Hyperosmolar coma: sanadin, bayyanar cututtuka, ganewar asali, magani

• Hallucinations
• Rarrashi
• Rashin Ingancin magana
• Rashin hankali
• Ciki
• Appara yawan ci
• Temperaturearancin zafin jiki
• Pressurearancin saukar karfin jini
• Jin ƙishirwa
• Rashin ƙarfi
• Rage nauyi
• Cramps
• Fata bushe
• Dry mucous membranes
• Wani bangare na raɗaɗi

Hyperosmolar coma matsala ce ta sankarar mahaifa, wanda yanayin halayyar jini, ke haifar da shi. An bayyana shi cikin bushewa (bushewa) da kuma rashin ketoacidosis. Ana lura da shi a cikin marasa lafiya waɗanda suka girmi shekaru 50 waɗanda suke da nau'in insulin-dogara da ciwon sukari mellitus, za a iya haɗe su tare da kiba. Mafi yawanci yakan faru ne a cikin mutane saboda rashin kulawa da cutar ko rashinsa.

Hoto na asibiti zai iya haɓaka kwanaki da yawa har sai an sami cikakken asarar rai da rashin mayar da martani ga ƙwarin gwiwa na waje.

Ana gano shi ta hanyar dakin gwaje-gwaje da hanyoyin binciken kayan aiki. Maganin an yi shi ne don rage yawan sukarin jini, dawo da ma'aunin ruwa da cire mutum daga kwaro. Tsinkayen ba shi da kyau: a cikin 50% na lokuta mummunan sakamako na faruwa.

Hyperosmolar coma a cikin ciwon sukari mellitus wani abu ne wanda yake sabawa na al'ada kuma ana lura da shi a cikin 70-80% na marasa lafiya. Hyperosmolarity wani yanayi ne da ke da alaƙa da wani babban abun ciki na abubuwa kamar su glucose da kuma sodium a cikin jinin mutum, wanda hakan ke haifar da ƙonewar kwakwalwa, bayan haka dukkan jiki ke bushewa.

Cutar na faruwa ne sakamakon kasancewar kamuwa da cutar siga a cikin mutum ko kuma sakamakon cin zarafin ƙwayoyin halittar carbohydrate ne, kuma wannan yana haifar da raguwar insulin da haɓaka taro a cikin glucose tare da jikin ketone.

Jinin jinin mai haƙuri ya tashi saboda dalilai masu zuwa:

• fitar da ruwa a jiki bayan tsananin amai, gudawa, karamin adadin ruwan da ake sha, zagi da diuretics,
• increasedara yawan glucose na hanta wanda ya lalace ta hanyar lalata ko magani mara kyau,
• Rage yawan glucose mai yawa bayan gudanar da hanyoyin kwantar da hankali.

Bayan wannan, aikin kodan ya lalace, wanda ke shafar cirewar glucose a cikin fitsari, kuma yawanta mai guba ne ga jiki baki ɗaya. Wannan kuma yana hana samar da insulin da amfani da sukari ta hanyar wasu kyallen takarda. Sakamakon haka, yanayin mai haƙuri ya tsananta, zubar jini ya ragu, ana lura da ƙonewar ƙwaƙwalwar ƙwaƙwalwa, damuwa yana da damuwa, zubar jini yana yiwuwa, rikicewa a cikin tsarin tallafi na rayuwa kuma mutum ya faɗi cikin rashin lafiya.

Cutar sankararwar mahaifa Hyperosmolar wani yanayi ne na faduwar jiki tare da nakasa aiki na dukkan tsarin jikin mutum, lokacin da farfadowa ya ragu, aikin zuciya yana faduwa, kuma yanayin zafi yana raguwa. A wannan yanayin, akwai babban haɗarin mutuwa.

