochi isi iyi insulin (ma ọ bụ were mbadamba ọgwụ hypoglycemic), iwepu ọgwụ hypoglycemic na-enweghị ikike, mmebi nke usoro nchịkwa insulin, mgbakwunye nke ọrịa ndị ọzọ (ọrịa, trauma, ịwa ahụ, ịtụrụ ime, infarction myocardial, ọrịa strok, nrụgide, wdg) , nsogbu nri (ọtụtụ carbohydrates), imega ahụ na oke glycemia, ị alcoholụbiga mmanya ókè, oke njide onwe onye nke metabolism, na-ewere ụfọdụ ọgwụ nnyh ọgwụ (corticosteroids, calcitonin, saluretics, acetazolamide, β-blockers, diltiazem, isoniazid, phenytoin et al.).

Ọtụtụ mgbe, etiology nke DKA ka amabeghị. Ekwesịrị icheta na n'ihe dị ka 25% nke ikpe, DKA na-eme na ndị ọrịa nwere ọrịa mellitus ọhụrụ chọpụtara ọrịa ọhụrụ.

E nwere ụzọ atọ nke ketoacidosis ọrịa mamịrị: ketoacidosis dị ala, precoma, ma ọ bụ ketoacidosis, kooma.

Nsogbu nke ketoacidotic coma gụnyere nnukwu akwara nke ụkwara ume ọkụ, ụkwara ume ọkụ, akwara umeji, ọria ụbụrụ, ọria ụbụrụ, ọnya afọ, ọnya afọ, oria, adịkarịghị GLC na ischemic colitis, mbufụt ọgbụgba, ọrịa obi. Okuku ume iku ume, oliguria na ọdịda akwara mara. Ihe ndi mmadu na achoputara aru aru bu oria na obara, hypoglycemia, hypokalemia, hyponatremia, hypophosphatemia.

Usoro nyocha maka DKA

Otu njiri mara nke DKA bụ mmepe nwayọ nwayọ, ọ na-abụkarị ọtụtụ ụbọchị.
Ihe mgbaàmà nke ketoacidosis (isi nke acetone na ume iku ume, Kussmaul iku ume, ọgbụgbọ, vomiting, anorexia, mgbu afọ).
Ọnụnọ nke ihe mgbaàmà nke akpịrị ịkpọ nkụ (mbelata anụ ahụ, ụda anya, ụda olu, mgbanwe ahụ, ụda ahụ na ọbara mgbali).

Mgbe ị na-achọpụta DKA n'oge prehospital, ọ dị mkpa ịchọpụta ma onye ọrịa ahụ na - arịa ọrịa shuga mellitus, ma enwere akụkọ banyere DKA, ma onye ọrịa ahụ na - anata ọgwụgwọ hypoglycemic, ọ bụrụ na ọ bụ, gịnị bụ oge ikpeazụ ị theụrụ ọgwụ ahụ, oge nri ikpeazụ gara aga, ma ọ bụ imega ahụ dị oke egwu. ị alcoholụ mmanya na-egbu egbu, nke ọrịa ndị na-adịbeghị anya buterema, bụ polyuria, polydipsia na adịghị ike.

Usoro ọgwụgwọ nke DKA na prehospital ogbo (lee okpokoro 1) chọrọ nlebara anya pụrụ iche iji zere njehie.

