ሕማም ሽኮርያ ኬቶኣሲዶሲስ (DKA)ን ሃይፐሮስሞላር ሃይፐርግላይሰሚክ ስቴት (HHS)ን¶

ሽኮርያ ኬቶኣሲዶሲስ (DKA)ን ሃይፐሮስሞላር ሃይፐርግላይሰሚክ ስቴትን (HHS) ኣብ ክንክን ሕማም ሽኮርያ ክልተ ኣዝዮም ሓደገኛታት ሕዱር ልዕሊ ዓቐን ሽኮር ዘለዎም ህጹጽ ኩነታት ኮይኖም፡ ከቢድ ምውሓድ ማይ፡ ስንባደ ዑደት ደም፡ ሕበጥ ሓንጎል (ሴረብራል ኤዴማ)፡ ኮማን፡ ብቕልጡፍ ብፈሳሲ ሰራውር ደም ሆስፒታል፡ ምትካእ ኤሌክትሮላይት፡ ከምኡ’ውን ሞት ከስዕቡ ዝኽእሉ እዮም። ኢንሱሊን ዝበሃል ምዃኑ ይፍለጥ። DKA ኣብ ውሽጢ ሰዓታት ብቕልጡፍ ክሳብ ፍጹም ወይ ከቢድ ሕጽረት ኢንሱሊን ጸላም ከብዲ ስብሒ ናብ ኣሲዳዊ ኬቶን ከተቃጽል ዘገድዳ መዓልቲ ክምዕብል እንከሎ፡ HHS ኣብ ውሽጢ ሓያሎ መዓልታት ክሳብ ሰሙናት (መብዛሕትኡ ግዜ ኣብ ዓይነት 2 ሕማም ሽኮር ዘለዎም ኣረጋውያን ዓበይቲ) ይሃንጽ፡ ሽኮር ደም ናብ ልዑል ደረጃ ይድርኾን ክሳብ 9 ክሳብ 12 ሊትሮ (2.4 ክሳብ 3.2 ጋሎን) ማይ ካብቲ... ኣካል። ከም ተምላስ፡ ቃንዛ ከብዲ፡ ዓሚቝ ቅልጡፍ ምስትንፋስ፡ ወይ ምድንጋር ዝኣመሰሉ ናይ መጠንቀቕታ ምልክታት ብቕልጡፍ ምልላይ፡ ምስ ናይ ገዛ ደም ኬቶን መርመራን ህጹጽ ህጹጽ ሕክምናዊ መጓዓዝያን ተጻሚዱ፡ ህይወት የድሕን።

