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Diabetic Ketoacidosis (DKA) ne Hyperosmolar Hyperglycemic State (HHS)

Nomba ya malu a tshimpitshimpi idi mishilangane bilondeshile ditunga. Dibeji edi didi dienza mudimu ne 911, nomba wa ditunga dia États-Unis ne dia Canada. Matunga makuabu a bungi adi ne nomba wa 112, 999 anyi nomba mukuabu. Keba nomba wa ditunga dienu.

Diabetic Ketoacidosis (DKA) ne Hyperosmolar Hyperglycemic State (HHS) ke masama abidi adi ne njiwu ya bungi mu diondapa dia diabete, adi mua kufikisha ku dipanga dia mâyi mu mubidi, ku dinyanguka dia mashi, ku divula dia buongo (edema wa mu buongo), ku koma, ne ku lufu padibu kabayi babaondapa ne lukasa ne manga a mu lupitadi, ne mashi a mu mikolo ne insuline. Padi DKA wenda ukola ne lukasa mu mêba a bungi too ne ku dituku padi dipanga dia insuline dikole anyi dikole dienzeja tshifu bua kuosha mafuta mu ketone ya acide, HHS udi wenda ukola mu matuku a bungi too ne ku mbingu (misangu ya bungi kudi bantu bakulumpe badi ne disama dia diabete wa mushindu 2), udi ufikisha sukadi mu mashi ku tshipiminu tshikole ne ujimija too ne ku 9 too ne ku 12 litre (2.4 to ne ku 2.3) ya mayi mu mubidi. Dijingulula dia lukasa dia bimanyinu bu mudi diela, disama dia mu difu, dipuyakana dia lukasa, anyi dipanga dia lungenyi, pamue ne diteta dia ketone mu mashi a ku nzubu ne dienda dia lukasa dia luondapu, bidi bisungila mioyo.

Kuela manyi ne disama dia diabete anyi ketone mivule i bualu bua lukasa, ki mbualu bua mu tshifu to

Disama dia mutshima, disama dia tshiadi, ne disama dia mu difu bidi bimanyinu bia kale bia Diabete Ketoacidose (DKA), ki nganu dia gastroenterite virale to. Kuena ne bua kuela meji ne: muntu udi ne disama dia diabete wa mushindu 1 anyi 2 udi utua mikemu udi anu ne disama dia tshiadi anyi grippe wa mu tshifu to. Kabidi, babedi badi banua manga adi akandamija SGLT2** (bu mudi empagliflozin, dapagliflozin, canagliflozin, anyi ertugliflozin) badi mua kupeta disama dia Euglycemic DKA didi mua kubashipa nansha padi sukadi mu mashi abu umueneka pabuipi ne wa pa tshibidilu (muinshi mua \(11.1\textxtol{mm/\)2/00/00000 mg/dL}$). Dîba dionso didi muntu udi ne disama dia diabete wela nsukadi misangu ne misangu, upuyakana bikole ne lukasa, ulua tulu anyi unyanguka, anyi uleja ketones mu mashi ku \(1.5\text{ to }3.0\text{ mmol/L}\) anyi kupita apu, bikila bena mudimu ba lupitadi lua lukasa anyi ndaku diakamue mu nzubu wa luondapu lua lukasa.

Enza nunku mpindieu

  1. Bikila nimero wa lupitadi lua muaba unudi diakamue pikala muntu au mubungame, mulale tulu, mupuya mukole ne lukasa, mupuya misangu ne misangu, anyi ne ketones mu mashi \(\ge 3.0\text{ mmol/L}\). Ela 911 mu États-Unis ne mu Canada, 112 mu Union européenne, 99 mu Royaume-Uni anyi mu ditunga dijima nomba ya tshimpitshimpi. Ambila muntu udi utuma bantu ne: mubedi udi ne disama dia Diabete Ketoacidosis (DKA) anyi Hyperosmolar Hyperglycemic State (HHS) ne udi dijinga ne diambuluisha dia mâyi a mu mishipa ne dikonkonona dia electrolyte.
  2. Teta glucose wa mu mashi ne beta-hydroxybutyrate ketones mu mashi diakamue (bikala tshipiminu tshikalaku). Kueyemenyi anu dibala dia tshiamu tshia Continuous Glucose Monitor (CGM) mu tshikondo tshia dipanga dia mâyi anyi dia tshimpitshimpi, bualu mâyi a mu mubidi adi ashala panyima pa bungi bua mashi. Funda bungi bulelela bua sukadi mu mashi (anyi funda pikala tshipiminu tshifunda "HI", tshidi tshiumvuija pa mutu pa \(27.8\text{ too ne ku }33.3\text{ mmol/L}\) [\(500\text{ too ne ku }600\text{ mg/dL}\)]) ne tshipiminu tshilelela tshia ketone mu mashi mu \({mg/dL}\)/mmol/L}$ dikala dia ketone).
  3. Lama njila wa lupepele pa kuteka muntu udi mulale tulu, udi mubungame anyi udi upela ku luseke luabu mu muaba wa kuondopibua. Kupeshi muntu yonso udi mutshioke, udi upanga kuakula bimpe, udi mubungame anyi udi utua mishiku mâyi a mukana, biakudia anyi manga, bualu udi mua kuela mâyi mu mikolo yende bipepele (disama dia pneumonie). Shi muntu udi mubike, udimuke, ne udi mua kumina kayi utua tshiadi, umukankamije bua kunua mayi malelela anyi mayi adi kaayi ne nsukadi (pabuipi ne 250 millilitres [8 fluid ounces] kunyima kua minite 15 anyi 30 bua muntu mukole) padiye muindile luondapu.
  4. Tangila tshiamu tshia insuline bua kumona ni tshiamu tshia nzembu tshidi tshinyanguke anyi tshilema tshia tshiamu tshia nzembu, ne KUENJI KUENZA insuline ya bungi muinshi mua dikoba to. Shi mubedi wenza mudimu ne tshiamu tshia nzembu tshia insuline ne udi ne glucose wa bungi mu mashi ne ketones mibandile (\(\ge 1.5\text{ mmol/L}\)), ela meji ne: muaba wa tshiamu tshia nzembu mmunyanguke: **kufidi tshiamu tshia nzembu tshia dilongolola ku diambuluisha dia tshiamu tshia insuline to. Pamutu pa nanku, londesha tshidibu bakuambile bua kuenza mu dituku dia disama ku diambuluisha dia tshiamu tshipiatshipia tshia insuline tshia muinshi mua dikoba anyi tshintu tshia kuela natshi mashi mu tshitupa tshipiatshipia tshia dikoba. Kuena ne bua kufila insuline minene ku mpukapuka anyi misangu ne misangu ("misangisha") bua kupuekesha sukadi mu mashi kumpala kua baminganga kufikabu to, bualu dipuekesha dia sukadi mu mashi anyi osmolality wa mashi lukasa lukasa kuyi muanji kuela saline ne potassium mu mishipa bidi mua kufikisha ku lufu lua cerebral edema (divulangana dia buongo) ne hypokalemic cardiac.
  5. KUPESHI muana anyi nsonga udibu bela meji ne: udi ne disama dia DKA acetaminophen (paracetamol), aspirine anyi ibuprofen, ne kuepuka bicarbonate. DKA wa bana udi ne njiwu mikole ya disama dia buongo didi mua kushipa muntu mu mêba 12 anyi 24 a kumpala a luondapu; ikala ne mutu ne makaya a mubedi bibandishibue kakese mu tshitupa tshia 30-degree pikalaye mubike, ne lekela bena mudimu ba lupitadi batangile luya ne acidose bimpe.
  6. Sangisha bintu bionso bia disama dia diabete, liste ya manga (nangananga SGLT2 inhibitors ne steroids), ne mikanda ya metre ya matuku mashale aa bua baminganga. Pesha bena mudimu ba mu ambulanse tshipiminu tshia glucose/ketone tshia mubedi, bipese bia insuline anyi tshilejilu tshia pompe, ne liste wa manga onso a dituku dionso bua tshibambalu tshia malu a mpukapuka tshituadije diakamue protocole wa dibueja dia insuline ne insuline mu mashi.