Enwere ike inwe njehie na ọgwụgwọ na nchoputa na prehospital ogbo

Ọgwụ insulin ọgwụ ọgwụ n'ụlọ ọgwụ na-enweghị glycemic njikwa.
Isi mesiri ya ike na ọgwụgwọ bụ ọgwụgwọ ọgwụ insulin kpụ ọkụ n'ọnụ na-enweghị mmiri ọkụ dị mma.
Nri mmiri na ezughi oke.
Ntinye nke usoro ọgwụgwọ hypotonic, karịsịa na mmalite ọgwụgwọ.
Iji mmanu diuresis mee ihe kama inye mmiri mmiri. Ojiji nke mmịkọ na ntinye nke mmiri ga - akwụsịlata nhazigharị nke mmiri, yana hyperosmolar coma, nhọpụta nke ịba ọcha n'anya.
Therapymalite iji ọgwụgwọ sodium bicarbonate nwere ike igbu egbu. Ekwuputara na ọgwụgwọ insulin zuru oke n'ọtụtụ ọnọdụ na-enyere aka wepu acidosis. Ejikọtara acidosis na sodium bicarbonate nwere nnukwu ihe egwu nke nsogbu. Ntinye nke alkalis na-eme ka hypokalemia dịkwuo mma, na-akpaghasị nkewapu nke oxygenhemoglobin, carbon dioxide guzobere n'oge nchịkwa nke sodium bicarbonate, na-eme ka acidosis intracellular (ọ bụ ezie na ọbara pH nwere ike ịbawanye na nke a), a na-ahụkwa acidosis paradoxical na mmiri cerebrospinal, nke nwere ike itinye aka na ọrịa ụbụrụ " nwetaghachi alkalosis. Nlekọta ngwa ngwa nke sodium bicarbonate (jet) nwere ike ibute ọnwụ n'ihi mmepe nke hypokalemia dị mkpụmkpụ.
Iwebata ihe ngwọta nke sodium bicarbonate na-enweghị ịkọwa potassium ọzọ.
Dradọrọ ma ọ bụ nchịkwa insulin na ndị ọrịa nwere DKA na onye ọrịa na-enweghị ike iri nri.
Nlekọta jet nke intulin. Naanị nkeji izizi nke 15-20, a na-eleba anya n'ihe banyere ọbara n'ọkwa zuru oke, yabụ ụzọ a isi nchịkwa adịghị arụ ọrụ.
Ugboro atọ ruo ugboro nke nchịkwa insulin na-adị mkpụmkpụ (ICD) subcutaneously. ICD dị irè maka awa 4-5, karịsịa na ọnọdụ ketoacidosis, yabụ, ekwesịrị ịkọ ya opekata mpe ise ruo isii kwa ụbọchị n’enweghi mgbede.
Ojiji nke ọgwụ ọmịiko iji luso mbibi ahụ ọgụ, nke, nke mbụ, bụ homonụ contrainsulin, na nke abụọ, na ndị ọrịa mamịrị, mmetụta ha na-akpali akpali na nzuzo glucagon siri ike karịa na ndị mmadụ nwere ahụ ike.
Nchọpụta ezighi ezi nke DKA. Na DKA, a na-ahụkarị ihe a na-akpọ "onye ọrịa mamịrị pseudoperitonitis, nke na-egosipụta mgbaàmà nke" afọ na - adịghị ala ala "- esemokwu na ọnya nke mgbidi dị n'ime ime, mbelata ma ọ bụ mwepu nke mkpesa na - emetụta ụfụ, mgbe ụfọdụ mmụba nke serum amylase. Nchọpụta oge nke leukocytosis nwere ike ibute njehie na nchoputa, n'ihi nke onye ọrịa na-abanye na ngalaba na-efe efe ("ọrịa eriri afọ") ma ọ bụ ogwugwo ("nnukwu afọ") ngalaba. N'okwu niile nke "afọ ime" ma ọ bụ mgbaàmà dyspeptik na onye ọrịa nwere ọrịa mellitus, mkpebi siri ike nke glycemia na ketotonuria dị mkpa.
Menttụnye ihe ọria na - arịa ọrịa glycemia maka onye ọrịa ọ bụla nọ n'ọnọdụ amaghị ihe ọ bụla, nke na - abụkarị usoro nyocha nke njehie - "ihe mberede ụbụrụ", "coma nke etiology na - edoghị anya", ebe onye ọrịa ahụ nwere nnukwu metabolic metabolic de metabolic.

Hyperosmolar na-abụghị ketoacidotic coma

A na - amata hyperosmolar na-abụghị ketoacidotic coma site na akpịrị ịkpọ nkụ, nnukwu hyperglycemia (nke dịkarịsịrị elu 33 mmol / L), hyperosmolarity (karịa 340 mOsm / L), hypernatremia karịa 150 mmol / L, na enweghị ketoacidosis (ketonuria kacha (+ kachasị)). Ọ na - etolite n'ime ndị ọrịa agadi nwere ọrịa shuga 2. Ọ dịkarịa ala ugboro iri karịa na DKA. Ejiri ọnụọgụ ọnwụ dị elu (15-60%). Ihe mere maka mmepe nke hyperosmolar coma bụ ụkọ insulin na ihe ndị na-akpata ọria mmiri.

Ihe ndị na-enye aka: insulin ọgwụ ezughi ezu ma ọ bụ na-ahapụ isi iyi insulin (ma ọ bụ were mbadamba ọgwụ hypoglycemic), iwepu ọgwụ hypoglycemic na-enweghị ikike, imebi usoro nke nchịkwa insulin, mgbakwunye nke ọrịa ndị ọzọ (ọrịa, nnukwu pancreatitis, trauma, ịwa ahụ, ime ime, infarction myocardial, ọrịa strok, nrụgide na wdg), nsogbu nri (ọtụtụ carbohydrates), ị certainụ ụfọdụ ọgwụ (diuretics, corticosteroids, beta-blockers, wdg), jụrụ oyi, enweghị ike ịkwụsị ịkpọ nkụ. ọkụ, vomiting ma ọ bụ afọ ọsịsa, hemodialysis ma ọ bụ mgbawa peritoneal.

Ekwesiri icheta na otu ụzọ n’ụzọ atọ nke ndị ọrịa nwere hyperosmolar coma enweghị nchọpụta gara aga banyere ọrịa shuga.