Tsara

Hyperosmolar coma yana da ire-irensu:

• Maganin rashin lafiya. An lura dashi tare da karuwa a cikin sukari na jini, wanda ke haifar da maye da ƙwaƙwalwar ƙwayar cuta, na iya kasancewa tare da karuwa a cikin taro na lactic acid.
• Hypeglycemic hyperosmolar coma wata cakuda cuta ce irin ta cuta yayin da ƙwaƙwalwar ƙwayar cuta ke faruwa saboda yawan sukari da ƙwaƙwalwar ƙwayar ƙwayar osmotic mai ƙoshin ƙarfe. Lokacin da za a bincika, ya zama dole a bincika mai haƙuri don kasancewar cututtukan kamuwa da cuta a cikin kodan, a cikin ƙusoshin hanci, don bincika rami na ciki da jijiyoyin jiki, tunda babu ketoacidosis a cikin wannan nau'in.
• Cutar Ketoacidotic. Yana da alaƙa da rashin insulin saboda ƙarancin zaɓaɓɓen magani, wanda ke ba da gudummawa ga rushewar samar da glucose a cikin sel da kuma rage yawan amfani da shi. Bayyanar cututtuka na haɓaka cikin hanzari, hangen nesa na lada yana da kyau: murmurewa yana faruwa a cikin kashi 85% na lokuta. Mai haƙuri na iya fuskantar ƙishirwa mai zafi, zafin ciki, mara lafiya yana da ishara mai zurfi tare da ƙanshin acetone, rikicewa ya bayyana a cikin tunani.
• Hyperosmolar non-ketoacidotic coma. An kwatanta shi da mummunar cuta na rayuwa tare da kazantar fitsari da exsicosis. Babu tarin ketone jikin, yana da wuya. Dalilin shine karancin insulin da bushewar ruwa. Tsarin ci gaba yayi jinkiri - kimanin makonni biyu tare da alamun raunin hankali a hankali.

Kowane ɗayan nau'ikan yana da alaƙa da babban dalilin - ciwon sukari. Hyperosmolar coma na tasowa a tsakanin makonni biyu zuwa uku.

Symptomatology

Hyperosmolar coma yana da alamomin gaba ɗaya masu zuwa, waɗanda ke gab da keta faɗakarwa:

• matsananciyar ƙishirwa
• bushe fata da mucous membranes,
• nauyin jiki yana raguwa
• janar gaba daya da rashin karfin jiki.

Mara lafiyar jini na mara haƙuri yana raguwa, zazzabin jiki ya ragu, kuma ana lura dashi:

A cikin mawuyacin yanayi, hallucinations, disorientation, paralysis, rashin iya magana yana yiwuwa. Idan ba a ba da kulawa ta asibiti ba, to kuwa barazanar mutuwa tana ƙaruwa sosai.

Tare da ciwon sukari a cikin yara, akwai raunin nauyi mai yawa, ƙarancin ci, da lalata yana haifar da matsaloli tare da tsarin zuciya. A lokaci guda, ƙanshin daga bakin yana kama da ƙanshin 'ya'yan itace.

Binciko

A mafi yawan lokuta, mai haƙuri tare da ganewar asali na hyperosmolar non-ketoacidotic coma nan da nan ya tafi cikin kulawa mai zurfi, inda aka gano dalilin wannan yanayin cikin gaggawa. An bawa mai haƙuri kulawa ta farko, amma ba tare da fayyace yanayin gaba ɗaya ba, ba shi da isasshen amfani kuma yana bada damar kawai don daidaita yanayin mai haƙuri.

• gwajin jini don insulin da sukari, da na lactic acid,
• bincike na waje na mai haƙuri yana gudana, ana tantance halayen.

Idan mara lafiya ya fadi kafin farkon tashin hankalin, zai wajabta masa gwajin jini, gwajin fitsari don sukari, insulin, don gaban sodium.

An wajabta wani cardiogram, na'urar duban dan tayi na zuciya, kamar yadda ciwon sukari na iya haifar da bugun zuciya ko bugun zuciya.

Dole ne likita ya banbanta hanyoyin daga cututtukan hanji, don kar a ƙara dagula lamura ta hanyar sanya diuretics. Ana lissafin tomography na kai ana yi.

Lokacin da aka tabbatar da ingantaccen ganewar asali, an kwantar da maraice a asibiti kuma an wajabta magani.

Kulawar gaggawa ta ƙunshi waɗannan ayyukan:

• an kira motar asibiti,
• ana duba bugun jini da hawan jini kafin likita ya isa,
• An duba kayan magana na mara lafiya, an kamata a shafa 'yan kunne, a manne a kan kunci domin kada mara lafiyar ya yi asarar hankali,
• idan mai haƙuri yana kan insulin, to insulin allurar ciki kuma ana bayar da abin sha mai yawa tare da ruwan sha.