Hyperglycemic crisis triage ne ketone action decision tree

Ingidija tshikandakanda etshi tshia luondapu bua kukonkonona bungi bua sukadi mu mashi, kumvuija dibala dia ketone mu mashi anyi mu mashi, ne kuangata dipangadika pankatshi pa dilama dia dituku dia disama dia ku nzubu ne diya dia lukasa lukasa ku lupitadi.

flowchart TD
    Start["Muntu udi ne disama dia diabete dimanyike anyi didi kadiyi dimanyike udi ne:<br/>Glucose mu mashi >= 13.9 mmol/L (250 mg/dL)<br/>ANYI Disama dionso / Disama dia mutshima / Disama (Nansha mudi Glucose < 13.9 mmol/L pa SGLT2i)"] --> RedFlags{"Kudi mabenda makunze a tshimpitshimpi anyi?<br/>1. Dipuya dia munda, dia lukasa (Kussmaul respirations) anyi dipuya dia mamuma<br/>2. Disama dia kashidi anyi dipanga dia kulama mayi panshi munkatshi mua mêba >2 anyi 4<br/>3. Disama dikole dia mu difu, dipanga dia lungenyi, dipanga dia lungenyi, anyi ngakuilu mubi<br/>4. Ketones ya mu mashi >= 3.0 mmol/L (anyi 'Large' urine ketones)<br/>5. Tshipiminu tshidi tshileja 'HI' (>33.3 mmol/L / 600 mg/dL) ne dipanga dia mayi mu mubidi"}

    RedFlags -->|"EYOWA: Dibendele dionso dikunze didiku"| CallEMS["BUALU BUA LUPILU BUA LUPITU (DKA anyi HHS):<br/>1. Bikila 911 / 112 / 999 diakamue<br/>2. Shi udi ulala tulu anyi udi upela: Muaba wa kuondopa & Kakuyi tshintu ku mukana (NPO)<br/>3. Shi udi mudimuke ne kuyi wela: kunua mayi makese<br/>4. KUENJI bua kuela insuline ya bungi kumpala kua kuela mâyi a mu tshifu/potassium to"]

    RedFlags -->|"NO: Didimuija, dipuyakana bimpa,<br/>kuyi utua mishiku misangu yonso"| CheckKetones{"Tangila Ketone ya mu mashi (Beta-Hydroxybutyrate)<br/>anyi tshitupa tshia Ketone tshia mu mashi"}

    CheckKetones -->|"Ketone ya mu mashi 1.5 too ne ku 2.9 mmol/L<br/>(ketone ya mu mashi)"| ModKetones["Ketonemia wa munkatshi (Impending DKA Warning):<br/>1. Udi mua kubikila bena mudimu ba disama dia diabete anyi telefone wa diambuluisha dia lukasa lukasa<br/>2. Shi udi pa pompe wa insuline: Fila dilongolola dia lukasa ku diambuluisha dia PEN/SYRINGE<br/> muaba mupiamupia ne ushintulule tshisumbu tshijima tshia infusion tshia pompe<br/>3. Nua 250 mL (8 oz) ya mayi adi kaayi ne nsukadi kunyima kua minite 30 too ne ku 60<br/>4. Tangila kabidi glucose ne ketones mu mashi mu meba 2 (Ndaku ku ER shi udi wenda ubanda)"]

    CheckKetones -->|"Ketones ya mashi 0.6 to 1.4 mmol/L<br/>(Trace to Small Urine Ketones)"| MildKetones["Mild / Trace Ketonemia:<br/>1. Londa mikenji ya dituku dia disama bua kupeta insuline wa lukasa<br/>2. KULEKEDI nansha kakese insuline wa basal/wa mutantshi mule (nansha wewe kuyi udia)<br/>3. Ela mayi (anyi mayi a carb pikala glucose < 10 mmol/L / 180 mg/dL)<br/>4. Tangila kabidi bungi bua glucose ne ketones mu mashi kunyima kua mêba 2 anyi 4"]

    CheckKetones -->|"Mashi a Ketones < 0.6 mmol/L (Normal)<br/>NE Glucose 13.9 to 22.2 mmol/L (250-400 mg/dL)"| NoKetones["Hyperglycemia Without Ketosis:<br/>- Angata dose wa insuline udi wenza mudimu lukasa<br/>- Nua mayi a bungi ne utangile bimanyinu bia dipanga dia mâyi mu HHS<br/>- Keba luondapu pikala glucose mushale >16.7 mmol/L (300 mg/dL) bua 2 checks"]

Kujingulula tshidi tshikebesha: Bua tshinyi DKA ne HHS bidi bikola ne mudibi bishilangane

Nansha mudi DKA ne HHS bifumina ku dipanga dia mudimu wa insuline pamue ne dikola dia hormone ya tunyinganyinga (glucagon, cortisol, epinephrine, ne hormone wa dikola), bidi bilonda njila ibidi mishilangane ya biochemie idi yumvuija bua tshinyi bimanyinu biabu, mushinga wa laboratware, ne njiwu ya diakamue ya lupitadi idi mishilangane.