እዚ ሕጂ ግበሩ¶

1. እቲ ሰብ ተደናጊሩ፣ ድቃስ እንተሰሚዕዎ፣ ኣዕሚቑን ብቕልጡፍን ዘስተንፍስ፣ ብተደጋጋሚ ተምላስ እንተሃልይዎ፣ ወይ ድማ ናይ ደም ኬቶን \(\ge 3.0\text{ mmol/L}\) እንተሃልይዎ ብቕልጡፍ ናብ ናይ ከባቢኹም ቁጽሪ ህጹጽ ረድኤት ደውሉ። ኣብ ኣሜሪካን ካናዳን 911 ኣብ መላእ ሕብረት ኤውሮጳ 112፣ ኣብ ዓባይ ብሪጣንያ 999፣ ወይ ኩሉ ርአ ናይ ህጹጽ እዋን ቁጽሪ. እቲ ሕሙም ኣብ ጥርጡር ሽኮርያ ኬቶኣሲዶሲስ (DKA) ወይ ሃይፐሮስሞላር ሃይፐርግላይሰሚክ ስቴት (HHS) ከምዘሎን ኣብ ሆስፒታል ብውሽጢ ሰራውር ፈሳሲ ምትንሳእን ኤሌክትሮላይት ምክትታልን ከምዘድልዮን ነቲ ዲስፓቸር ንገሮ።
2. ንኽልቲኡ ናይ ኣጻብዕቲ ደም ግሉኮስን ደም ቤታ-ሃይድሮክሲቡታይሬት ኬቶንን ብቕጽበት መርምሮ (ሜትሮ እንተሃልዩ)። ኣብ እዋን ከቢድ ምውሓድ ማይ ወይ ስንባደ ኣብ ቀጻሊ ግሉኮስ ሞኒተር (CGM) ሴንሰር ንባባት ጥራይ ኣይትጸጋዕ፣ ምኽንያቱ ፈሳሲ ቲሹ ካብ ክብርታት ደም ድሕሪት ስለዝተርፍ። ልክዕ ቁጽሪ ሽኮር ደም ጽሓፍ (ወይ ድማ እቲ ቆጻሪ "HI" እንተ ኣንቢቡ ኣስተውዕል፣ እዚ ማለት መብዛሕትኡ ግዜ ልዕሊ \(27.8\text{ ክሳብ }33.3\text{ mmol/L}\) [\(500\text{ ክሳብ }600\text{ mg/dL}\)]) ከምኡ’ውን ልክዕ ደረጃ ኬቶን ደም ብ \(\text{mmol/L}\) (ወይ ሕብሪ ኬቶን ሽንቲ)።
3. ድቃስ ዝሰኣነ፣ ዝተደናገረ፣ ወይ ተምላስ ዘለዎ ሰብ ኣብ ጎድኑ ኣብቲ ናይ ምሕዋይ ቦታ ብምቕማጥ ንመተሓላለፊ ኣየር ምክልኻል። ንዝደኸመ፣ ዘረባኡ ዝደናገረ፣ ዝተደናገረ፣ ወይ ብንጥፈት ተምላስ ዘለዎ ሰብ፣ ብቐሊሉ ፈሳሲ ናብ ሳንቡኡ ከስተንፍስ ስለ ዝኽእል (ኣስፒሬሽን ኒሞንያ) ኣፍ ማይ፣ መግቢ፣ ወይ ከኒና ፈጺምካ ኣይትሃቦ። እቲ ሰብ ምሉእ ብምሉእ ንቑሕ፡ ንቑሕ፡ ብዘይ ተምላስ ክውሕጥ ዝኽእል እንተኾይኑ፡ ሕክምናዊ ክንክን እናተጸበየ፡ ንቡር ማይ ወይ ሽኮር ዘይብሉ ኤሌክትሮላይት ማይ (ንዓቢ ሰብ ኣብ ነፍሲ ወከፍ 15 ክሳብ 30 ደቓይቕ ብግምት 250 ሚሊሊተር [8 ፈሳሲ ኦውንስ]) ክሰቲ ኣተባብዖ።