Bayan asibiti na mara lafiya da gano dalilai, an wajabta magani mai dacewa dangane da nau'in kwayar cutar.

Hyperosmolar coma ta ƙunshi waɗannan ayyukan warkewa:

• kawar da rashin ruwa da rawar jiki,
• sabunta ma'aunin lantarki,
• jini an kawar da jini,
• idan aka gano lactic acidosis, ƙarshe da daidaituwa na lactic acid an yi shi.

An kwantar da majinyacin asibiti, an wanke ciki, an saka matattarar urinary, ana yin maganin oxygen.

Tare da wannan nau'in coma, ana wajabta rehydration a cikin manyan kundin girma: yana da girma sama da yadda ake amfani da ketoacidotic coma, a cikin yin ruwa, da insulin therapy, shima ana wajabta shi.

Ana warkar da cutar ta hanyar dawo da yawan ruwa a jikin mutum, wanda ke iya kunsar glucose da kuma sodium duka. Koyaya, a wannan yanayin, akwai babban haɗarin mutuwa.

Tare da ƙwayar hyperglycemic coma, ana lura da karuwar insulin, don haka ba a sanya shi ba, kuma ana gudanar da babban adadin potassium a maimakon. Ba a yin amfani da alkalis da yin burodi tare da ketoacidosis ko tare da cope hymorosmolar.

Shawarwarin asibiti bayan cire mara lafiya daga rashin daidaituwa da daidaituwa duk ayyukan cikin jiki sune kamar haka:

• dauki magunguna bisa ga lokaci,
• Kar ku ƙaddara yawan abin da aka wajabta,
• sarrafa sukari na jini, dauki gwaji akai-akai,
• sarrafa hawan jini, amfani da kwayoyi waɗanda ke ba da gudummawa ga al'adarta.

Karka wuce gona da iri, ka huta sosai, musamman yayin gyaran.

Matsaloli da ka iya yiwuwa

Mafi rikicewar rikice rikice na hyperosmolar sune:

A farkon alamun bayyanar cututtuka na asibiti, mai haƙuri yana buƙatar samar da kulawa, dubawa da kuma ba da magani.

Coma a cikin yara ya zama mafi yawan gama gari fiye da na manya kuma ana saninsa da tsinkayen mummunan ra'ayi. Sabili da haka, iyaye suna buƙatar saka idanu kan lafiyar jariri, kuma a farkon alamun suna neman taimakon likita.

Sanadin cututtukan jini na hyperosmolar

Hyperosmolar coma na iya haɓaka saboda:

• fitsari mai kaifi (tare da amai, gudawa, ƙonewa, jinya na tsawan lokaci tare da diuretics),
• ffarancin ko rashin isar da ruwa da / ko insulin ruwa mai motsa jiki (alal misali, saboda karancin maganin insulin ko kuma a rashi),
• needarin buƙatar insulin (tare da babban cin zarafin abinci ko tare da gabatarwar mafita na glucose, kazalika da cututtukan cututtuka, musamman cututtukan huhu da cututtukan urinary fili, sauran cututtuka masu haɗari, raunin da ya faru, tiyata, maganin ƙwaƙwalwa tare da kaddarorin insulin antagonists, glucocorticosteroids, kwayoyi na hormones na jima'i, da sauransu.

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Ba a fahimci yanayin pathogenesis na hyperosmolar coma ba. Mai tsananin hyperglycemia yana faruwa ne sakamakon yawan glucose a cikin jiki, yawan haɓakar glucose ta hanta, guban glucose, ƙinƙarin insulin insulin da kuma amfani da glucose ta ƙwararren yanki, sannan kuma saboda ƙonewar jiki. An yi imani da cewa kasancewar insulin na endogenous yana lalata lipolysis da ketogenesis, amma bai isa ya hana samuwar glucose ta hanta ba.

Don haka, gluconeogenesis da glycogenolysis suna haifar da mummunan hyperglycemia. Koyaya, maida hankali ga insulin a cikin jini tare da ketoacidosis na ciwon sukari da coperosmolar coma kusan iri ɗaya ne.

