Ketoacidosis da cutar ketoacidotic

FASAHA, ITA DA PATHOGENESIS

Comparancin kuzarin carbohydrate, mai, metabolism metabolism, da kuma ma'aunin ruwa-electrolyte da ma'aunin acid-base, tare da hyperglycemia, hyperketonemia, ketonuria da acidosis metabolic sakamakon kwatsam da karancin insulin. Siffar halayyar shine kasancewar jikin ketone a cikin jini da fitsari. Zai iya faruwa a lokacin kowane nau'in mellitus na ciwon sukari, mafi yawan lokuta shi ne farkon bayyanuwar nau'in ciwon sukari na 1. Sakamakon rashi na insulin, akwai hadaddun samuwar glucose a cikin hanta sakamakon gluconeogenesis, gami da karuwar lipolysis tare da samuwar sassan jikin ketone. Sakamakon wannan shine: hyperglycemia, asarar glucose a cikin fitsari, osmotic diuresis, bushewar jiki, tashin hankali na lantarki (musamman hyperkalemia tare da raunin ƙwayar ƙwayar ƙwayar ciki na ciki) da acidosis metabolic. Abubuwan da ke haifar da damuwa: dakatar da maganin insulin (alal misali saboda wata cuta ta hanji, mai haƙuri ya guji cin abinci) ko kuma rashin amfani da insulin, kamuwa da cuta (ƙwayoyin cuta, kwayar cuta, fungal), cututtukan zuciya da naƙasa (myocardial infarction, bugun jini), jinkirta binciken sukari nau'in 1 ciwon sukari, cututtukan cututtukan fata, shan barasa, ciki, duk yanayin da ke haifar da karuwa kwatsam cikin buƙatar insulin. a sama

1. Alamomin aiki: ƙishirwa mai yawa, bushewar bushe, polyuria, rauni, gajiya da nutsuwa, ƙarancin hankali har zuwa rashin farin ciki, amai da ciwon kai, tashin zuciya da amai, tashin zuciya, ciwon ciki. a sama

2. Bayyanar cututtuka: hypotension, tachycardia, kara da zurfi, sannan numfashi mara zurfi, alamu na rashin nutsuwa (nauyin jiki, raguwar fata), rage kiba, kamshi na acetone daga bakin, jan fuska, raguwar ƙwallon ido, ƙara tashin hankali na bangon ciki. (kamar yadda tare da peritonitis)

An kafa tushen binciken dangane da sakamakon gwajin gwajin tebur. 13.3-1. A cikin marasa lafiya da aka bi da su tare da inhibitor SGLT-2, glycemia na iya zama ƙasa.

Mai ciwon sukari Ketoacidotic Coma (DKA)

DKA mummunan rikice-rikice ne na ciwon sukari mellitus, wanda aka kwatanta shi da acidosis na metabolic (pH kasa da 7.35 ko bicarbonate maida hankali ƙasa da 15 mmol / L), haɓakar anionic, hauhawar hyperglycemia sama da 14 mmol / L, ketonemia. Yawancin lokaci yana tasowa tare da nau'in ciwon sukari na 1. DKA asusun 5 zuwa 20 ne ga marasa lafiya 1000 a shekara (2/100). Mutuwa a cikin wannan yanayin shine 5-15%, ga marasa lafiya waɗanda suka girmi shekaru 60 - 20%. Fiye da 16% na marasa lafiya da ke da nau'in ciwon sukari na 1 suna mutuwa daga cutar ketoacidotic. Dalilin ci gaban DKA shine cikakkiyar magana ko ƙarancin rashi na insulin saboda rashin isasshen maganin insulin ko kuma buƙatar ƙarin insulin.

Abubuwan da ke ba da damuwa: isasshen kashi na insulin ko tsallake allura na insulin (ko shan allunan hypoglycemic jamiái), karɓar rashin izini na maganin rashin lafiya, cin zarafin fasahar gudanarwar insulin, ƙari da wasu cututtuka (kamuwa da cuta, rauni, tiyata, ciki, infarction na zuciya, bugun jini, damuwa, da dai sauransu). , rikicewar abinci (yawan carbohydrates da yawa), aiki na jiki tare da glycemia mai yawa, lalatawar giya, rashin iya sarrafa kansa na metabolism, shan wasu magunguna. nnyh kwayoyi (corticosteroids, calcitonin, saluretics, acetazolamide, β-blockers, diltiazem, isoniazid, phenytoin et al.).