1. Diabetic Ketoacidosis (DKA): Nzala munkatshi mua bintu bia bungi

Mu Diabete Ketoacidose (DKA), kudi dipanga dia insuline dikole anyi dia tshishiki. Padi muntu kayi ne insuline, glucose udi ushala mu mashi ne kena mua kubuela mu mifuba anyi mu selile ya mafuta bua kupeta bukole to. Patudi tuela meji ne mubidi udi ne nzala, glandes adrénales ne pancréas bidi bipatula bungi bua bungi bua glucagon, adrenaline, ne cortisol, bidi bijula ​​njiwu ibidi: - Lipolyse ne Ketogenesis kayiyi mimanyibue (Metabolic Acidose): Mafuta (mafuta) adi anyanguka lukasa mu mafuta a tshianana, adi aya ku tshifu. Tshifu tshidi tshikudimuna mafuta aa mu mibidi isatu ya ketone: beta-hydroxybutyrate (acide wa kumpala udi wenda mu DKA), acetoacetate, ne acetone (udibu bapatula mu mikolo, upatula mupuya muimpe wa "poire" anyi mupuya wa vernis-pa mutu pa mupuya). Ketoacid mikole eyi idi ipita bukole bua bicarbonate mu mashi, ipuekesha mashi a mu mishipa \(\text{pH}\) muinshi mua \(7.30\) (ne muinshi mua \(7.00\) mu DKA mukole). - Osmotic Diuresis and Electrolyte Depletion: Padi glucose mu mashi upita tshipiminu tshia tshiadi tshia pabuipi ne \(10.0\text{ to }11.1\text{ mmol/L}\) (\(180\text{ to }200\text{ mg/dL}\)), glucose ne ketoine bidi bikoka mu tshifu, bungi bua mayi, sodium, potassium, magnésium, ne phosphate bipatuka mu mubidi. Muntu mukole udi mu DKA utu ujimija 5 to ne 7 litres (1.3 to 1.8 gallons) ya mayi a mubidi (\(100\text{ mL/kg}\)) mu meba 24.

2. Hyperosmolar Hyperglycemic State (HHS): Dipanga dia mayi mu mubidi ne mashi makole

Hyperosmolar Hyperglycemic State (HHS) udi wenzeka nangananga kudi bantu bakulumpe badi ne diabete wa mushindu 2 (nansha mudiye umueneka bikole kudi bansonga ne bansonga badi ne disama dia obesite ne diabete wa mushindu 2). Bishilangane na DKA, muntu udi mu HHS utshidi anu upatula insuline wa pancréas wa ku ntuadijilu udi mukumbane bua kupangisha dinyanguka dia mafuta (lipolyse) ne dienza dia ketone, kadi insuline kayi mukumbane bua kupangisha tshifu bua kuela glucose mu mashi anyi bua kufikisha glucose mu selile. - Bu mudi mubedi kayi ulua acidose diakamue (kakuyi diela dia lukasa anyi dipuekesha dia Kussmaul mu mêba 24 a kumpala), kabatu bumvua disama dikole mu Dituku dia 1 to. Pamutu pa nanku, glucose mu mashi udi ubanda bikole mu matuku a bungi too ne ku mbingu 2, misangu ya bungi ufika ku \(33.3\text{to}666\6. mmol/L}\) (\(600\text{ to }1,200\text{ mg/dL}\)). - Diurese dia osmotique didi kadiyi dijika didi dipatula 9 too ne ku 12 litre (2,4 too ne ku 3,2 gallons) ya mâyi (\(100\text{ to }200\text{ mL/kg}\), anyi too ne ku 20 pa lukama ya mâyi onso a mubidi) mu mubidi wa mubedi. Padi disama, tshipupu, dipanga dia lungenyi, anyi dipanga dia kuendakana mu nzubu wa bakulakaje dipangisha muntu bua kunua mayi makumbane bua kuikala ne makanda, osmolality wa mashi udi ubanda pa mutu pa \(320\text{ mOsm/kg}\). Mâyi adi apatuka buludiludi mu selile ya mu buongo, adi akebesha dipanga dia lungenyi dikole, dipanga dia lungenyi didi difuanangane ne disama dia avc, disama dia tshiadi, koma, ne mashi a mu mishipa anyi a mu mishipa (embolie pulmonaire anyi disama dia mutshima). Bu mudi babedi batamba kuikala bakulumpe ne kabayi ne mâyi mu mubidi, HHS udi ne tshipiminu tshia lufu tshia 10 to ne ku 20 pa lukama, tshidi pabuipi ne tshipiminu tshia lufu tshia DKA misangu 5 too ne ku 10.

Difuanyikija dia mutu ne mutu: DKA vs. Euglycemic DKA vs. HHS vs. Hypoglycemia

Ingidija tshibambalu etshi tshia dikonkonona dia masama (tshidi ne 2024 Joint ADA / EASD / JBDS / AACE / DTS Consensus Report on Hyperglycemic Crises in Adults ne ISPAD Pediatric Guidelines) bua kusunguluja ntatu ya diabete:

