Skip to content

Ketoacidosis mate huka (DKA) me te Hyperosmolar Hyperglycemic State (HHS)

He rereke nga nama ohorere i ia whenua. Ka whakamahia e tenei wharangi te 911, te nama mo te United States me Canada. He maha nga whenua e whakamahi ana i te 112, 999, tetahi atu nama ranei. Kimihia te nama mo to whenua.

Ko te Ketoacidosis Diabetic (DKA) me te Hyperosmolar Hyperglycemic State (HHS) e rua nga mate ohorere tino kino i roto i te tiaki mate huka, ka kaha te matewai, te ohorere o te rere, te pupuhi o te roro (cerebral edema), te koma, me te mate ki te kore e rongoa wawetia me te wai whakaroto o te hohipera, te whakakapi i te hiko, me te insulin. Ahakoa he tere te whakawhanaketanga o te DKA i roto i nga haora ki te ra ka kaha te kore o te insulin ki te tahu i te ngako ki roto i nga ketone waikawa, ka hanga te HHS mo etahi ra ki te wiki (te nuinga o nga pakeke ki te mate huka Momo 2), ka piki te huka toto ki nga taumata tino nui, ka heke ki te 9 ki te 12 rita (2.4 ki te 3.2 karani wai mai i te tinana). Ko te mohio tonu ki nga tohu whakatupato penei i te ruaki, te mamae o te puku, te manawa tere, te rangirua ranei, ka honoa ki te whakamatautau ketone toto ki te kainga me te kawe hauora ohorere, ka ora.

Ko te ruaki ki te mate huka, ki te ketone teitei ranei he ohorere rongoa, ehara i te mate puku

Ko te nausea, te ruaki, me te mamae o te puku he tohu matarohia o Diabetic Ketoacidosis (DKA), kaua ko te gastroenteritis viral anake. Kaua rawa e whakaaro he mate huka Momo 1, momo 2 ranei e ruaki ana he kai paihana, he rewharewha puku ranei. I tua atu, ko nga turoro e tango ana i nga rongoā aukati SGLT2** (pērā i te empagliflozin, dapagliflozin, canagliflozin, ertugliflozin ranei) ka mate pea te Euglycemic DKA ahakoa te ahua o te huka toto o te maihao (i raro iho i te \(11.1\text{ mmol/L}\)\(200\) ranei). I nga wa katoa ka ruaki te tangata mate huka, ka manawa hohonu, ka tere, ka moe, ka rangirua ranei, ka whakaatu ranei i nga ketone toto i runga ake ranei i te \(1.5\text{ to }3.0\text{ mmol/L}\), waea atu ki nga ratonga hauora whawhati tata, haere ranei ki te ruma ohorere.

Mahia tenei inaianei

  1. Waea atu ki to nama whawhati tata tonu mena kei te rangirua te tangata, e moe ana, e manawa hohonu ana, e tere ana, e ruaki ana, he toto ketone ranei tona \(\ge 3.0\text{ mmol/L}\). Waea 911 i Amerika me Kanata, 112 puta noa i te Kotahitanga o Europi, 999 i te United Kingdom, tirohia katoa ranei tau ohorere. Korero atu ki te Kaituku kei te whakapaehia te Diabetic Ketoacidosis (DKA) ranei Hyperosmolar Hyperglycemic State (HHS) me te hiahia ki te whakaora i te wai i roto i te hohipera me te tirotiro hiko.
  2. Whakamatauhia te huka toto toto me nga ketone beta-hydroxybutyrate toto e rua (mehemea kei te waatea he mita). Kaua e whakawhirinaki ki nga panui pukoro Aroturuki Tuturu (CGM) anake i te wa o te matewai nui, te wiri ranei, i te mea kei muri te wai o te kiko i muri i nga uara toto. Tuhia te tau tika o te huka toto (me tuhi ranei mena ka panui te mita "HI", ko te tikanga kei runga ake i te \(27.8\text{ ki }33.3\text{ mmol/L}\) [\(500\text{ to }600\text{ mg/dL}\)]) me te taumata ketone toto tika i te \(\text{mmol/L}\) (te tae ketone mimi ranei).
  3. Whakaorangia te huarahi hau ma te tuu i te tangata e moe ana, e rangirua ana, e ruaki ana ranei ki tona taha ki te waahi whakaora. Kaua rawa e hoatu he wai-waha, he kai, he pire ranei ki te tangata e ngengere ana, e pohehe ana te korero, e rangirua ana, e ruaki kaha ana ranei, no te mea ka ngawari te ngongo o te wai ki roto i o ratau puku (aspiration pneumonia). Mena kei te katoa te oho, te mataara, me te kaha ki te horomia me te kore e ruaki, whakatenatena ia ia ki te inu i te wai noa, i te wai hiko kore huka ranei (tata ki te 250 mira [8 hekere wai] ia 15 ki te 30 meneti mo te pakeke) i te wa e tatari ana ki te tiaki hauora.
  4. Tirohia te papu insulin mo te ngongo ngongo, te ngoikore ranei o te cannula, KAUA rawa e whakahiatohia nga werohanga insulin i raro i te kiri. Ki te whakamahi te manawanui i te papu insulin me te nui o te huka toto me nga ketone teitei (\(\ge 1.5\text{ mmol/L}\)), whakaarohia kua rahua te waahi papu: kaua e hoatu he bolus whakatikatika ma te papu. Engari, me whai i ta raatau Mahere Mahi o te Ra Mauiui ma te whakamahi i te pene insulin subcutaneous hou, te syringe ranei ki te waahi kiri hou. Kaua rawa e tukuna nga werohanga insulin matapōkere ("whakapae") ki te whakaheke i te huka toto nui i mua i te taenga mai o nga paramedic, i te mea ka tere rawa te heke o te huka toto, te osmolality ranei o te toto ki te kore he tote me te pāhare pāporo i mua ka mate cerebral edema (te pupuhi roro) me te ** hypokalemic cardiac arrest**.
  5. Kaua e hoatu te acetaminophen (paracetamol), te aspirini, te ibuprofen ranei ki te tamaiti, ki te taiohi ranei kei te whakapaehia he DKA, ka karo i te bicarbonate. Ko te DKA mo nga tamariki he nui te mate o te pupuhi roro whakamomori i roto i nga haora 12 ki te 24 tuatahi o te maimoatanga; kia paku whakanekehia te mahunga me nga pakihiwi o te manawanui ki te koki 30-tohu mena e oho ana ratou, me waiho ma te roopu hohipera e whakahaere te pāmahana me te waikawa waikawa.
  6. Kohikohia nga taonga katoa mo te mate huka, nga rarangi rongoa (ina koa ko te aukati SGLT2 me te steroids), me nga raarangi mita tata mo nga kaiparapara. Hoatu ki te kaihautu waka tūroro te mita huka/ketone a te manawanui, pene insulin, nga taipitopito tauira papu, me te rarangi o nga rongoa katoa o ia ra kia taea ai e te tari whawhati tata tonu te timata i te tika o te saline me te kawa whaowhia o te insulin.