4. ንናይ ኢንሱሊን ፓምፕ ቱቦታት ምጥምዛዝ ወይ ካኑላ ምብልሻው መርምሩ፣ ከምኡ’ውን ዓበይቲ ትሕቲ ቆርበት መርፍእ ኢንሱሊን ፈጺምኩም ኣይትደራረቡ። እቲ ሕሙም ኢንሱሊን ፓምፕ ዝጥቀምን ልዑል መጠን ሽኮር ደም ዘለዎን ልዑል ኬቶን ዘለዎን እንተኾይኑን (\(\ge 1.5\text{ mmol/L}\))፣ እቲ ናይ ፓምፕ ቦታ ከም ዝፈሸለ ጌርካ ንሕሰብ: ብመንገዲ እቲ ፓምፕ ናይ መአረምታ ቦሉስ ኣይትሃብ። ኣብ ክንድኡስ፡ ሓድሽ ትሕቲ ቆርበት ኢንሱሊን ብርዒ ወይ መርፍእ ናብ ፍሩይ ቦታ ቆርበት ብምጥቃም፡ ነቲ ዝተኣዘዝዎ ውጥን ስራሕ መዓልቲ ሕሙማት ተኸተሉ። ቅድሚ ፓራሜዲክስ ምምጽኦም ልዑል መጠን ሽኮር ደም ብሓይሊ ንምውራድ ብዘይተሓሰበ ወይ ተደጋጋሚ ("ዝተደራረበ") ዓበይቲ መርፍእ ኢንሱሊን ፈጺምካ ኣይትሃብ፣ ምኽንያቱ ብዘይ ኣቐዲሙ ብውሽጢ ሰራውር ጨውን ፖታስየምን ኣዝዩ ቅልጡፍ ምጉዳል ሽኮር ደም ወይ ኦስሞላሊቲ ደም ኣዝዩ ቀታሊ ሴረብራል ኤዴማ (ሕበጥ ሓንጎል)ን ሃይፖካለሚክ ምቁራጽ ልቢን የስዕብ።
5. ኣብ ጥርጡር DKA ንዝርከብ ህጻን ወይ መንእሰይ ኣሰታሚኖፈን (ፓራሲታሞል)፣ ኣስፕሪን፣ ወይ ኢቡፕሮፈን ኣይትሃብ፣ ባይካርቦኔት ድማ ምውጋድ። ናይ ህጻናት DKA ኣብተን ቀዳሞት 12 ክሳብ 24 ሰዓታት ሕክምና ንህይወት ኣብ ሓደጋ ዘእቱ ሕበጥ ሓንጎል ልዑል ሓደጋ ኣለዎ፤ እቲ ሕሙም ንቑሕ እንተኾይኑ ርእሱን ኣብራኹን ብ30 ዲግሪ ኩርናዕ ቁሩብ ልዕል ኣቢልካ ምግባር፣ እቶም ናይ ሆስፒታል ጉጅለ ድማ ሙቐትን ኣሲዶሲስን ብጥንቃቐ ከማሓድሩ ይፍቀደሎም።
6. ኩሉ ቀረብ ሕማም ሽኮር፣ ዝርዝር መድሃኒታት (ብፍላይ SGLT2 ተዓጻጸፍትን ስቴሮይድን)፣ ከምኡ’ውን ኣብ ቀረባ እዋን ንፓራሜዲክስ ዝኸውን ናይ መለክዒ ምዝገባታት ኣኪብካ ምእካብ። ንሰራሕተኛታት ኣምቡላንስ ናይቲ ሕሙም መለክዒ ግሉኮስ/ኪቶን፣ ዝርዝር ናይ ኢንሱሊን ብርዒ ወይ ሞዴል ፓምፕ፣ ከምኡ’ውን ዝርዝር ናይ ኩሎም መዓልታዊ መድሃኒታት ኣረክቦም፣ ምእንቲ ክፍሊ ህጹጽ ረድኤት ብቕጽበት ቅኑዕ ናይ ውሽጢ ሰራውር ጨውን ኢንሱሊንን ፕሮቶኮል ምእታው።