Tshimanyinu tshia luondapu anyi tshia biochimie Disama dia diabete dia kale (DKA) Euglycemic DKA (euDKA) Hyperosmolar Hyperglycemic State (HHS) Dikepela dia sukadi mu mashi (Dikepela dia sukadi mu mashi)
Muyuki wa mubedi wa pa tshibidilu Misangu ya bungi diabete wa mushindu 1 (kusangisha ne bana/bakulumpe badibu bapeta lelu), anyi diabete wa mushindu 2 udi ne disama dia ketosis mu tshikondo tshia ntatu mikole/disama. Diabete wa mushindu 1 anyi 2 udi unua SGLT2 inhibitors, anyi dimita, dijila dia biakudia, didia dia ketogène, dipanda dia bariatric, anyi dinua dia maluvu makole. Misangu ya bungi bantu bakulumpe badi ne disama dia diabete wa mushindu 2 (misangu ya bungi ne disama dia tshiadi, tshiadi, disama dia mutshima, dia diuretique, anyi dipanga dia mushindu wa kupeta nyota). Muntu yense udi unua insulin anyi sulfonylurea pills (glipizide, glimepiride, glyburide).
Lubilu lua ntuadijilu Lubilu: mêba 4 too ne ku 24 (udi mua kukola mu muinshi mua mêba 4 pikala tshiamu tshia insuline tshipatuka anyi tshikanga). Lubilu too ne mu tshitupa tshîpi: mêba too ne matuku makese (misangu ya bungi dimanya dia disama didi dienda dijika bualu sukadi mu mashi udi umueneka muimpe). Bitekete bitekete ne bia budimu: matuku a bungi too ne ku mbingu ibidi ya polyuria, polydipsia, ne butekete. Minute: Dibanga dia tshimpitshimpi dia dikankamika, dipatuka dia tuishi, dipanga dia lungenyi, anyi disama dia tshiadi.
Tshipimu tshia glucose mu mashi Pa tshibidilu \(\ge 11.1\text{ mmol/L}\) (\(\ge 200\text{ mg/dL}\)) (pa tshibidilu \(14\text{ too ne ku }30\text{ mmol/L}\) [\(250\text{ to }550\text{ mg/L}\)}). Muinshi mua \(11.1\text{ mmol/L}\) (\(< 200\text{ mg/dL}\)), imue misangu bimpa (\(5.5\text{ to }9.0\text{ mmol/L}\) [\(100\text{ to }160\text{m/dL}\)}). \(\ge 33.3\text{ mmol/L}\) (\(\ge 600\text{ mg/dL}\)), misangu ya bungi udi ubala "HI" pa biamu bia ku nzubu (\(600\text{ to }1,200+\text{ mg/dL}\)). Kuinshi kua \(3.9\text{ mmol/L}\) (\(< 70\text{ mg/dL}\)); disama dia neuroglycopenia dikole muinshi mua \(3.0\text{ mmol/L}\) (\(54\text{ mg/dL}\)).
Blood Ketones (\(\beta\)-Hydroxybutyrate) \(\ge 3.0\text{ mmol/L}\) (anyi urine ketones \(\ge 2+\) / moderate-to-large). \(\ge 3.0\text{ mmol/L}\) (nansha mudi sukadi mu mashi mubandile anyi mubandile kakese). \(< 3.0\text{ mmol/L}\) (kakuyi anyi anu ketones ya nzala mikese; ketones ya mu mashi idi mibi anyi mikese). Normal (\(< 0.6\text{ mmol/L}\)).
Arterial/Venous pH & Bicarbonate Acidotic: \(\text{pH} < 7.30\) ne serum bicarbonate \(< 18\text{ mmol/L}\) (\(< 10\text{ mmol/L}\) mu DKA mukole). Acidotic: \(\text{pH} < 7.30\) ne serum bicarbonate \(< 18\text{ mmol/L}\). Kayi ne acidotic wa mushinga mukole: \(\text{pH} \ge 7.30\) ne serum bicarbonate \(\ge 15\text{ to }18\text{ mmol/L}\). PH wa pa tshibidilu.
Mushindu wa kupuya ne mupuya wa kupuya Kussmaul respirations (deep, rapid, laboured gasping sighs to blow off \(\text{CO}_2\)) + sweet/fruity acetone breath. Kussmaul respirations + mupuya wa bimuma + disama dia mutshima/difuisha. Dipuyakana dia patupu anyi dia pa tshibidilu (pa kumbusha pikala disama dia tshiadi anyi dia sepsis ke didi dijula); kakuena mupuya wa acétone wa bimuma to. Dipuyakana dia pa tshibidilu anyi dia lukasa; mutoke, muwule tente ne tuishi tua mashika.
Bimanyinu bia mu tshifu Prominent: Disama dikole dia mutshima, disama dia nsukadi didi kadiyi dijika, ne disama dia mu difu didi ditangalake bikole (difuanangana ne disama dia appendicite anyi dia pancréatite). Prominent: Disama dia mutshima, disama dia nsukadi, dipanga dia dijinga dia kudia, disama dia mu difu, ne disama dia mubidi. Mukese anyi kayiku: Disama dia mu difu kadiena ditamba kuenzeka to, anu padidi difumina ku disama dia mu difu. Nzala ku ntuadijilu, uya kumpala too ne ku dipanga dia lungenyi anyi dibenga kuandamuna.
Nsombelu wa mitu Didimuija mu DKA mukese; tulu, tulu, anyi tulu mu DKA wa munkatshi ne wa bukole. Mutshioke, mutekete, mutu, ne tshiji; udi uya kumpala too ne ku stupor pikalaye kayi muondapibue. Dipanga dia mudimu mukola dia mitu: Dipanga dia lungenyi, dimona dia malu mu mpukapuka, disama dia tshiadi (difuanyikija dia tshiadi), disama dia tshiadi, anyi dipanga dia lungenyi bua Serum Osmolality \(> 320\text{ mOsm/kg}\). Dibungama dia tshimpitshimpi, ngakuilu mubi, disama dia tshiadi, anyi dipanga dia lungenyi; udi upingana lukasa ne glucose/glucagon.
Dipanga dia mayi (muntu mukulumpe) \(5\text{ to }7\text{ litres}\) (\(100\text{ mL/kg}\)). \(3\text{ to }5\text{ litres}\) (dikese dia osmotic glucose diuresis, pa kumbusha padi disama dikole). \(9\text{ to }12\text{ litres}\) (\(100\text{ to }200\text{ mL/kg}\)). Kakuena (bidi bikengela diakamue glucose anyi glucagon; tangila malu a tshimpitshimpi a disama dia diabete).

Kumanya bimanyinu bia didimuija ne diteyi dia SGLT2 inhibiteur "Euglycemic DKA"

Mushindu udi bimanyinu bia DKA bienda bikola kumbukila ku Ketosis wa kumpala too ne ku dikuluka dia acidotic