Ko te whakamatautau mo te mate hyperglycemic me te rakau whakatau mahi ketone

Whakamahia tenei mahere rerenga haumanu ki te arotake i te huka toto tiketike, ki te whakamaori i nga panui ketone o te toto, mimi ranei, me te whakatau i waenga i te whakahaeretanga o nga ra mate ki te kainga me te kawe i te hohipera ohorere.

flowchart TD
    Start["Ko te tangata whai mate huka e mohiotia ana, kaore ranei i kitea he:<br/>te huka toto >= 13.9 mmol/l (250 mg/dl)<br/>he mate ranei / nausea / ruaki (ahakoa te huka < 13.9 mmol/l i runga i te SGLT2i)"] --> RedFlags{"He Kara Whero Ohotata?<br/>1. Te manawa hohonu, tere (Kussmaul respirations) or manawa hua<br/>2. Te ruaki tonu, te kore ranei e kaha ki te pupuri wai mo te >2 ki te 4 haora<br/>3. Te mamae nui o te puku, te rangirua, te tino ngenge, te korero pohehe ranei<br/>4. Toto Ketones >= 3.0 mmol/L (he 'nui' urine ketones)<br/>5. Ka panui te mita 'HI' (>33.3 mmol/L / 600 mg/dL) me te tino matewai"}

    RedFlags -->|"ĀE: He haki whero kotahi kei reira"| CallEMS["OHOHORAE WHAKAMAHI KAUPAPA (DKA, HHS ranei):<br/>1. Waea 911 / 112 / 999 Inamata<br/>2. Mēnā ka momoe, ka ruaki rānei: Te tūnga whakaora & Karekau mā te Māngai (NPO)<br/>3. Ki te tino mataara me te kore e ruaki: He iti te topa o te wai noa<br/>4. KAUA e whakaputuhia nga horopeta nui o te insulin i mua i te wē IV/pāhare pāporo"]

    RedFlags -->|"KO: Kia mataara, kia rite te manawa,<br/>kaore e ruaki tohe"| CheckKetones{"Tirohia nga Ketone Toto (Beta-Hydroxybutyrate)<br/>ranei Urine Ketone Strip"}

    CheckKetones -->|"Nga Ketone toto 1.5 ki te 2.9 mmol/L<br/>(Nga Ketone Mimi Tika)"| ModKetones["Te Ketonemia (Whakatupato DKA e tata ana):<br/>1. Whakapa atu ki te roopu mate huka, ki te waea awhina hauora ohorere ranei<br/>2. Mēnā kei runga i te papu insulin: Homai he whakatikatika tere ma te PEN/SYRINGE<br/> ki te waahi hou ka huri i te huinga whaowhanga papu katoa<br/>3. Inu 250 mL (8 oz) wai kore huka ia 30 ki te 60 meneti<br/>4. Tirohia ano te huka toto me te ketone i roto i te 2 haora (Haere ki te ER mena ka piki)"]

    CheckKetones -->|"Nga Ketone Toto 0.6 ki te 1.4 mmol/L<br/>(Whakaahua ki nga Ketone Mimi Iti)"| MildKetones["Te Ketonemia ngawari:<br/>1. Me whai i nga Ture o te Ra Mauiui kua tohua mo te insulin mahi tere ake<br/>2. KAUA E whakamutua te insulin basal/mahi roa (ahakoa kare e kai)<br/>3. Horoihia ki te wai (he wai waro ranei mena he huka <10 mmol/L / 180 mg/dL)<br/>4. Tirohia ano te huka toto me te ketone ia 2 ki te 4 haora"]

    CheckKetones -->|"Nga Ketone Toto <0.6 mmol/L (Taunoa)<br/>ME Te huka 13.9 ki te 22.2 mmol/L (250-400 mg/dL)"| NoKetones["Hyperglycemia Karekau he Ketosis:<br/>- Tangohia te horopeta whakatikatika kua whakaritea mo te insulin mahi tere<br/>- Inu nui te wai me te aro turuki mo nga tohu whakaheke HHS<br/>- Rapua he tiaki hauora mena kei te noho te huka >16.7 mmol/L (300 mg/dL) mo te 2 tirotiro"]

Te mohio ki te pathophysiology: He aha te DKA me te HHS i whanake ai me pehea te rereke

Ahakoa ka puta mai te DKA me te HHS i te iti o te mahi insulin me nga homoni taumahatanga (glucagon, cortisol, epinephrine, me te hormone tupu), ka whai ratou i nga ara matū koiora e rua e whakamarama ana he aha te rerekee o o ratou tohu, uara taiwhanga, me nga tupono o te hohipera tonu.