Dangane da wata ka'ida, tare da hyperosmolar coma, yawan haɗarin hormone na somatotropic da cortisol suna ƙasa da na ketoacidosis na ciwon sukari, ƙari, tare da ƙwayar hyperosmolar, yawan insulin / glucagon shine mafi girma fiye da na ketoacidosis na masu ciwon sukari. Plasma hyperosmolarity yana haifar da takunkumi na sakin FFA daga nama adiedi kuma yana hana lipolysis da ketogenesis.

Hanyar samarda hyperosmolarity na plasma ya hada da kara samarda sinadarin aldosterone da cortisol domin magance fitsarin rashin ruwa, a sakamakon wanzuwar cutar sankara. Babban hauhawar jini da hypernatremia yana haifar da hauhawar jini na plasma, wanda hakan kuma yake haifar da zubar bushewar ciki. A lokaci guda, sinadarin da ke cikin sodium shima yakan hauhawa a cikin ƙwayar cerebrospinal. Take hakkin ruwa da daidaituwar kwakwalwa a cikin sel kwakwalwa na haifar da ci gaban bayyanar cututtukan cututtukan cututtukan jijiyoyi, guguwar kwakwalwa da kuma coma.

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Bayyanar cututtukan cututtukan mahaifa

Hyperosmolar coma yana tasowa a cikin 'yan kwanaki ko makonni.

Mai haƙuri yana haɓaka alamun bayyanar cututtukan cututtukan ƙwayar cuta, wanda ya haɗa da:

• polyuria
• ƙishirwa
• bushe fata da mucous membranes,
• asarar nauyi
• rauni, adynamia.

Bugu da kari, akwai alamun rashin ruwa,

• fata turgor,
• raguwar karnukan gira,
• raguwa a cikin karfin jini da zafin jiki.

Alamar ƙwayoyin jijiyoyin ƙwayar cuta sune halayyar:

• sabbinna,
• hyperreflexia ko areflexia,
• mai raunin hankali
• rashi (a cikin 5% na marasa lafiya).

A cikin yanayin rashin ƙarfi, marasa daidaituwa na yanayin hyperosmolar, wawa da sihiri na ciki. Mafi rikitattun rikice rikice na hyperosmolar sun hada da:

• amo mai rarrafe
• thrombosis mai zurfi,
• maganin ciwon huhu
• na gazawar.

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Bambancin ganewar asali

Amfani da cocin hyperosmolar ya bambanta da sauran abubuwanda zasu iya haifar da sanyin kwakwalwa.

Ganin tsofaffi na marasa lafiya, yawancin lokuta ana gudanar da rarrabuwar kai tare da keta hurumin mahaifa da kuma hematoma subdural.

Babban aiki mai mahimmanci shine bambancin ganewar asali na hyperosmolar coma tare da ketoacidotic mai ciwon sukari kuma musamman ƙwayar cuta na hypoglycemic.

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Hyperosmolar coma magani

Dole ne a kwantar da marasa lafiya tare da kwayar cutar hyperosmolar a cikin sashin kulawa mai zurfi / ɓangaren kulawa mai zurfi. Bayan an tabbatar da ciwo kuma an fara maganin, marasa lafiya suna buƙatar kulawa da kulawa akai-akai game da yanayin su, gami da saka idanu kan mahimman sigogin hemodynamic, zafin jiki, da sigogi na dakin gwaje-gwaje.

Idan ya cancanta, marassa lafiya za su sha iska, injin ƙurar mafitsara, shigar da ɗakunan katako na tsakiya, da abinci mai ƙoshin abinci. A cikin rukunin kulawa mai ƙarfi / naúrar kulawa mai gudana:

• bincike mai sauri na glucose na jini 1 lokaci a awa daya tare da glucose na ciki ko 1 lokaci 3 hours lokacin da zazzagewa zuwa gudanarwar subcutaneous,
• ƙuduri na jikin ketone a cikin jini sau 2 a rana (idan ba zai yiwu ba - ƙaddarar jikin ketone a cikin fitsari 2 r / day),
• ƙuduri na matakin K, Na cikin jini sau 3-4 a rana,
• nazarin acid-base state sau 2-3 a rana har zuwa akai normalization na p,
• awa daya na sarrafa fitar fitsari har sai an daina fitar da ruwa,
• Kulawa ECG
• sarrafa karfin jini, bugun zuciya, zafin jiki a kowane awanni 2,
• daukar hoto na huhu
• cikakken bincike na jini, fitsari sau 1 cikin kwanaki 2-3.