Sau da yawa, etiology na DKA ya kasance ba a sani ba. Ya kamata a tuna cewa a kusan 25% na lokuta, DKA yana faruwa a cikin marasa lafiya da sabon cutar mellitus da aka gano.

Akwai matakai guda uku na ketoacidosis na masu ciwon sukari: ketoacidosis matsakaici, precoma, ko ketoacidosis mai laushi, coma.

Hadarin da ke tattare da cutar ketoacidotic ya hada da zurfin jijiya mara nauyi, da cutar sankarar hanji, sankarar mahaifa (maikalchi infarction, cerebral infarction, necrosis), aspiration pneumonia, cerebral edema, na huhu, kamuwa da cuta, da wuya GLC da ischemic colitis, cututtukan cututtukan jini na hanji, cututtukan hanji, cututtukan hanji, ciwan ciki An lura da gazawar matsalar numfashi, oliguria da gazawar koda. Hadarin da ke tattare da jiyya shine cututtukan cerebral da na huhu, hypoglycemia, hypokalemia, hyponatremia, hypophosphatemia.

Kayan bincike na DKA

Wani fasali na DKA shine ci gaba na hankali, yawanci akan kwanaki da yawa.
Bayyanar cututtuka na ketoacidosis (ƙanshi na acetone a cikin numfashin numfashi, Kussmaul numfashi, tashin zuciya, amai, anorexia, ciwon ciki).
Kasancewar alamun bayyanar bushewar jiki (raguwar narkewar nama, sautin ƙwallon ido, sautin tsoka, raunin jiki, zafin jiki da hawan jini).

Lokacin da ake bincika DKA a matakin prehospital, ya zama dole a gano ko mara lafiyar yana fama da cutar sankara, ko akwai tarihin DKA, ko mara lafiyar yana karɓar maganin cututtukan zuciya, idan kuwa haka ne, menene lokacin ƙarshe da kuka sha maganin, lokacin cin abinci na ƙarshe, ko kuma yawan motsa jiki da aka lura da shi ko shan barasa, wanda cututtukan baya-bayan nan suka gabata na rashin lafiya, sune polyuria, polydipsia da rauni.

Farfesa na DKA a matakin prehospital (duba tebur 1) yana buƙatar kulawa ta musamman don kauce wa kurakurai.