1. Ketoacidosis Diabetic (DKA): Te matekai i waenganui i te tini

I roto i te Diabetic Ketoacidosis (DKA), he nui, he kore rawa ranei o te insulin huri noa. Ki te kore he insulin, ka mau tonu te huka ki roto i te toto, kare e taea te uru ki nga uaua, ngako ngako ranei mo te kaha. Ki te whakaaro kei te hiakai te tinana, ka tukuna e nga repe adrenal me te pancreatic te nui o te glucagon, adrenaline, me te cortisol, e rua nga rerenga kino: - Kare i tirohia te Lipolysis me te Ketogenesis (Metabolic Acidosis): Ka pakaru tere te kiko adipose (ngako) ki nga waikawa ngako kore utu, ka haere ki te ate. Ka huri te ate i enei waikawa ngako ki roto i nga ketone tinana: beta-hydroxybutyrate (te waikawa rere tuatahi i roto i te DKA), acetoacetate, me acetone (e whakahaa ana e nga ngongo, ka puta he kakara reka "pear drop" ranei nail-polish-remover i te manawa). Ko enei ketoacids kaha ka whakapouri i te punaha parepare bicarbonate o te toto, ka heke te toto toto \(\text{pH}\) ki raro i te \(7.30\) (me raro iho i te \(7.00\) mo te DKA kino). - Osmotic Diuresis and Electrolyte Depletion: Kia neke ake te huka toto i te paepae whatukuhu tata ki te \(10.0\text{ to }11.1\text{ mmol/L}\) (\(180\text{ to }200\text{ mg/dL}\)), te huka me te ketones ka rere ki roto i te mimi, te konupora me te konutai konutai ki waho o te mimi, te konupora me te konutai o te konutai ki waho. Ko te pakeke i DKA ka ngaro 5 ki te 7 rita (1.3 ki te 1.8 karani) o te wai tinana (\(100\text{ mL/kg}\)) i roto i te 24 haora.

2. Hyperosmolar Hyperglycemic State (HHS): Tino matewai me te toto matotoru

Hyperosmolar Hyperglycemic State (HHS) ka puta te nuinga ki nga pakeke pakeke me Momo 2 te mate huka (ahakoa ka piki haere te puta ki nga taiohi me nga taiohi pakeke me te momi me te mate huka Momo 2). Kaore i rite ki te DKA, ka whakaputa tonu te tangata i roto i te HHS ** he nui noa iho te insulin pancreatic baseline hei aukati i te pakaru o te ngako (lipolysis) me te hanga ketone**, engari kaore i te nui o te insulin hei aukati i te ate ki te ringihia te huka ki roto i te toto, ki te neke huka ki roto i nga ruma. - Na te mea karekau te turoro e tino waikawa i tenei wa tonu (kaore he ruaki tere, he manawa Kussmaul ranei i nga haora 24 tuatahi), kare ia e tino mate i te Ra 1. Engari, ka piki haere te huka toto i roto i etahi ra ki te 2 wiki, ka tae ki te \(33.3\text{ to }66.6\text{ mmol/L} mg/dL}\)). - Ko tenei osmotic diuresis e tuku 9 ki te 12 rita (2.4 ki te 3.2 karani) o te wai (\(100\text{ to }200\text{ mL/kg}\), neke atu ranei ki te 20 paiheneti o te wai tinana katoa) mai i te tinana o te turoro. I te wa e kore ai te tangata e inu i te wai nui e te mate, te patu patu, te mate ngakau, te noho korekore ranei o te whare ngote, ka piki ake te osmolality toto ki runga \(320\text{ mOsm/kg}\). Ka ngotea te wai ki waho o nga pūtau roro, ka puta te ngenge hohonu, nga ngoikoretanga o te roro e rite ana ki te whiu, hopukina, coma, me nga toka toto totika ranei (pulmonary embolism ko te mate ngakau ranei). Na te mea he pakeke ake nga turoro me te tino mate waikore, He 10 ki te 20 paiheneti te mate o te HHS, he 5 ki te 10 nga wa teitei ake i te reiti mate o DKA.

Whakataurite mahunga ki te upoko: DKA vs. Euglycemic DKA vs. HHS vs. Hypoglycemia

Whakamahia tenei ripanga tātaritanga haumanu (whakauruhia te 2024 Joint ADA / EASD / JBDS / AACE / DTS Consensus Report on Hyperglycemic Crises in Pakeke me ISPAD Pediatric Guidelines) ki te wehewehe i waenga i nga mate ohorere:

Ahuatanga Haumanu, Biochemical ranei Matarohia te Ketoacidosis mate huka (DKA) Euglycemic DKA (euDKA) Te Hunga Hiperglycemic Hyperosmolar (HHS) Hipoglikemia Tino (Tuku Toto Iti)
Kotaha Turoro Tikanga Ko te nuinga o Te mate huka Momo 1 (tae atu ki nga tamariki/pakeke katahi ano ka kitea), ko te ketosis-prone Te mate huka Momo 2 i raro i te taumahatanga/mate. Momo 1, Momo 2 ranei te mate huka e tango ana i nga Kaipiri SGLT2, i te ** haputanga** ranei, te nohopuku, te kai ketogenic, te pokanga bariatric, te whakamahi waipiro nui ranei. Ko te nuinga ko nga pakeke e mau ana i te mate huka Momo 2 (i te nuinga o te wa ka pangia e te mate, te whiu, te mate ngakau, te diuretics, te mate matewai ranei). Ko te tangata e tango ana i te insulin me te sulfonylurea pire (glipizide, glimepiride, glyburide).
Te tere o te timatanga ** Tere: 4 ki te 24 haora** (ka tupu i roto i i raro i te 4 haora mena ka momotuhia, ka paraka ranei te papu insulin). Ka tere ki te whakaheke: haora ki etahi ra (he maha nga wa ka whakaroa te tātaritanga na te mea he ahua noa te huka toto). Te puhoi me te hianga: he maha nga ra ki te 2 wiki o te polyuria, polydipsia, me te ngoikore. Miti: Ka puta ohorere mai te wiri, te werawera, te rangirua, te hopu ranei.
Taumata huka toto Ko te tikanga \(\ge 11.1\text{ mmol/L}\) (\(\ge 200\text{ mg/dL}\)) (te tikanga \(14\text{ to }30\text{ mmol/L}\) [\(250\text{ to }550\text{ mg/dL}\)]). I raro iho i te \(11.1\text{ mmol/L}\) (\(< 200\text{ mg/dL}\)), i etahi wa ka tino noa (\(5.5\text{ ki }9.0\text{ mmol/L}\) [\(100\text{ ki }160\text{ mg/dL}\)]). \(\ge 33.3\text{ mmol/L}\) (\(\ge 600\text{ mg/dL}\)), he maha nga panui "HI" ki nga mita o te kainga (\(600\text{ ki }1,200+\text{ mg/dL}\)). I raro iho i te \(3.9\text{ mmol/L}\) (\(< 70\text{ mg/dL}\)); neuroglycopenia kino i raro i te \(3.0\text{ mmol/L}\) (\(54\text{ mg/dL}\)).
Blood Ketones (\(\beta\)-Hydroxybutyrate) \(\ge 3.0\text{ mmol/L}\) (he mimi ketone \(\ge 2+\) / āhua-ki-nui). \(\ge 3.0\text{ mmol/L}\) (ahakoa te nui o te huka toto, he iti noa iho ranei). \(< 3.0\text{ mmol/L}\) (kei te ngaro, he ketone ngawari noa iho ranei te matekai; ko te mimi ketone he kino, he tohu ranei). Taunoa (\(< 0.6\text{ mmol/L}\)).
Arterial/Venous pH & Bicarbonate Acidotic: \(\text{pH} < 7.30\) me te serum bicarbonate \(< 18\text{ mmol/L}\) (\(< 10\text{ mmol/L}\) i te DKA kino). Acidotic: \(\text{pH} < 7.30\) me te serum bicarbonate \(< 18\text{ mmol/L}\). Kaore i te tino waikawa: \(\text{pH} \ge 7.30\) me te serum bicarbonate \(\ge 15\text{ ki }18\text{ mmol/L}\). ** pH noa**.
Tauira Manawa me te Hongi Manawa Kussmaul respirations (hohonu, tere, he mapu mapu ki te pupuhi \(\text{CO}_2\)) + manawa acetone reka/hua. Kussmaul respirations + manawa hua + nausea/ruaki. Te manawa papaku, noa noa ranei (mehemea ko te pneumonia me te sepsis te keu); kahore he kakara acetone hua. Te manawa papaku tere ranei; koma, makuku i te werawera makariri.
Nga tohu mate whekau Whakaahua: Te maunu nui, te ruaki tonu, me te mamae o te puku o te puku (he rite ki te appendicitis acute or pancreatitis). Whakaahua: Nausea, ruaki, ngaronga o te hiahia, te puku o te puku, me te koretake. He ngawari, kei te ngaro ranei: He iti noa te mamae o te puku engari mena he mate puku. Ko te matekai i te tuatahi, ka ahu whakamua ki te rangirua, ki te kore whakautu ranei.
Tūnga Neurological Matohi i te DKA ngawari; te momoe, te ngenge, te wahangu ranei i roto i te DKA ahua-ki-kino. Te ngenge, te ngoikore, te ngenge, me te nausea; ka haere ki te porangi ki te kore e rongoatia. Te mate o te neuropi hohonu: Te rangirua, te pohehe, te hemiparesis (whakarite whiu), te hopu, te koma ranei na te Serum Osmolality \(> 320\text{ mOsm/kg}\). He ohooho ohorere, he korero pohehe, he hopu, he kore mohio ranei; ka huri tere me te glucose/glucagon.
Wawaenga o te Tapeke Wai (Pakeke) \(5\text{ ki }7\text{ rita}\) (\(100\text{ mL/kg}\)). \(3\text{ to }5\text{ rita}\) (he iti ake te osmotic glucose diuresis, mena ka kaha te ruaki). \(9\text{ ki }12\text{ rita}\) (\(100\text{ to }200\text{mL/kg}\)). Karekau (e hiahia tonu ana te huka, te glucagon ranei; tirohia ohorere mate huka).

Te mohio ki nga tohu whakatupato me te mahanga SGLT2 "Euglycemic DKA".

He pehea te ahu whakamua o nga tohu DKA mai i te Ketosis Moata ki te Tiango Acidotic

  1. Wāhanga 1: Hiperglycemia moata me te Ketonemia (Haora 1 ki te 6):
  2. Ko te matewai e kore e tineia (polydipsia), te waha maroke maroke, me te haere auau ki te mimi (polyuria), tae atu ki te oho i nga wa maha i te po (he makuku moe ohorere ranei i roto i te tamaiti kua whakangungua ki te wharepaku).
  3. Ko te ngoikoretanga o te uaua, te ngenge, te ahua pouri, me te mahunga.
  4. Ko te huka toto kei runga ake i te \(13.9\text{ mmol/L}\) (\(250\text{ mg/dL}\)) me nga ketone toto e piki ana i waenga i te \(0.6\text{ me }1.5\text{ mmol/L}\).
  5. Wāhanga 2: Te Ketoacidosis Whakapumau (Haora 6 ki te 18):
  6. Te nausea, te ruaki tonu, me te mamae nui o te puku: Ko te waikawa me te mate o te puku ka whakapataritari i te papa o te puku me te pakitara whekau. Kia timata te ruaki, kare e taea e te manawanui te pupuri i te wai-a-waha ki raro, ka tere te matewai ki raro.
  7. Kussmaul breathing ("air hinger"): Na te mea he tino waikawa te toto, ka akiaki te pokapu manawa o te roro ki te tango manawa hohonu, te tere, me te aue ki te pupuhi atu i te hauhā waikawa (\(\text{CO}_2\)). He maha nga wa ka pohehe te hunga e noho ana i tenei aue hohonu mo te pawera, te mate huango ranei, ahakoa te tangi o te ngongo.
  8. Ko te "pear drop" hua, te manawa tango-nail-polih-remover: I takea mai i te hau acetone rorirori e whakaeto ana i roto i nga pukoro.
  9. Wāhanga 3: DKA kua whakahekehia me te Ru (Hora 12 ki te 24+):
  10. Ko nga kanohi kua paheke, ka maroke te arero hiako, he kino te kiri kiri, he tere ngoikore (\(> 120\text{ bpm}\)), te heke toto, te rangirua, te kore e ara, te edema cerebral, me te mate ngakau.