ሃይፐርግላይሰሚክ ቅልውላው ምፍላይን ኬቶን ስጉምቲ ውሳነ ገረብ¶

ነዚ ክሊኒካዊ ፍሎውቻርት ተጠቒምካ ልዑል መጠን ሽኮር ደም ንምግምጋም፣ ንባባት ደም ወይ ሽንቲ ኬቶን ንምትርጓም፣ ከምኡ’ውን ኣብ መንጎ ምሕደራ መዓልቲ ሕማም ኣብ ገዛን ቅልጡፍ መጓዓዝያ ሆስፒታልን ምውሳን።

flowchart TD
    Start["ዝፍለጥ ወይ ዘይተረጋገጸ ሕማም ሽኮር ዘለዎ ሰብ፡<br/>ግሉኮስ ደም >= 13.9 ሚሊሞል/ሊትር (250 ሚግ/ዲኤል)<br/>ወይ ዝኾነ ሕማም / ረስኒ / ተምላስ (ዋላ ግሉኮስ < 13.9 ሚሊሞል/ሊትር ኣብ SGLT2i)"] --> RedFlags{"ዝኾነ ናይ ህጹጽ እዋን ቀያሕቲ ባንዴራታት ኣለዉ ድዮም?<br/>1. ዓሚቝን ቅልጡፍን ትንፋስ ምትንፋስ (Kussmaul respirations) ወይ ፍሩታ ዝመስል ትንፋስ<br/>2. ቀጻሊ ተምላስ ወይ ፈሳሲታት ን>2 ክሳብ 4 ሰዓታት ትሑት ክኸውን ዘይምኽኣል<br/>3. ከቢድ ቃንዛ ከብዲ፡ ምድንጋር፡ ኣዝዩ ድኻም፡ ወይ ምዝራብ ምድንጋር<br/>4. ደም ኬቶን >= 3.0 ሚሊሞል/ሊትር (ወይ 'ዓበይቲ' ናይ ሽንቲ ኬቶን)<br/>5. ሜተር ምስ ልዑል ምውሓድ ማይ 'HI' (>33.3 mmol/L / 600 mg/dL) ይንበብ"}

    RedFlags -->|"እወ፡ ዝኾነ ንጽል ቀያሕ ባንዴራ ተረኺቡ።"| CallEMS["ቅልጡፍ ህጹጽ ኩነታት ሆስፒታል (DKA ወይ HHS):<br/>1. ብቕልጡፍ ናብ 911 / 112 / 999 ደውሉ<br/>2. ድቃስ እንተ ኣልዩ ወይ ተምላስ እንተሃልዩ: ናይ ምሕዋይ ኣቀማምጣ & ብኣፍ ዋላ ሓንቲ የለን (NPO)<br/>3. ምሉእ ብምሉእ ንቑሕ እንተኾይኑ & እንተዘይተምላስ: ንኣሽቱ ምሕንባስ ስሩዕ ማይ<br/>4. ቅድሚ IV ፈሳሲ/ፖታሽየም ዓበይቲ መጠን ኢንሱሊን ኣይትደራረቡ።"]

    RedFlags -->|"ኣይፋልን፡ ንቑሕ፡ ንቡር ምትንፋስ፡<br/>ብቐጻሊ ዘይምትምላስ"| CheckKetones{"ደም ኬቶን (ቤታ-ሃይድሮክሲቡታይሬት)<br/>ወይ ሽንቲ ኬቶን ስትሪፕ ምፍታሽ"}

    CheckKetones -->|"ደም ኬቶን 1.5 ክሳብ 2.9 ሚሊሞል/ሊትር<br/>(ማእከላይ ሽንቲ ኬቶን)"| ModKetones["ማእከላይ ኬቶነሚያ (ዝመጽእ መጠንቀቕታ ዲ.ኬ.ኤ):<br/>1. ብቕልጡፍ ምስ ጉጅለ ሕማም ሽኮር ወይ ህጹጽ ሕክምናዊ ሓገዝ መስመር ርኸብ<br/>2. ኣብ ኢንሱሊን ፓምፕ እንተኾይኑ: ብቕልጡፍ ዝሰርሕ መአረምታ ብመንገዲ PEN/SYRINGE<br/> ናብ ፍሩይ ቦታ ምሃብን ምሉእ ፓምፕ ኢንፍዩዥን ሴት ምቕያርን<br/>3. ኣብ ነፍሲ ወከፍ 30 ክሳብ 60 ደቓይቕ 250 ሚሊ ሊትር (8 ኦንስ) ሽኮር ዘይብሉ ፈሳሲ ስተ<br/>4. ድሕሪ 2 ሰዓታት ሽኮርን ኬቶንን ደም ዳግማይ ምፍታሽ (እንተደይቡ ናብ ER ኪድ)"]