Kamar yadda tare da ketoacidosis na masu ciwon sukari, manyan hanyoyin kulawa da marasa lafiya tare da cutar hyperosmolar shine rehydration, insulin therapy (don rage yawan cutar glandoniya da hyperosmolarity), gyaran rikicewar electrolyte da rikicewar acid-base).

Zazzagewa

Sodium chloride, 0.45 ko 0.9% bayani, cikin ruwa na cikin ruwa 1-1.5 L a lokacin 1 awa na jiko, 0.5-1 L lokacin 2nd da 3rd, 300-500 ml a cikin m hours. An magance yawan haɗarin sodium chloride da matakin sodium a cikin jini. A matakin Na + 145-165 meq / l, ana sarrafa maganin sodium chloride a cikin taro na 0.45%, a matakin Na + +> 165 meq / l, an gabatar da gabatarwar mafita na saline, a cikin irin waɗannan marasa lafiya ana amfani da maganin glucose don farfadowa.

Dextrose, 5% bayani, cikin ruwa mai narkewa 1-1.5 L a lokacin 1 awa na jiko, 0.5-1 L lokacin 2nd da 3rd, 300-500 ml - a cikin sa'o'i masu zuwa. Osmolality na jiko mafita:

• 0.9% kilogiram sodium - kilogram 308 / kg,
• 0.45% sodium chloride - 154 masallaci / kg,
• 5% dextrose - 250m / kg.

Ingancin ruwa mai narkewa yana taimakawa rage yawan zubar jini.

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Harkokin insulin

Ana amfani da magungunan gajeriyar magana:

Insulin matsala (kwayoyin halittar mutum ko Semi-roba) a cikin maganin sodium chloride / dextrose a kan kudi na 00.5-0.1 U / kg / h (yayin da matakin glucose a cikin jini ya kamata yai kasa da kilo 10 / kg / h).

Game da haɗakar ketoacidosis da cututtukan hyperosmolar, ana gudanar da jiyya daidai da ƙa'idodin janar na maganin cutar ketoacidosis.

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Kimantawar tasirin magani

Alamun ingantacciyar jiyya don tasirin hyperosmolar sun hada da maido da tunani, kawar da alamun bayyanar cututtuka na hyperglycemia, cimma nasarar matakan glucose na jini da kuma matsalar osmolality plasma na al'ada, bacewar acidosis da rikicewar electrolyte.

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Kurakurai da alƙawura marasa hankali

Zazzage zafin jiki da raguwa sosai a cikin glucose na jini na iya haifar da raguwa cikin hanzarin ƙwayar plasma da haɓakar edema (musamman yara).

Ganin tsofaffin shekarun marasa lafiya da kasancewar cututtukan da ke tattare da juna, koda isasshen aikin shan ruwa yakan iya haifar da gushewar zuciya da huhun hanji.

Rage saurin matakan glucose na jini zai iya haifar da ƙwayar sel ta motsi a cikin sel kuma ta haɓaka da jijiyoyin jini da oliguria.

Yin amfani da potassium ko da hypokalemia na matsakaici a cikin mutane masu oligo- ko anuria na iya haifar da hyperkalemia na barazanar rayuwa.

Alƙawarin foshate a cikin gazawar haɓaka ya haɗu.

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Kwayoyin cutar sankarau

Bugu da kari, ana kuma iya gano alamun daga tsarin mai juyayi:

• alada
• hemiparesis (raunana ƙungiyoyi na son rai),
• rikicewar magana, ana yinsa ne,
• m cramps
• Areflexia (rashin sassauci, ɗaya ko fiye) ko hyperlefxia (karuwar reflexes),
• tashin hankali na tsoka
• mai raunin hankali.

Kwayar cutar ta bayyana 'yan kwanaki kafin haihuwar hyperosmolar ta taso a cikin yara ko majinyacin.

Yin rigakafin rikitarwa

Hakanan ana buƙatar hana tsarin jijiyoyin jini, wato, rigakafin faduwar zuciya. Don wannan dalili, ana amfani da "Cordiamin", "Strofantin", "Korglikon". Tare da rage matsin lamba, wanda yake a matakin yau da kullun, ana bada shawara don gudanar da maganin DOXA, kazalika da gudanarwar cikin jini na plasma, hemodesis, albumin mutum da jini gaba daya.