Te Euglycemic DKA (euDKA) Rore: He aha te take ka huna tonu te huka toto noa i te DKA whakamate

I roto i nga tau tekau kua pahure ake nei, ko Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors, tae atu ki te empagliflozin (Jardiance), dapagliflozin (Farxiga/Forxiga), canagliflozin (Invokana), ertugliflozin (Steglatro), me te sotagliflozin (Inpefascribe), kua riro te mate o te ngakau maamaa (Inpefascribe)**. Ka mahi enei rongoa ma te akiaki i nga whatukuhu kia maka te 60 ki te 100 karamu o te huka ki roto i te mimi ia ra.

Na te mea kei te whakakore tonu nga whatukuhu i te huka i roto i te toto ki roto i te mimi, mena ka mate te turoro e tango ana i te aukati SGLT2, ka mutu te kai i te wa o te wheori puku, ka pokaia, ka tiimata te kai iti-karbohydrate/ketogenic, ka whakaheke ranei i te horopeta insulin, ka ringihia e to ratou ate nga ketone waikawa i te wa e noho tonu ana te huka toto o te maihao (\(60 noa. }11.0\text{ mmol/L}\) \(110\text{ ki }199\text{ mg/dL}\)).

Ko te Ture STOP DKA mo SGLT2 Inhibitors

Ko nga aratohu mate huka o te ao (ADA, EASD, UK JBDS, me nga matohi Hauora Canada / FDA) e whakahau ana i te "STOP DKA" mo te tangata e tango ana i te aukati SGLT2 (empagliflozin, dapagliflozin, canagliflozin, ertugliflozin): - Sme tango tonu i te papa aukati SGLT2 mena ka tino mate koe, ka kirikaa, ka nausea, ka ruaki, ka kore ranei e kaha ki te kai me te inu noa, ka mutu 3 ki te 4 ra i mua i te pokanga kua whakaritea, te colonoscopy ranei. - Test blood ketones (ehara i te huka toto anake) i nga wa katoa ka rongo koe i te nausea, i te ngenge, i te poto o te manawa, i te mamae puku ranei, ahakoa ka panui noa to mita huka toto (\(5.5\text{ to }10.0\text{ mmol/L}\) / \(100\text{ to }180\text{ mg/dL}\)). - Waiwao me nga warowaiha Oral: Mena kua piki ake nga ketone toto (\(> 0.6\text{ ki }1.5\text{ mmol/L}\)) a he mea noa te huka toto, me tino hiahia te manawanui ** nga warowaiha e rua (15 ki te 30 karamu o te huka/wai) ME te insulin tere tere** i te hohipera ki te whakakore i te tahu ngako ate. - Prenga atu ki te tari whawhati tata me te tino korero ki te taote whakamatautau: "Ka tango ahau i te aukati SGLT2 me te hiahia ki te tirotiro i te ketone beta-hydroxybutyrate toto me te tirotiro hau toto ki te whakakore i te Euglycemic DKA."

Te whakamatautau ketone toto me nga taahi ketone mimi: He aha te mea he pai ake nga mita toto i roto i te ohorere

I te wa e tirotirohia ana mo te DKA i te kainga, ** nga mita ketone toto capillary** (e ine ana i te beta-hydroxybutyrate [\(\beta\)-OHB] ma te whakamahi i te riipene matimati, penei i te mita hukahuka) he tino tika ake me te mahi atu i te ruku-ka-panui ** riihi ketone mimi** (ko te ine anake i te acetoacetate ma te tauhohenga nitroprusside):

  1. Ka ngaro te DKA moata i nga takai mimi: I te DKA kino, ka whakaputa te ate ki te 10 whakarea ake te beta-hydroxybutyrate i te acetoacetate. Na te mea kare e taea e nga mimi mimi te kite i te beta-hydroxybutyrate, ka kitea noa e te tiihi mimi nga ketone "tohu", "iti" ranei i te wa e noho ana te beta-hydroxybutyrate toto ki te \(3.5\text{ mmol/L}\).
  2. Ka aukati te matewai ki te mimi: Ko te manawanui tino mate wai i roto i te DKA, i te HHS ranei e kore e taea te whakaputa tauira mimi mo nga haora, engari he 10 hēkona te roa o te whakaheke toto maihao.
  3. Ka hangaia e nga takai mimi he whakaoho teka i te wa e whakaora ana: I te wa e whakatau ana te DKA me te maimoatanga, ka huri te beta-hydroxybutyrate ki te acetoacetate ka rehia ki roto i te mimi, ka huri te mimi ki te papura pouri ("nui") haora i muri i te maatanga o te waikawa o te toto.

Me pehea te whakamaori i nga nama ketone beta-hydroxybutyrate (\(\beta\)-OHB) toto

Panui Ketone Toto (\(\text{mmol/L}\)) Tata ki te Rihi Mimi Te Tikanga Haumanu me te Mahi Tere e hiahiatia ana
Kei raro i te \(0.6\kuputuhi{ mmol/L}\) He kino Awhe noa. Karekau he ketosis. Whakahaerehia te huka toto tiketike me nga pota whakatika me te wai.
\(0.6\kuputuhi{ ki }1.4\kuputuhi{ mmol/L}\) Whakataki ki te Iti (\(+\)) Ketonemia ngawari (Whakatupato moata). Kua timata te tinana ki te tahu ngako na te iti o te insulin, te nohopuku ranei. Whakamahia nga Ture o te Ra Mauiui: tango i te insulin tere tere, inu 250 ki te 500 mL (8 ki te 16 oz) o te wai ia haora, ka whakamatautau ano i te huka toto me nga ketone i roto i te 2 haora.
\(1.5\kuputuhi{ ki }2.9\text{ mmol/L}\) Whakaōrite (\(++\)) He nui te tupono ki te whakawhanake DKA. Whakapa atu ki to whare haumanu mate huka, waea awhina hauora ohorere ranei inaianei. Mena kei te whakamahi i te papu insulin, hoatu he horopeta whakatika ma te pene insulin-i raro i te kiri/puoro ka whakakapi i te huinga whaowhanga papu katoa. Inu wai ia 30 meneti ka whakamatautau ano i roto i te 1 ki te 2 haora; haere ki te rūma ohorere mena ka puta te ruaki, karekau ranei nga taumata e heke.
\(3.0\kuputuhi{ mmol/L}\) teitei ake ranei Nui (\(++++\) ki te \(++++\)) Maiora Ohotata: Ketoacidosis Diabetic (DKA) pea. Waea 911 / 112 / 999, whakarite ranei i te kawe tere i te hohipera mo te tote, te pāhare pāporo, me te rongoa insulin.