    CheckKetones -->|"ደም ኬቶን 0.6 ክሳብ 1.4 ሚሊሞል/ሊትር<br/>(ንኣሽቱ ሽንቲ ኬቶናት ኣሰር)"| MildKetones["ቅልል ዝበለ / ኣሰር ኬቶነሚያ:<br/>1. ንተወሳኺ ቅልጡፍ ተግባር ዘለዎ ኢንሱሊን ዝተኣዘዘ ሕግታት መዓልቲ ሕማም ተኸተል<br/>2. መሰረታዊ/ነዊሕ እዋን ዝሰርሕ ኢንሱሊን (ዋላ’ውን እንተዘይበላዕካ) ፈጺምካ ኣይተቋርጽ<br/>3. ብማይ (ወይ ድማ ግሉኮስ < 10 ሚሊሞል/ሊትር / 180 ሚግ/ዲኤል እንተኾይኑ ብፈሳሲ ካርቦሃይድሬት) ሃይድሬት ምግባር<br/>4. ኣብ ነፍሲ ወከፍ 2 ክሳብ 4 ሰዓታት ሽኮርን ኬቶንን ደም ዳግማይ ምፍታሽ"]

    CheckKetones -->|"ደም ኬቶን < 0.6 ሚሊሞል/ሊትር (ንቡር)<br/>ከምኡውን ግሉኮስ 13.9 ክሳብ 22.2 ሚሊሞል/ሊትር (250-400 ሚሊግራም/ዲኤል)"| NoKetones["ልዕሊ ዓቐን ሽኮር ብዘይ ኬቶሲስ:<br/>- ስታንዳርድ ዝተኣዘዘ ናይ ምእራም መጠን ቅልጡፍ ተግባር ዘለዎ ኢንሱሊን ምውሳድ<br/>- ብዙሕ ማይ ምስታይን ምልክታት ምውሓድ ማይ HHS ምክትታልን<br/>- ግሉኮስ >16.7 ሚሊሞል/ሊትር (300 ሚሊግራም/ዲኤል) ን2 መርመራታት እንተጸኒሑ ሕክምናዊ ክንክን ምድላይ"]

ምርዳእ ፓቶፊዚዮሎጂ፡ ስለምንታይ DKAን HHSን ይምዕብሉን ብኸመይ ይፈላለዩ።¶

ክልቲኦም DKAን HHSን ምስ ምውሳኽ ጸቕጢ ሆርሞናት (ግሉካጎን፡ ኮርቲሶል፡ ኤፒነፍሪንን ሆርሞን ዕብየትን) ተደሚሩ ካብ ዘይእኹል ስጉምቲ ኢንሱሊን ዝፍጠሩ እኳ እንተኾኑ፡ ምልክታቶም፡ ናይ ቤተ-ፈተነ ክብርታቶምን ቅጽበታዊ ሓደጋታት ሆስፒታልን ንምንታይ ከም ዝፈላለ ዝገልጹ ክልተ ፍሉያት ባዮኬሚካላዊ መንገድታት ይኽተሉ።