  1. Tshitupa 1: Divula dia mashi mu mashi ne dikola dia mashi (Mêba 1 too ne ku 6):
  2. Nyota idi kayiyi mua kujika (polydipsia), mukana muume udi ulamakaja, ne ngendu ya bungi ya kuya kusukula (polyuria), kusangisha ne dijuka misangu ya bungi butuku (anyi disukula dia tshimpitshimpi dia muana uvua mulonge bua kuya mu tshina tshia mâyi).
  3. Butekete bua mubidi, ditshioka, dipanga dia kumona, ne mutu usama.
  4. Suka mu mashi udi pa mutu pa \(13.9\text{ mmol/L}\) (\(250\text{ mg/dL}\)) ne ketones ya mu mashi idi ivula pankatshi pa \(0.6\text{ ne }1.5\text{ mmol/L}\).
  5. Tshitupa 2: Disama dia Ketoacidose (Mêba 6 too ne ku 18):
  6. Disama dia mutshima, difu dia misangu ne misangu, ne disama dikole dia mu difu: Disama dia aside ne dipanga dia tshifu didi dibungamija tshitupa tshia munda ne tshimanu tshia mala. Padi muntu utuadija kuela nsukadi, mubedi kena kabidi mua kulama mâyi a mukana panshi to, ne bidi bienza bua dijimija dia mâyi mu mubidi dilue dipueka.
  7. Kussmaul breathing ("air hunger"): Because the blood is dangerously acidic, the brain's respiratory center forces the lungs to take deep, rapid, sighing breaths to blow off acidic carbon dioxide (\(\text{CO}_2\)). Bystanders often mistake this deep sighing for a panic attack or asthma, even though the lungs sound clear.
  8. Fruit "pear drop" anyi nail-polish-remover breath: Difumina ku gaz volatile acétone udi upatuka mu mishipa ya mu mikolo.
  9. Tshitupa 3: DKA mupangile ne tshipupu (mêba 12 too ne ku 24+):
  10. Sunken eyes, dry leathery tongue, poor skin turgor, fast weak pulse (\(> 120\text{ bpm}\)), falling blood pressure, confusion, inability to stay awake, cerebral edema, and cardiac arrest.

The Euglycemic DKA (euDKA) Trap: Why normal blood sugar can still hide lethal DKA

Over the past decade, Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors, including empagliflozin (Jardiance), dapagliflozin (Farxiga/Forxiga), canagliflozin (Invokana), ertugliflozin (Steglatro), and sotagliflozin (Inpefa), have become widely prescribed for Type 2 diabetes, heart failure, and chronic kidney disease. These medications work by forcing the kidneys to dump 60 to 100 grams of glucose into the urine every day.

Because the kidneys are constantly clearing sugar out of the bloodstream into the urine, if a patient taking an SGLT2 inhibitor develops an infection, stops eating during a stomach virus, undergoes surgery, starts a low-carbohydrate/ketogenic diet, or reduces their insulin dose, their liver pours out acidic ketones while their fingerstick blood glucose stays deceptively normal or only mildly elevated (\(6.0\text{ to }11.0\text{ mmol/L}\) or \(110\text{ to }199\text{ mg/dL}\)).

The STOP DKA Rule for SGLT2 Inhibitors

International diabetes guidelines (ADA, EASD, UK JBDS, and Health Canada / FDA alerts) mandate the "STOP DKA" protocol for anyone taking an SGLT2 inhibitor (empagliflozin, dapagliflozin, canagliflozin, ertugliflozin): - Stop taking the SGLT2 inhibitor tablet immediately if you become acutely ill, feverish, nauseated, vomiting, or unable to eat and drink normally, and stop it 3 to 4 days before any scheduled surgery or colonoscopy. - Test blood ketones (not just blood sugar) whenever you feel nauseated, exhausted, short of breath, or have stomach pain, even if your blood glucose meter reads normal (\(5.5\text{ to }10.0\text{ mmol/L}\) / \(100\text{ to }180\text{ mg/dL}\)). - Oral fluids and carbohydrates: If blood ketones are elevated (\(> 0.6\text{ to }1.5\text{ mmol/L}\)) and blood glucose is normal, the patient actually needs both carbohydrates (15 to 30 grams of sugar/juice) AND rapid-acting insulin at the hospital to switch off liver fat burning. - Present to an emergency department immediately and explicitly tell the triage doctor: "I take an SGLT2 inhibitor and need a blood beta-hydroxybutyrate ketone and venous blood gas check to rule out Euglycemic DKA."

Blood ketone testing vs. urine ketone strips: Why blood meters are superior in an emergency

When checking for DKA at home, capillary blood ketone meters (which measure beta-hydroxybutyrate [\(\beta\)-OHB] using a fingerstick strip, just like a glucose meter) are vastly more accurate and actionable than dip-and-read urine ketone strips (which only measure acetoacetate via the nitroprusside reaction):

  1. Urine strips miss early DKA: During severe DKA, the liver produces up to 10 times more beta-hydroxybutyrate than acetoacetate. Because urine strips cannot detect beta-hydroxybutyrate at all, a urine strip may show only "trace" or "small" ketones when blood beta-hydroxybutyrate is already at a life-threatening \(3.5\text{ mmol/L}\).
  2. Dehydration prevents urination: A severely dehydrated patient in DKA or HHS often cannot produce a urine sample for hours, whereas a fingerstick blood drop takes 10 seconds.
  3. Urine strips create false alarms during recovery: As DKA resolves with treatment, beta-hydroxybutyrate converts back into acetoacetate and is flushed into the urine, making urine strips turn dark purple ("large") hours after the blood acidosis has actually cleared.

How to interpret blood beta-hydroxybutyrate (\(\beta\)-OHB) ketone numbers

Blood Ketone Reading (\(\text{mmol/L}\)) Approximate Urine Strip Equivalent Clinical Meaning and Immediate Action Required
Below \(0.6\text{ mmol/L}\) Negative Normal range. No ketosis present. Manage high blood glucose with standard prescribed correction doses and water.
\(0.6\text{ to }1.4\text{ mmol/L}\) Trace to Small (\(+\)) Mild ketonemia (Early warning). Body is beginning to burn fat due to insufficient insulin or fasting. Apply Sick Day Rules: take prescribed extra rapid-acting insulin, drink 250 to 500 mL (8 to 16 oz) of fluid per hour, and re-test blood glucose and ketones in 2 hours.
\(1.5\text{ to }2.9\text{ mmol/L}\) Moderate (\(++\)) High risk of developing DKA. Contact your diabetes clinic or urgent medical helpline now. If using an insulin pump, give a correction dose via subcutaneous insulin pen/syringe and replace the entire pump infusion set. Drink fluids every 30 minutes and re-test in 1 to 2 hours; go to the emergency room if vomiting occurs or levels do not drop.
\(3.0\text{ mmol/L}\) or higher Large (\(+++\) to \(++++\)) Medical Emergency: Probable Diabetic Ketoacidosis (DKA). Call 911 / 112 / 999 or arrange immediate emergency hospital transport for intravenous saline, potassium, and insulin therapy.