He aha me KAUA e whakararangihia nga pota insulin nui ki te kainga i mua i te taenga mai ki te hohipera

Ka kite tetahi turoro, mema ranei o te whanau i te mita huka toto e panui ana \(28.0\text{ mmol/L}\) (\(500\text{ mg/dL}\)) ranei "HI", he maha nga wa ka werohia e te parapara he horopeta nui o te insulin tere-mahi (he tukurua ranei nga werohanga ia 30 meneti) i mua i te haere ki te hohipera. Ko te hoatu inenga nui o te insulin kaore i rurihia, kua whakahiahia ranei ki tetahi turoro kua mate waikore i DKA, HHS ranei i waho o te hohipera he mea kino mo nga take ahuwhenua e toru:

1. Ko te matewai nui ka aukati i te whakaurunga o te insulin ki raro i te kiri, katahi ka tukuna katoatia.

Ki te matewai te manawanui i roto i te DKA, i te HHS ranei i te 5 ki te 10 rita, ka piri nga oko toto i roto i te kiri me te ngako subcutaneous hei pupuri i te rere o te toto ki te ngakau me te roro. He maha nga pota o te insulin mahi tere i werohia i raro i te kiri ka noho mau ki roto i te putunga o raro kiri kore parai. I te wa ka timata nga paramedics ki te tote i roto i te toto ka hoki mai te tohanga kiri, ka tere te putunga putunga ki roto i te rerenga toto i te wa kotahi, ka puta te wiri hypoglycemic nui.

2. Ko te kuia o te pāhare pāporo ki roto i ngā pūtau i mua i te tirotiro i nga taiwhanga toto ka mau te ngakau

I te wa o te DKA me te HHS, ka whakahekehia e te diuresis osmotic te nui o te potassium (\(\text{K}+\)) ki roto i te mimi. Ahakoa kua pau katoa te pāhare pāporo o te tinana, he rite tonu te ahua o te pāhare pāporo serum i te tuatahi na te mea ka peia e te waikawa te pāhare pāporo ki waho o ngā pūtau. Ka akiakihia e te insulin te pāhare pāporo mai i te rere toto ki roto i ngā pūtau. Mena ka tukuna he insulin nui i mua i te tirotiro a te hōhipera i te pāhare pāporo serum (a i mua i te whakaurunga o te pāhare pāporo pūhaumāota ki roto i te toto ina \(\text{K}+ <5.0\text{ ki }5.2\text{ mmol/L}\), i te wa ranei e mau ana te insulin ki te $\text{K}+ < 3.5} paramu i roto i te toto. ** hypokalemic ventricular arrhythmias and cardiac arrest**.

3. Ko te whakaheke tere o te huka toto i roto i te HHS, i te Pediatric DKA ranei, ka mate te Cerebral Edema me te Vascular Collapse.

  • I roto i te HHS: Ko te huka toto teitei te kaha osmotic matua e pupuri ana i te wai i roto i nga uaua whakaheke, a kua huri nga pūtau roro i roto i nga ra ki te osmolality tino (\(> 320\text{ mOsm/kg}\)). Ko nga aratohu a te hohipera (UK JBDS me ADA/EASD 2024 whakaaetanga) e kii ana ko te haora tuatahi o te maimoatanga HHS ko te \(0.9\%\) te whakaora i te wai tote noa KOE, ka whakaheke i te huka toto ma te haumaru ma te \(2.8\text{ ki }4.2\text{ mmol/L/hr}{ (\)50\text/hr} $75). Ko te hoatu pota nui o te insulin i te tuatahi ka ngotea te wai mai i nga uaua (e paheke ai te rere toto) ki roto i nga ruma roro, ka puta te ** edema cerebral or osmotic demyelination**.
  • I roto i te DKA Pediatric: Ko nga tamariki me nga taiohi he whakaraerae motuhake ki te DKA-associated cerebral edema, e mau ana i te 20 ki te 25 paiheneti te reeti mate. Ko te whakaheke tere i te huka toto me te insulin boluses (te hoatu ranei i te konutai konutai konutai ki roto i te toto) ka nui ake te mate o te pupuhi roro mate.

Te mohio ki te edema cerebral (te pupuhi roro) i roto i nga tamariki me nga taiohi pakeke

Tirohia nga tamariki katoa, taiohi, taiohi pakeke ranei me te DKA mo nga tohu o te piki haere o te pehanga intracranial (cerebral edema), ka timata i mua i te taenga mai ki te hohipera, 4 ki te 12 haora ranei i muri i te tiimata o te maimoatanga:

Nga tohu haki whero o te edema cerebral (Ohotata neurocritical tonu)

  • **He mahunga hou, kei te kino haere ranei ** (ina koa i muri i te whakapainga tuatahi).
  • ** Huringa ohorere i roto i te whanonga:** He riri rerekee, he ohooho, he ohooho, he momoe ohorere ranei me te kore e kaha ki te oho ake.
  • Te tere o te manawa (bradycardia) e honoa ana me te pikinga o te pehanga toto (Cushing's triad): I roto i te turoro DKA kua maroke, he tere te tere o te ngakau (\(110\text{ ki }150\text{ bpm}\)). Mēnā ka heke ohorere te manawa o te tamaiti ki te \(60\text{ ki }70\text{ bpm}\) i a ia e momoe ana, me whakapae tonu he mate roro.
  • Ko te ruaki auau, ko nga tauira rerekee, ko nga karu whiti, ko te tuunga rerekee, ko te koretake ranei.
  • Te mahi tere: Whakanuia te mahunga o te moenga ki te 30 nga nekehanga, kia mau tonu te raina waenga o te kaki, me te whakatupato i nga kaimatai i nga wa tonu kia taea ai e ratou te tuku i roto i te toto hypertonic \(3\%\) saline (\(3\text{ to }5\text{ mL/kg}\)) or ** mannitol (\(0.5\text{ to }1.0}\)text{**)

He ahuatanga ohorere motuhake: Ko te kore o te papu insulin me te ture "Pene Tuatahi".