M kurakurai a cikin far da ganewar asali a prehospital mataki

Harkokin insulin asibiti na asibiti ba tare da kulawar glycemic ba.
Sisarfafa a cikin jiyya shine a kan maganin insulin mai zurfi in babu ingantaccen farfadowa.
Rashin ruwa mai ƙarancin ƙarfi.
Gabatarwar hanyoyin magance cututtukan jini, musamman a farkon jiyya.
Yin amfani da karfi da diureis maimakon rehydration. Yin amfani da diuretics tare da gabatarwar ruwaye kawai zai rage jinkirin dawo da daidaiton ruwa, kuma tare da cutar hyperosmolar, sanya diuretics ya saba sosai.
Farawa farawa tare da sodium bicarbonate na iya zama mai m. An tabbatar da cewa isasshen ilimin insulin a mafi yawan lokuta yana taimakawa kawar da acidosis. Gyara acidosis tare da sodium bicarbonate yana haɗuwa da babban haɗarin rikitarwa. Gabatar da alkalis yana inganta hypokalemia, yana rushe rarrabuwar oxygenhemoglobin, carbon dioxide wanda aka kirkira yayin gudanar da sodium bicarbonate, yana inganta acidosis na jini (kodayake ana yin pH na jini a cikin wannan yanayin), ana kuma lura da acidosis na paradoxical acidosis a cikin cerebrospinal fluid, wanda na iya ba da gudummawa ga cerebral edema, ci gaba ba sake alkalami. Gudanarwa na gaggawa na sodium bicarbonate (jet) na iya haifar da mutuwa sakamakon ci gaba na jinkirin hypokalemia.
Introductionaddamar da wani bayani na sodium bicarbonate ba tare da ƙarin adana potassium ba.
Drawacewa ko rashin gudanar da insulin a cikin marasa lafiya tare da DKA ga mara lafiya wanda bai iya cin abinci ba.
Gudun cikin jirgin sama na insulin. Kawai minti na farko na 15-20, maida hankali ne cikin jini ya isa sosai, don haka wannan tafarkin gudanarwa ba shi da tasiri.
Uku zuwa sau hudu na aiwatar da insulin gajere-aiki (ICD) subcutaneously. ICD yana da tasiri don sa'o'i 4-5, musamman a cikin yanayin ketoacidosis, don haka ya kamata a tsara shi aƙalla sau biyar zuwa shida a rana ba tare da hutu na dare ba.
Amfani da magungunan sympathotonic don magance lalacewar, wanda, da farko, sune hormones contrainsulin, kuma, na biyu, a cikin marasa lafiya masu cutar sukari, tasirin tasirinsu a cikin ɓoye glucagon yana da ƙarfi sosai fiye da lafiyar mutane.
Ba daidai ba ne cutar ta DKA. A cikin DKA, ana samun abin da ake kira "mai ciwon sukari mai ciwon sukari", wanda ke sauƙaƙa alamun bayyanar "matsanancin ciki" - tashin hankali da tashin hankali na bango na ciki, raguwa ko ɓacewa na gunaguni, wani lokacin karuwa a cikin ammlase serum. Gano lokaci guda na leukocytosis na iya haifar da kuskure a cikin ganewar asali, sakamakon abin da mai haƙuri ya shiga cikin cututtukan fata ("kamuwa da hanji") ko tiyata ("ƙoshin ciki"). A duk yanayin "m ciki" ko alamomin dyspeptiki a cikin haƙuri tare da ciwon sukari mellitus, ƙuduri na glycemia da ketotonuria ya zama dole.
Wani ma'aunin rashin daidaituwa na ƙwayar cuta ta glycemia ga kowane mara lafiya wanda ke cikin yanayin rashin sani, wanda yawanci yana tattare da haɓakar cututtukan kurakurai - "haɗarin cerebrovascular", "coma of etiology wanda ba a san shi ba", yayin da mai haƙuri yana da matsanancin ciwon sukari mai narkewa.

Hyperosmolar non-ketoacidotic coma

Wani halin rashin lafiyar ketoacidotic ne wanda ke cikin yanayin rashin ruwa, sanyin jiki mai mahimmanci (yawanci sama da 33 mmol / L), hyperosmolarity (fiye da 340 mOsm / L), hypernatremia sama da 150 mmol / L, da kuma rashin ketoacidosis (matsakaicin ketonuria (+)). Yawancin lokaci yana tasowa a cikin tsofaffi marasa lafiya da ke dauke da ciwon sukari na 2. Yana da sau 10 ƙasa da na kowa fiye da DKA. An kwatanta shi da hauhawar yawan mace-mace (15-60%). Abubuwan da suka haifar da haɓakar ƙwayar cuta ta jiki shine karancin insulin da kuma abubuwan da ke haifar da faruwar rashin ruwa a jiki.

Abubuwan da ke ba da damuwa: isasshen insulin kashi ko tsallake allurar insulin (ko shan allunan hypoglycemic jamiái), karɓar rashin izini na maganin rashin ƙarfi, ƙetare hanyar dabara na sarrafa insulin, ƙari na wasu cututtuka (kamuwa da cuta, matsanancin ƙwaƙwalwa, rauni, tiyata, ciki, ciki, infarction na zuciya, bugun jini, damuwa da da sauransu), rikicewar abinci (yawan carbohydrates da yawa), shan wasu magunguna (diuretics, corticosteroids, beta-blockers, da sauransu), sanyaya sanyi, rashin iya magance ƙishirwa. ƙonewa, vomiting ko zawo, hemodialysis ko peritoneal dialysis.

Ya kamata a tuna cewa kashi ɗaya bisa uku na marasa lafiya da ke fama da cutar rashin ƙwaƙwalwar ƙwayar cuta ba su da wani bincike na farko game da ciwon sukari.