Why you must NEVER stack massive insulin doses at home before hospital arrival

When a patient or family member sees a blood glucose meter reading \(28.0\text{ mmol/L}\) (\(500\text{ mg/dL}\)) or "HI", the instinct is often to inject a large dose of rapid-acting insulin (or repeat injections every 30 minutes) before going to the hospital. Giving unmeasured or stacked large insulin doses to a severely dehydrated patient in DKA or HHS outside a hospital is dangerous for three physiological reasons:

1. Dipanga dia mayi mu mubidi didi dipangisha dikuata dia insuline muinshi mua dikoba, pashishe didi diela bionso musangu umue

Padi mubedi udi mu DKA anyi HHS mupangile mâyi mu mubidi ne litre 5 too ne ku 10, mijilu ya mashi idi mu dikoba ne mafuta adi muinshi mua dikoba idi idiunda bua kulama mashi adi apita mu mutshima ne mu buongo. Ma dose a bungi a insuline udi wenza mudimu lukasa adibu bele muinshi mua dikoba adi mu tshilaminu tshia muinshi mua dikoba tshidi katshiyi tshibueja mashi. Dîba didi baminganga batuadija kuela mâyi a mukele mu mishipa ne dipingana dia mashi mu dikoba, tshibutshilu atshi tshidi tshibuela lubilu mu mashi musangu umue, tshijula ​​tshipupu tshikole tshia hypoglycémie.

2. Kubueja potassium mu selile kumpala kua kutangila nzubu ya mashi kudi kufikisha ku diimanyika dia mutshima

Mu tshikondo tshia DKA ne HHS, osmotic diuresis udi upatuisha bungi bua bungi bua potassium (\(\text{K}^+\)) mu mashi. Nansha mudi potassium wa mubidi mujima mukepele, potassium wa mu mashi udi umueneka bu muimpe bualu acidose udi upatula potassium mu selile. Insuline udi wenzeja potassium wa mu mashi bua kupingana munda mua selile. Shi insuline wa bungi kumpala kua lupitadi kutangila potassium mu mashi (ne kumpala kua kuela chloride wa potassium mu mushipa padi \(\text{K}^+ < 5.0\text{ to }5.2\text{ mmol/\)} anyi pikala insuline <{K}^+ 3.5\text{ mmol/L}$), potassium mu mashi udi upueka mu minite mikese, udi ukebesha hypokalemic ventricular arrhythmias ne cardiac stop.

3. Kupuekesha sukadi mu mashi lukasa mu HHS anyi mu DKA wa bana kudi kufikisha ku edema wa mu buongo ne dikuluka dia mijilu

  • Mu HHS: Sukadi wa bungi mu mashi ke bukole bunene budi bulama mayi munda mua mijilu idi mipuekele, ne selile ya mu buongo mmimanyine mu matuku a bungi bua kufika ku osmolality mikole (\(> 320\text{ mOsm/kg}\)). Mikenji ya lupitadi (UK JBDS ne ADA/EASD 2024 consensus) idi ileja ne: dîba dia kumpala dia luondapu lua HHS didi \(0.9\%\) diondopangana dia mâyi a mukele nkayadi, didi dipuekesha sukadi mu mashi bimpe ne \(2.8\text{ too ne ku }4.2\text{ mmol/L/h/h\)} (too ne }75\text{ mg/dL/hr}$). Kufila insuline mivule kudi kuanji kukoka mayi mu mishipa (kuenza bua mashi apita) ne kubuela mu selile ya mu buongo, kufikisha ku edema wa mu buongo anyi dijimija dia osmotic demyelination.
  • Mu DKA wa bana: Bana ne bansonga badi mu njiwu ya pa buayi ya DKA-associated cerebral edema, udi ne tshitupa tshia lufu tshia 20 too ne ku 25 pa lukama. Kupuekesha sukadi mu mashi lukasa lukasa ne insuline bolus (anyi kufila bicarbonate de sodium mu mushipa) kudi kuvudija bikole njiwu ya disama dia buongo didi mua kushipa muntu.

Kujingulula disama dia buongo (divulangana dia buongo) kudi bana ne bansonga

Tangila muana yonso, nsonga, anyi nsongalume udi ne DKA bimpe bua kumona bimanyinu bia dibandila dia tension wa mu mutu (edema wa mu buongo), udi mua kutuadija kumpala kua kufika mu lupitadi anyi mêba 4 anyi 12 kunyima kua diondapangana dimane kutuadija:

Bimanyinu bikunze bia edema wa mu buongo (Disama dia lukasa dia mu lungenyi)

  • Mutu mupiamupia anyi udi wenda ukola (nangananga kunyima kua dilengejibua dia kumpala).
  • Dishintuluka dia tshimpitshimpi dia ngikadilu: Dibungama dia pa tshibidilu, dibungama, dipanga dia dikisha, anyi dilala tulu dia tshimpitshimpi ne dipanga dia kujuka.
  • Diteketa dia muoyo (bradycardia) pamue ne dibandila dia mashi (Triad wa Cushing): Mu mubedi wa DKA udi kayi ne mâyi mu mubidi, mutshima udi wenda lubilu (\(110\text{ to }150\text{ bpm}\)). Shi dikuma dia muoyo wa muana dipueka mu tshimpitshimpi too ne ku \(60\text{ to }70\text{ bpm}\) padiye wenda ulala tulu, udi mua kuela meji ne: udi ne disama dia buongo diakamue.
  • Difuka dia misangu ne misangu, mêsu adi kaayi malelela, mêsu matapuluka, kuikala ne mubidi mubi, anyi dipanga dia kulama makanda.
  • Tshia kuenza diakamue: Bandisha mutu wa bulalu too ne ku 30 degrés, ikala ne nshingu munkatshi, ne udimuije baminganga diakamue bua bobu kukupesha hypertonic \(3\%\) saline (\(3\text{ to }5\text{ mL/kg}\)) anyi mannit{t\t{\(50t{to. }1.0\text{ g/kg}\)).

Tshilumbu tshia pa buadi tshia tshimpitshimpi: Dinyanguka dia pompe wa insuline ne mukenji wa "Pen First"

Babedi badi benza mudimu ne tshiamu tshia insuline tshia muinshi mua dikoba (CSII) pompe wa insuline badi ne lutatu lua pa bualu lua DKA udi utuadija lukasa: - Bishilangane na bantu badi benza mudimu ne tshiamu tshia nzembu badi banua dituku dionso insuline wa tshimpitshimpi (glargine, degludec, anyi detemir) udi ushala wenza mudimu muinshi mua dikoba munkatshi mua mêba 24 too ne ku 42, pompe wa insuline udi anu ne insuline udi wenza mudimu lukasa (lispro, aspart, anyi glulisine). - Shi tshiamu tshia Teflon tshidi muinshi mua dikoba tshinyanguka, tshipatuka, anyi tshikanga, insuline udi wenda upuekela ku zero mu mêba 2 anyi 3, ne DKA mujima udi mua kukola mu mêba 4 anyi 6.