1. ሕማም ሽኮር ኬቶኣሲዶሲስ (DKA): ኣብ ማእከል ብዙሕ ጥሜት።¶

ኣብ ሕማም ሽኮርያ ኬቶኣሲዶሲስ (DKA)፡ ከቢድ ወይ ፍጹም ሕጽረት ናይ ዑደት ኢንሱሊን ኣሎ። ብዘይ ኢንሱሊን፡ ግሉኮስ ኣብ ደም ተዓጽዩ ስለ ዝጸንሕ፡ ጸዓት ንምርካብ ናብ ዋህዮታት ጭዋዳታት ወይ ስብሒ ክኣቱ ኣይክእልን። ኣካላት ብጥሜት ከም ዝሓሰበ ብምሕሳብ፡ ጽክታት ኣድረናልን ሽኮርያን ብብዝሒ ግሉካጎን፡ ኣድሪናሊንን ኮርቲሶልን ይለቅቑ፡ እዚ ድማ ክልተ ሓደገኛታት ውሕጅ ይለዓዓሉ፤ - ዘይተቖጻጸረ ሊፖሊሲስን ኬቶጀነሲስን (ሜታቦሊክ ኣሲዶሲስ)፦ ስብሒ (ስብሒ) ቲሹ ብቕልጡፍ ናብ ነጻ ስብሒ ኣሲድ ይበታተን፣ እዚ ድማ ናብ ጸላም ከብዲ ይጓዓዝ። ጸላም ከብዲ ነዞም ስብሒ ኣሲዳት ናብ ሰለስተ ኬቶን ኣካላት ይቕይሮም፡ ቤታ-ሃይድሮክሲቡቲሬት (ኣብ DKA ቀንዲ ኣብ ዙረት ዝዘውር ኣሲድ)፡ ኣሴቶኣሴቴት፡ ከምኡ'ውን ኣሲቶን (እዚ ብሳንቡእ ዝወጽእ፡ ኣብ ትንፋስ ምቁር "ንጣብ ፐር" ወይ ጽፍሪ-ፖሊሽ-መወገዲ ጨና የፍሪ)። እዞም ሓያላት ኬቶኣሲዳት ነቲ ናይ ደም ባይካርቦኔት መከላኸሊ ስርዓት ብምዕብላል፡ ደም ሻምብቆታት \(\text{pH}\) ትሕቲ \(7.30\) (ኣብ ከቢድ DKA ድማ ትሕቲ \(7.00\)) የውድቑ። - ኦስሞቲክ ዲዩረሲስን ምውዳቕ ኤሌክትሮላይትን: ሽኮር ደም ካብቲ ብግምት \(10.0\text{ ክሳብ }11.1\text{ mmol/L}\) (\(180\text{ ክሳብ }200\text{ mg/dL}\)) ዝኾነ ደረት ኩሊት ምስ ሓለፈ፡ ግሉኮስን ኬቶንን ናብ ሽንቲ ይፈስስ እሞ፡ ብብዝሒ ማይ፡ ሶድየም፡ ፖታስየም፡ ማግነዝየምን ፎስፌትን ካብ ኣካላትና ወጺኡ። ኣብ DKA ዝርከብ ዓቢ ሰብ ብተለምዶ ኣብ ውሽጢ 24 ሰዓታት ካብ 5 ክሳብ 7 ሊትሮ (ካብ 1.3 ክሳብ 1.8 ጋሎን) ማይ ኣካላት (\(100\text{ mL/kg}\)) ይስእን።