Hoto na asibiti

Jin ƙishirwa, polyuria, rashin ruwa mai ƙarfi, ƙonewar jijiya, tachycardia, mai da hankali ko haɓaka tasirin girma da yawa na kwanaki ko makonni. Idan tare da DKA, rikice-rikice na tsarin juyayi na tsakiya da tsarin jijiyoyin mahaifa suna ci gaba kamar faduwar hankali na hankali da kuma hanawar jijiyoyin jiki, to ƙwayar hyperosmolar tana tare da raunin tunani da jijiyoyin jini da dama. Baya ga yanayin soporotic, wanda kuma yawanci ana lura dashi a cikin hyperosmolar coma, rikicewar kwakwalwa sau da yawa ana ci gaba azaman maganin delirium, m hallucinatory psychosis, da ciwon catotonic. Ana nuna rikicewar jijiyoyin zuciya ta hanyar bayyanar cututtuka na jijiya (aphasia, hemiparesis, tetraparesis, damuwa damuwa na polymorphic, ragin jijiyoyin jijiyoyin jijiyoyin cuta, da dai sauransu).

Hyma na jini

Powanƙwalwar jini na haɓakawa saboda raguwar raguwar glucose jini (ƙasa da 3-3.5 mmol / l) da ƙarancin kuzari mai ƙarfi a cikin kwakwalwa.

Abubuwan da ke ba da damuwa: yawan insulin da TSS, tsallakewa ko rashin isasshen abinci, ƙara yawan aiki a jiki, yawan shan barasa, shan magunguna (ckers-blockers, salicylates, sulfonamides, da sauransu).

Matsalolin bincike da kuma kurakurai marassa lafiya

Attemptoƙarin gabatar da samfuran carbohydrate (sukari, da sauransu) a cikin rami na bakin mara lafiyar mai haƙuri. Wannan yawanci yakan haifar da tsammani ne da shawo kansa.
Aikace-aikace don dakatar da hypoglycemia na samfuran da ba su dace da wannan ba (gurasa, cakulan, da sauransu). Waɗannan samfuran ba su da isasshen sakamako na haɓaka sukari ko haɓaka matakan sukari na jini, amma a hankali.
Ba daidai ba ganewar asali na hypoglycemia. Wasu cututtukan cututtukan hypoglycemia za a iya kuskure su azaman azabtar bacci, bugun jini, "rikicin ciyayi", da dai sauransu A cikin haƙuri yana karɓar maganin cututtukan cututtukan zuciya, tare da tuhuma mai ƙoshin lafiya, yakamata a dakatar da shi nan da nan, tun ma kafin a sami amsa wurin gwaji.
Bayan cire mai haƙuri daga yanayin cutar rashin ƙarfi na jini, ba a yin la'akari da haɗarin sake dawowa cikin la'akari.

A cikin marasa lafiya a cikin yanayin da ba a san asalinsa ba, koyaushe wajibi ne don ɗauka kasancewar ƙwayar cutar glycemia. Idan abin dogaro ne a san cewa mai haƙuri yana da ciwon sukari mellitus kuma a lokaci guda yana da wuya a bambanta yanayin hypo- ko hyperglycemic genma na coma, gudanarwar glucose mai narkewa a cikin kashi 20- 40-60 ml na maganin 40% ana bada shawarar don bambancin ganewar asali da kuma kulawar gaggawa don hypoglycemic coma. Game da batun hypoglycemia, wannan yana rage tsananin bayyanar cututtuka kuma, don haka, zai bada damar bambance waɗannan yanayi biyu. Tare da ƙwayar cuta na hyperglycemic, irin wannan adadin glucose ba zai kusan tasiri yanayin yanayin mai haƙuri ba.

A duk yanayinda ake amfani da ma'aunin glucose nan da nan ba zai yiwu ba, yakamata a gudanar da glucose sosai. Idan ba a tsayar da hypoglycemia cikin gaggawa ba, zai iya zama mai mutuwa.

Thiamine 100 MG iv, glucose 40% 60 ml da naloxone 0.4-2 mg iv ana ɗauka su zama magunguna na asali ga marasa lafiya a cikin wari, da rashin yiwuwar fayyace ganewar asali da asibiti mai gaggawa. An tabbatar da inganci da amincin wannan haɗuwa a aikace.

Kh. M. Torshkhoeva, Dan takarar ilimin kimiyyar likitanci
A. L. Vertkin, Likita na Kimiyyar Likita, Farfesa
V.V. Gorodetsky, dan takarar ilimin kimiyyar likitanci, farfesa
Motar asibiti ta NNGO, MSMSU