Liste wa malu a dijikija dia ntatu ya pompe wa insuline ketone

  • Tshitupa 1: Shi sukadi mu mashi i \(\ge 13.9\text{ mmol/L}\) (\(250\text{ mg/dL}\)) ne ketone ya mu mashi i \(\ge 1.5\text{ mmol/L}\), ela meji ne: muaba wa diela mashi mu pompe mmupangile, nansha mudiku kakuyi tshimanyishilu.
  • Tshitupa 2: Kufidi bolus wa dilongolola ku diambuluisha dia pompe to. Enza mudimu ne tshiamu tshia insuline anyi tshintu tshia kuela natshi insuline tshia musangu umue bua kuela dose wa dilongolola dia lukasa mu tshitupa tshipiatshipia tshia mubidi.
  • Tshitupa 3: Umbusha tshiamu tshia kale, tangila dikoba bua kumona ni kudi tshitoke anyi mupuya wa insuline udi upatuka, ne wela tshiamu tshipiatshipia tshia kuela nabi mashi, tshilaminu, ne insuline mupiamupia muaba mupiamupia.
  • Tshitupa 4: Nua 250 too ne ku 500 millilitres (8 too ne ku 16 ounces ya mâyi) ya mayi ne utangile kabidi bungi bua glucose ne ketones mu mashi mu minite 90 too ne ku 120. Shi ketones mibandile nansha kutuadija kuela nsukadi, udi mua kubikila 911 / 112 / 999 anyi kuya ku nzubu wa lupitadi lua lukasa.

Mikenji ya or ya dilama dia matuku a disama dia ku nzubu bua kuepuka DKA ne HHS

Bantu bapite pa tshitupa tshia bantu bonso badibu babueja mu lupitadi bua DKA ne HHS badi bafumina ku masama a pa tshibidilu (masama a mu njila wa mashi, disama dia tshiadi, grippe, COVID-19, anyi gastroenterite) mudi tshilema tshia manga tshienzeka. Londa mikenji itanu ya matuku a disama idi mianyishibue kudi tshisumbu tshia bena Amerike tshia disama dia diabete (ADA), diabete UK, ne ISPAD:

  1. Mukenji 1: KULEKEDI nansha kakese kunua insuline webe wa basal (wa mudimu mutantshi mule), nansha wewe wenda upela ne udia biakudia bia zero.
  2. Mu tshikondo tshia luya anyi tshia disama, hormone ya tunyinganyinga itu yenza bua tshifu tshiebe tshipuekeshe glucose ne ketones mu mashi ebe misangu yonso, nansha wewe muikale ne tshifu tshitupu. Kulekela insuline wa matuku a bungi (Lantus, Toujeo, Tresiba, Levemir) bualu kuena udia ke tshintu tshinene tshidi tshikebesha DKA.
  3. Mukenji 2: Tangila glucose mu mashi ne ketones mu mashi kunyima kua meba 2 to ne ku 4 pa dîba (nansha butuku).
  4. Kueyemenyi anu tshiamu tshia kutangila natshi glucose (CGM) mu tshikondo tshia dijimija dia mayi mu mubidi, ne misangu yonso tangila ketones padi sukadi mu mashi upita \(13.9\text{ mmol/L}\) (\(250\text{ mg/dL}\)) anyi dîba dionso didi muntu ne tshiji.
  5. Mukenji 3: Nua 100 to ne 250 millilitres (3.5 to 8 ounces ya mayi) ya mayi kunyima kua minite 30 to ne 60, bilondeshela mishindu ya mayi ne sukadi mu mashi eba.
  6. Glucose wa mu mashi udi pa mutu pa \(10.0\text{ to }11.1\text{ mmol/L}\) (\(180\text{ to }200\text{ mg/dL}\)): Nua maluvu adi kaayi ne sukadi (mayi malelela, bintu bia electrolyte bidi kabiyi ne sukadi, anyi tshisuku tshia mukele).
  7. Glucose wa mu mashi udi muinshi mua \(10.0\text{ mmol/L}\) (\(180\text{ mg/dL}\)) ne disama dia mutshima anyi ketones mibandile: Nua maluvu adi ne hydrate (mayi a bimuma adibu balengeje, tshintu tshia kuondopa natshi mâyi mu mishiku, anyi ice pops) pamue ne kufunda insuline wa disama dia ketone dituku dionso dienza.
  8. Mukenji 4: Londa tshikandakanda tshia insuline wa dituku dia disama (pa tshibidilu 10% too ne ku 20% ya dose yonso wa dituku dionso) mufunda kudi munganga webe wa disama dia mashi.
  9. Bibambalu bia bungi bidi bifila tablo bilondeshela Dose mujima wa ku dituku (TDD) wa insuline. Padi glucose mu mashi muvula ne ketones mikese anyi ya pa tshibidilu (\(0.6\text{ to }2.9\text{ mmol/L}\)), babedi batu batamba kuangata 10 to 20 pa lukama ya TDD yabu bu insuline udi wenza mudimu lukasa kunyima kua mêba 2 to ne 4, bilondeshile plan wabu wa dilama udibu bafunde.
  10. Mukenji 5: Lekela manga a "SADMANS" mu tshikondo tshia dipanga dia mayi anyi dia nsukadi.
  11. Malongolodi a disama dia diabete adi enza mudimu ne "SADMANS" acronym bua mapilu a dituku dionso adi ne tshia kuimana bua tshitupa tshîpi padi muntu usama bikole, disama dia tshiadi, anyi dipanga dia mâyi mu mubidi bua kuepuka Euglycemic DKA, disama dia tshiadi, ne lactic acidose:
    • Sulfonylureas (glipizide, gliclazide, glimepiride: bidi bifikisha ku dipuekesha dia mashi mu mashi padibu kabayi badia)
    • Bintu bidi bipangisha ACE (lisinopril, ramipril, enalapril: bidi binyanga dilengeja dia mifuba padibu kabayi ne mâyi)
    • Diuretiques / water pills (furosemide, hydrochlorothiazide: worse dehydration and HHS)
    • Metformin (udi ukebesha disama dia lactic acidose pikala mifuba idi kayiyi ne mâyi kayiyi mua kumujikija)
    • Angiotensin Receptor Blockers / ARBs (losartan, valsartan, candesartan)
    • Non-steroidal anti-inflammatory drugs / NSAIDs (ibuprofen, naproxen: damage dehydrated kidneys)
    • SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin: trigger Euglycemic DKA)

Enza kalasa

Kulonga tulasa tua diambuluisha dia kumpala tua bianza kudi Croix-Rouge, St John Ambulance, anyi kudi mufidi wa tulasa tua lukasa lua muaba unudi, pamue ne programe wa dilongesha dia didilama dia diabete, kudi kukuambuluisha wewe ne bena mu dîku diebe bua kuandamuna ne ditalala ne mu bujalame ku ntatu ya sukadi mukese anyi wa bungi mu mashi.