Ko nga turoro e whakamahi ana i te whaowhia o te insulin subcutaneous (CSII) puu insulin ka mau i te whakaraeraetanga ahurei ki te DKA tere tere: - Kaore i rite ki nga kaiwhakamahi werohia e tango ana i te insulin i ia ra (glargine, degludec, detemir) e noho kaha ana i raro i te kiri mo te 24 ki te 42 haora, Kei roto i te papu insulin ANAKE te insulin tere tere (lispro, aspart, glulisine ranei). - Mēnā ka wiriwiri, ka mawehe, ka paraka ranei te kano Teflon i raro i te kiri, ka heke te insulin huri noa ki te kore i roto i te 2 ki te 3 haora, ka ka pupuhi te DKA i roto i te 4 ki te 6 haora.

Ma te taahiraa-i-te-taahiraa te papu insulin ketone rarangi arowhai raru

  • Taahiraa 1: Mena he \(\ge 13.9\text{ mmol/L}\) te huka toto he \(\ge 1.5\text{ mmol/L}\) (\(250\text{ mg/dL}\)) me nga ketones toto he \(\ge 1.5\text{ mmol/L}\), mehemea kua rahua te waahi whaowhia o te papu, ahakoa kaore he whakaoho aukati.
  • Step 2: KAUA e tuku i te bolus whakatika i roto i te papu. Whakamahia te tuara pene insulin tuku, te syringe ranei ki te werohia te horopeta whakatika tere kua tohua ki roto i te waahi tinana hou.
  • Taahiraa 3: Tangohia te cannula/pod tawhito, tirohia te kiri mo te whero, te pakaru ranei o te haunga o te insulin, ka whakauruhia he huinga whaowhia hou, he puna, me te insulin hou ki tetahi waahi hou.
  • Taahiraa 4: Inuhia te 250 ki te 500 milliliters (8 ki te 16 hekere wai) ka tirohia ano te huka toto me nga ketone i roto i 90 ki te 120 meneti. Mena ka piki ake nga ketones ka timata ranei te ruaki, waea atu ki 911/112/999, haere ranei ki te ruma ohorere.

Ko nga ture koura mo te Whakahaere o te Ra Mauiui o te kainga hei aukati i te DKA me te HHS

Neke atu i te haurua o nga whakaurunga katoa ki te hohipera mo DKA me te HHS ka pangia e nga mate noa (mate mimi, pneumonia, rewharewha, COVID-19, gastroenteritis ranei) ka puta he rongoa. A pee i enei ture e rima mo nga ra o te mate kua whakamanahia e te American Diabetes Association (ADA), Diabetes UK, me ISPAD:

  1. Ture 1: KAUA e mutu te tango i to insulin (he roa te mahi) ahakoa kei te ruaki koe me te kai kore kai.
  2. I te wa o te kirikaa, o te mate ranei, na nga homoni o te ahotea ka tuku to ate ki te riringi tonu i te huka me te ketone ki roto i to toto, ahakoa i runga i te kopu kore. Ko te whakamutu i te insulin roa-mahi (Lantus, Toujeo, Tresiba, Levemir) na te mea kaore koe e kai te take tuatahi mo te DKA.
  3. Ture 2: Tirohia te huka toto me nga ketone toto ia 2 ki te 4 haora huri noa i te karaka (tae atu ki te po).
  4. Kaua e ti'aturi noa ki te Continuous Glucose Monitor (CGM) i te wa e matewai ana, me te tirotiro tonu i nga ketone ka nui ake te huka toto i te \(13.9\text{ mmol/L}\) (\(250\text{ mg/dL}\)) i nga wa katoa e nausea ana.
  5. Ture 3: Inuhia te 100 ki te 250 milliliters (3.5 ki te 8 hekere wai) o te wai ia 30 ki te 60 meneti, kia rite te momo wai ki to huka toto.
  6. Ko te huka toto kei runga ake i te \(10.0\text{ ki te }11.1\text{ mmol/L}\) (\(180\text{ to }200\text{ mg/dL}\)): Inu ** nga wai kore huka** (wai noa, wairewa electrolyte kore huka, hupa tote marama ranei).
  7. Ko te huka toto kei raro iho i te \(10.0\text{ mmol/L}\) (\(180\text{ mg/dL}\)) me te nausea, me te ketone teitei ake ranei: Whakainu ** nga wai whai warowaihā** (wai hua kua waimeha, wairewa whakamahana-waha i ia wa, i te hukapapa ranei) i te taha o te whakahaunga o te insulin ki te whakaweto i te hanga o te ate ate mate.
  8. Ture 4: A pee i te Tutohi Insulin Tuhituhi a to endocrinologist i tuhia (te nuinga o te 10% ki te 20% o te Tapeke Hohenga o ia ra).
  9. Ko te nuinga o nga whare haumanu he tuutohi i runga i to Total Daily Dose (TDD) o te insulin. Ina whakanuia te huka toto me nga ketone ngawari (\(0.6\text{ to }2.9\text{ mmol/L}\)), ka tangohia e nga turoro he 10 ki te 20 paiheneti o to ratou TDD hei insulin tere tere ia 2 ki te 4 haora, ka arahina e ta raatau mahere tiaki tuhi.
  10. Ture 5: Whakatatarihia nga rongoa "SADMANS" i te wa o te mate wai, te ruaki ranei.
  11. Ka whakamahia e nga whakahaere mo te mate huka te "SADMANS" acronym mo nga pire o ia ra me whakataa mo te wa poto i te ruaki nui, te mate korere, te matewai ranei hei aukati i te Euglycemic DKA, te wharanga whatukuhu whakapeka, me te waikawa lactic:
    • Sulfonylureas (glipizide, gliclazide, glimepiride: ka puta te hypoglycemia ki te kore e kai)
    • ACE aukati (lisinopril, ramipril, enalapril: ka whakaparahako i te tātari whatukuhu ina mate wai)
    • Diuretics / pire wai (furosemide, hydrochlorothiazide: he kino te matewai me te HHS)
    • Metformin (ka puta te waikawa lactic ki te kore e taea e nga whatukuhu kua mate te wai)
    • Angiotensin Receptor Blockers / ARBs (losartan, valsartan, candesartan)
    • Non-steroidal anti-inflammatory drugs / NSAIDs (ibuprofen, naproxen: kino nga whatukuhu kua maroke)
    • SGLT2 aukati (empagliflozin, dapagliflozin, canagliflozin: whakaoho Euglycemic DKA)