Foto nyocha

Akpịrị ịkpọ nkụ siri ike, polyuria, akpịrị ịkpọ nkụ, akwara hypotension, tachycardia, ihe ọdịdọ ma ọ bụ ihe ọdịdọ na-etolite ọtụtụ ụbọchị ma ọ bụ izu. Ọ bụrụ na enwere DKA, nsogbu nke sistemụ akwara etiti yana sistemụ akwara na - aga n'ihu dị ka usoro nwayọ nke nwayọ na mgbochi mkpịsị akwara, mgbe ahụ hyperosmolar coma na - eso nsogbu dịgasị iche iche nke uche na akwara ozi. Na mgbakwunye na steeti soporotic, nke a na-ejikwa hyperosmolar coma na-ahụkarị, nsogbu nke uche na-aga n'ihu dị ka ọrịa delirium, akwara hallucinatory psychosis, na ọrịa catotonic. A na-egosipụta nkwarụ akwara ozi site na mgbaàmà isi akwara ozi (aphasia, hemiparesis, tetraparesis, polysorphic sensory disturbances, mgbanwe akwara pathologies, wdg).

Hypoglycemic coma

Hypoglycemic coma na-etolite n'ihi mbelata ọbara glucose dị ala (n'okpuru 3-3.5 mmol / l) na mbelata ụbụrụ ike.

Ihe ndị na-enye obi ụtọ: ị insụ ọgwụ insulin na TSS, ịppingụfe mmiri ma ọ bụ erughị nri, ịba ụba nke ahụ, ị ,ụ oké mmanya, ị medicationsụ ọgwụ (β-blockers, salicylates, sulfonamides, wdg)

Enwere ike ịchọpụta ọrịa na njehie ọgwụgwọ

Mgbalị iwepụta ngwaahịa nwere carbohydrate (shuga, wdg) n'ime ọnụ nke onye ọrịa amaghị ihe ọ bụla. Nke a na - edugakarị na nnabata.
Ngwa maka ịkwụsị hypoglycemia nke ngwaahịa adịghị mma maka nke a (achịcha, chọkọleji, wdg). Ngwaahịa ndị a enweghị mmetụta na-abawanye ike ma ọ bụ nwekwuo ọ̀tụ̀tụ̀ shuga dị n'ọbara, mana kwa nwayọ.
Nnyocha na-ezighi ezi nke hypoglycemia. Enwere ike icheta ụfọdụ ọrịa hypoglycemia dị ka ọrịa ọdịdọ, ọrịa strok, "nsogbu nke ahịhịa", wdg N'ime onye ọrịa na-anata usoro ọgwụgwọ hypoglycemic, ya na enyo ezi uche nke hypoglycemia, a ga-akwụsị ya ozugbo, ọbụna tupu ịnweta nzaghachi ụlọ nyocha.
Mgbe o wepụsịrị onye ọrịa na ọnọdụ nwere nnukwu hypoglycemia, a dịghị elekarị ihe ndọghachi azụ anya.

N'ime ndị ọrịa nọ n'ọgba amabughị mmalite, ọ dị mkpa mgbe niile iche ọnụnọ nke glycemia. Ọ bụrụ na a pụrụ ịdabere na onye ọrịa ahụ nwere ọrịa mellitus ma n'otu oge ọ siri ike ịkọwapụta usoro hypo- ma ọ bụ hyperglycemic genma nke coma, nchịkwa glucose dị n'ime 20-25 - 60 ml nke 40% ga-atụ aro maka nchọpụta ọdịiche na nlekọta mberede maka hypoglycemic. Coma. N'ihe banyere hypoglycemia, nke a na-ebelata oke nrịba ama nke mgbaàmà, ma, yabụ, ọ ga-enye ohere ịkewapụta ọnọdụ abụọ a. Conwe ume hyperglycemic, ịba ụba glucose dị otú ahụ agaghị emetụta ọria ọnọdụ onye ọrịa.

N'okwu niile ebe enwere ike ịgụta glucose ozugbo, ekwesịrị ịgwọ glucose dị ukwuu. Ọ bụrụ na akwụsịghị hypoglycemia n'oge ihe mberede, ọ nwere ike ịnwụ.

A na - ahụta Thiamine 100 mg iv, glucose 40% 60 ml na naloxone 0.4-2 mg iv bụ ọgwụ ndị bụ isi maka ndị ọrịa na nkụ, na enweghị ohere ịkọwapụta nchoputa na ụlọ ọgwụ ngwa ngwa. Ekwenyewo na ịdị irè na nchekwa nke nchikota a ugboro ugboro na omume.

M. Torshkhoeva, nwa akwukwo nke Sciences Ahụike
A. L. Vertkin, Dọkịta nke Sciences Medical, Prọfesọ
V.V. Gorodetsky, nwa akwukwo nke sayensị ọgwụ, prọfesọ na-esote
NNGO ambulance, MSMSU