Nkonko itubu bela misangu ya bungi

Mmunyi mundi mua kumanya dishilangana pankatshi pa sukadi mukese mu mashi (hypoglycémie) ne sukadi mu mashi muvule (DKA anyi HHS) meme tshiyi ne tshiamu tshia kupima natshi bintu ku bianza?

Hypoglycémie udi ulua mu minite mikese ne udi ukebesha dikankamika, tuishi tua mashika, dikoba ditoke, ne dipanga dia lungenyi dia tshimpitshimpi. Bishilangane, DKA ne HHS bidi bikola mu meba anyi matuku ne bidi bifikisha ku nyota mikole, ku diela mashi misangu ne misangu, dikoba diume, difu, ne mupuya mukole wa lukasa ne mupuya wa bimuma; shi kuena mua kuteta sukadi mu mashi, udi mua kuanji kuondopa disama dia hypoglycémie bualu sukadi mukese mu mashi udi unyanga buongo mu minite mikese, kadi 15 grame ya sukadi kayena mua kunyangakaja DKA anyi HHS to.

Muntu udibu kabayi banji kupeta disama dia diabete udi mua kupeta DKA mu tshimpitshimpi anyi?

Eyowa, bana batue ku 20 too ne ku 40 pa lukama, bansonga, ne bansonga badibu bapeta ne disama dia diabete wa mushindu wa kumpala badi anu bapeta disama diabu padibu babaya lubilu mu nzubu wa luondapu lua diabete wa diabete. Misangu yonso ikala wela meji ne disama dia diabete dia mushindu wa kumpala ne DKA pikala muana anyi muntu mukulumpe mujimije kilo mu mbingu 1 to ne ku 3 kayi umvuika, nyota misangu yonso, ne diela dia mashi misangu ne misangu (anyi diela dia mashi mu bulalu bupiabupia) dilonda kudi diela, disama dia mu difu, ne dipuyakana dia lukasa.

Bua tshinyi bidi ne njiwu bua muntu udi ne pompe wa insuline kuenza mudimu ne pompe bua kulongolola sukadi mu mashi ne ketone?

Bu mudi pompe wa insuline wenza mudimu anu ne insuline udi wenza mudimu lukasa ne insuline wa basal udi wenza mudimu mutantshi mule, bungi bua sukadi mu mashi pamue ne ketones mibandile (1,5 mmol/L anyi kupita apu) bitu bitamba kumvuija ne: kanyula udi muinshi mua dikoba mmukoseka anyi mmukanga. Kuela bolus wa dilongolola mu tshiamu tshia kanyula tshikanga kakuena kufila insuline to, kadi kudi kujimija mêba a bungi; Ela dose wa dilongolola ku diambuluisha dia tshiamu tshia insuline tshia ku bianza anyi tshintu tshia kuela natshi insuline mu tshitupa tshia mubidi tshipiatshipia ne kushintulula tshiamu tshijima tshia dibueja dia mashi mu pompe.

Bidi biumvuija tshinyi padi tshiamu tshia ku nzubu tshileja "HI" pamutu pa nomba?

Pa biamu bia kupima nabi bungi bua sukadi mu mashi a bantu badi basumba bintu, "HI" udi umvuija ne: sukadi mu mashi udi upita tshipiminu tshinene tshia tshiamu etshi, pa tshibidilu pa mutu pa 27,8 too ne ku 33,3 mmol/L (500 too ne ku 600 mg/dL). Dibala dia "HI" didi didimuija dia Diabetic Ketoacidosis (DKA) anyi Hyperosmolar Hyperglycemic State (HHS); Tangila ketones mu mashi diakamue, ne muntu yeye mupampakane, mulale tulu, muele nsukadi, anyi muikale ne ketones mipite pa 1,5 too ne ku 3,0 mmol/L, ubikile diakamue bena mudimu ba lupitadi lua lukasa.

Miaba mifumina

  • Tshisumbu tshia bena Amerike tshia disama dia diabete (ADA, États-Unis), Tshisumbu tshia ku Mputu tshia dilonga dia disama dia diabete (EASD), Tshisumbu tshia bena Grande-Bretagne tshia disama dia diabete tshia dilama dia babedi (JBDS, Royaume-Uni), Tshisumbu tshia bena Amerike tshia malu a disama dia diabete (AACE), ne Tshisumbu tshia malu a disama dia diabete (DTS): *Hypersussus: (Umpierrez et al., Diabetes Care / Diabetologia, 2024).
  • Tshisumbu tshia matunga masanga tshia disama dia diabete dia bana ne dia bansonga (ISPAD): Mikenji ya dianyisha dia mudimu wa luondapu wa ISPAD: Diabetic Ketoacidosis ne Hyperglycemic Hyperosmolar State mu bana ne bansonga (Glaser et al., Pediatric Diabetes).
  • Tshilongelu tshia ditunga tshia malu a bukola bua mubidi ne a dilama dia bantu (NICE, Royaume-Uni): Disama dia diabete dia mushindu wa kumpala mu bantu bakole: Dimanya ne dilama (NG17) ne Disama dia diabete (mushindu wa kumpala ne wa 2) kudi bana ne bansonga: Dimanya ne dilama (NG18, kusangisha ne edema wa mu buongo ne protocole ya dipingaja dia mâyi).
  • Bisumbu bia bena ditunga dia Grande-Bretagne bidi bitangila disama dia diabete (JBDS-IP, mu Royaume-Uni): Dilama dia disama dia diabete mu bantu bakole ne Dilama dia disama dia hyperglycémie dia hyperosmolar (HHS) mu bantu bakole.
  • United States Food and Drug Administration (FDA), European Medicines Agency (EMA), and Diabetes Canada: Safety Alerts and Clinical Guidance on SGLT2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis and Sick Day Medication Management ("SADMANS" & "STOPK").

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