Me whai akoranga

Ko te tango i tetahi akoranga awhina tuatahi mai i te Ripeka Whero, St John Ambulance, tetahi kaiwhakarato whakangungu whawhati tata ranei, i honoa ki tetahi kaupapa ako whakahaere mate huka whaimana, ka awhina koe me to whanau ki te whakautu marie me te tika ki nga raru huka toto iti me te teitei.

Pātai auau

Me pehea e mohio ai ahau ki te rerekee o te huka toto iti (hypoglycemia) me te huka toto tiketike (DKA, HHS ranei) mena karekau he mita e mau ana?

Ka puta te mate huka i roto i nga meneti ka puta te wiri, te werawera makariri, te kiri kiri, me te rangirua ohorere. He rereke, ka whanake te DKA me te HHS i roto i nga haora ki nga ra, ka nui te matewai, te mimi auau, te kiri maroke maroke, te ruaki, me te manawa hohonu hohonu me te manawa hua; ki te kore e taea e koe te whakamatautau i te huka toto, me rongoa tuatahi mo te whakapae hypoglycemic na te mea he iti te huka toto ka pakaru te roro i roto i nga meneti, engari ko te 15 karamu o te huka kaore e tino kino te DKA, te HHS ranei.

Ka taea e te tangata kaore ano kia rongohia he mate huka ka mate ohorere te DKA?

Ae, tata ki te 20 ki te 40 paiheneti o nga tamariki, rangatahi me nga rangatahi katahi ano ka pa ki te mate huka Momo 1 ka kitea noa to ratau mate ka rere ki te ruuma whawhati tata i te mate Ketoacidosis Diabetic. Me whakapae i nga wa katoa he mate huka Momo 1 me te DKA ka pa mai he tamaiti, pakeke ranei ki te 1 ki te 3 wiki te paheketanga o te taumaha kaore i te maarama, te matewai tonu, me te mimi auau (he makuku moenga hou ranei) ka whai i te ruaki, te mamae o te puku, me te manawa tere.

He aha te mea he kino mo te tangata whai papu insulin ki te whakamahi i te papu ki te whakatika i te huka toto tiketike me nga ketone?

Na te mea ka whakamahia e te papu insuline te insulin tere tere me te kore o te insulin basal roa, ko te huka toto tiketike e honoa ana me nga ketone teitei (1.5 mmol/L, teitei ake ranei) te tikanga ko te kano kei raro i te kiri ka kikii, ka aukatia ranei. Ko te pana i te bolus whakatika i roto i te kano kua araia ka kore he insulin i te wa e moumou ana nga haora; werohia te horopeta whakatika ma te whakamahi i te pene insulin a-ringa, te syringe ranei ki te waahi tinana hou ka huri i te huinga whaowhanga papu katoa.

He aha te tikanga ina whakaatu te mita huka toto i te kainga "HI" hei utu mo te nama?

I runga i te nuinga o nga mita huka toto o nga kaihoko, ko te tikanga "HI" ka nui ake te huka toto capillary i te tepe morahi ka taea te panui o te taputapu, i runga ake i te 27.8 ki te 33.3 mmol/L (500 ki te 600 mg/dL). Ko te panui "HI" he whakatupato mo te Ketoacidosis Diabetic (DKA) me te Hyperosmolar Hyperglycemic State (HHS); tirohia nga ketone toto i nga wa tonu, a mena kei te rangirua te tangata, e moe ana, e ruaki ana, he ketone ranei kei runga ake i te 1.5 ki te 3.0 mmol/L, waea atu ki nga ratonga hauora ohorere.

Kua tirohia nga puna

  • ** American Diabetes Association (ADA, United States), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS, United Kingdom), American Association of Clinical Endocrinology (AACE), me Diabetes Technology Society (DTS):** Hyperglycemic Crises i roto i nga Pakeke: He Ripoata Whakaaetanga * (Umpierrez Diabetes et al, *2 Diabetes Care) .
  • International Society for Pediatric and Adolescent Diabetes (ISPAD): ISPAD Clinical Practice Consensus Guidelines: Diabetic Ketoacidosis and the Hyperglycemic Hyperosmolar State in Children and Adolescents (Glaser et al., Pediatric Diabetes).
  • National Institute for Health and Care Excellence (NICE, United Kingdom): *Momo 1 Te mate huka i roto i nga Pakeke: Te Whakatairanga me te Whakahaere * (NG17) me te * Te mate huka (Momo 1 me te Momo 2) i roto i nga Tamariki me nga Rangatahi: Te Whakatairanga me te Whakahaere * (NG18, tae atu ki te edema cerebral me nga tikanga whakaora wai).
  • Ko nga Roopu Tiaki Mate o Ingarangi mo te Tiaki Turoro (JBDS-IP, United Kingdom): Te Whakahaerenga o te Ketoacidosis Diabetic i roto i nga Pakeke me te Te Whakahaerenga o te Hyperosmolar Hyperglycaemic State (HHS) i roto i nga Pakeke.
  • ** Te Whakahaere Kai me te Taakaro o te United States (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" & "STOP DKA" Protocols).

Nga kaiarahi e pa ana