2. ሃይፐሮስሞላር ሃይፐርግላይሰሚክ ስቴት (HHS)፦ ልዑል ምውሓድ ማይን ረጒድ ደምን።¶

ሃይፐሮስሞላር ሃይፐርግላይሰሚክ ስቴት (HHS) ብዓብላሊ መልክዑ ኣብ ዓይነት 2 ሕማም ሽኮር ዘለዎም ኣረጋውያን ይኽሰት (ዋላ እኳ ኣብ መንእሰያትን ስብሕን ዓይነት 2 ሕማም ሽኮርን ዘለዎም መንእሰያትን መንእሰያት ኣባጽሕን ብዝያዳ ይረአ)። ዘይከም DKA፡ ሓደ ሰብ ኣብ HHS ሕጂ’ውን እኹል መበገሲ ኢንሱሊን ሽኮርያ ጥራይ እዩ ዘፍሪ፡ ምብትታን ስብሒ (lipolysis)ን ምፍጣር ኬቶንን ንምክልኻል፡ ግን ጸላም ከብዲ ግሉኮስ ናብ ደም ከይፈስስ ወይ ግሉኮስ ናብ ዋህዮታት ንምንቅስቓስ ደው ዘብል እኹል ኢንሱሊን የብሉን። - እቲ ሕሙም ብኡንብኡ ኣሲዶቲክ ስለዘይኸውን (ኣብተን ቀዳሞት 24 ሰዓታት ቅልጡፍ ተምላስ ወይ ኩስማውል ምትንፋስ ስለዘየለ)፡ ኣብ መዓልቲ 1 ጽዑቕ ሕማም ኣይስምዖምን እዩ።ኣብ ክንድኡስ፡ ሽኮር ደም ኣብ ውሽጢ ሓያሎ መዓልታት ክሳብ 2 ሰሙን ብቐጻሊ ይድይብ፡ መብዛሕትኡ ግዜ ድማ \(33.3\text{ ክሳብ }66.6\text{ mmol/L}\) ይበጽሕ (\(600\ጽሑፍ{ ክሳብ }1,200\ጽሑፍ{ ሚግ/ዲኤል}\))። - እዚ ዘይሕለል ኦስሞቲክ ዲዩረሲስ ካብ ኣካላት እቲ ሕሙም 9 ክሳብ 12 ሊትሮ (2.4 ክሳብ 3.2 ጋሎን) ማይ (\(100\text{ ክሳብ }200\text{ mL/kg}\)፡ ወይ ክሳብ 20 ሚእታዊት ካብ ጠቕላላ ማይ ኣካላት) የፍስስ። ሕማም፡ ወቕዒ፡ ረሲዕነት ወይ ኣብ መዕበዪ ኣረጋውያን ምንቅስቓስ ዘይምህላው እቲ ሰብ ንኽቕጽል እኹል ማይ ከይሰቲ ምስ ዝኽልክሎ፡ ደም ኦስሞላሊቲ ልዕሊ \(320\text{ mOsm/kg}\) ይድይብ። ማይ ብቐጥታ ካብ ዋህዮታት ሓንጎል ይምጠጥ፣ እዚ ድማ ዓሚቝ ድኻም፣ ፎካላዊ ናይ ስነ-ኣእምሮ ሕጽረት የስዕብ፣ እዚ ድማ ንሀ ወቕዒ ምውቃዕ፣ ምውቃዕ፣ ኮማ፣ ከምኡ’ውን ምረጋግእ ደም ሻምብቆታት ወይ ሰራውር ደም (ናይ ሳንቡእ ኤምቦሊዝም ወይ ምውቃዕ ማይኦካርድያ)። መብዛሕትኡ ግዜ ሕሙማት ዝዓበዩን ኣዝዮም ዝያዳ ማይ ዝሰኣኑን ስለዝኾኑ፡ HHS ካብ 10 ክሳብ 20 ሚእታዊት ሞት ይስከም፡ እዚ ድማ ካብ መጠን ሞት DKA ብግምት ብ5 ክሳብ 10 ዕጽፊ ይዛይድ።

ርእሰ ንርእሲ ምውድዳር፡ ዲኬኤ ኣንጻር ዩግላይሰሚክ ዲኬኤ ኣንጻር ኤችኤችኤስ ኣንጻር ትሑት መጠን ሽኮር¶

ነዚ ናይ ክሊኒካዊ መርመራ ሰሌዳ (እዚ ዝሓለፈ 2024 Joint ADA / EASD / JBDS / AACE / DTS Consensus Report on Hyperglycemic Crises in Adults ከምኡ’ውን ISPAD Pediatric Guidelines ዘጠቓለለ) ካብ ህጹጽ ኩነታት ሕማም ሽኮር ንምፍላይ ተጠቐም፤

Recognizing the warning signs and the SGLT2 inhibitor "Euglycemic DKA" trap¶

How DKA symptoms progress from Early Ketosis to Acidotic Collapse¶

1. Stage 1: Early Hyperglycemia and Ketonemia (Hours 1 to 6):
2. Unquenchable thirst (polydipsia), dry sticky mouth, and frequent trips to urinate (polyuria), including waking up multiple times overnight (or sudden bedwetting in a previously toilet-trained child).
3. Generalized muscle weakness, fatigue, blurred vision, and headache.
4. Blood glucose typically above \(13.9\text{ mmol/L}\) (\(250\text{ mg/dL}\)) with blood ketones rising between \(0.6\text{ and }1.5\text{ mmol/L}\).
5. Stage 2: Established Ketoacidosis (Hours 6 to 18):
6. Nausea, repeated vomiting, and severe abdominal pain: Acidemia and gastric stasis irritate the stomach lining and bowel wall. Once vomiting begins, the patient can no longer keep oral fluids down, accelerating dehydration into a downward spiral.
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. Fruity "pear drop" or nail-polish-remover breath: Caused by volatile acetone gas evaporating out of the pulmonary capillaries.
9. Stage 3: Decompensated DKA and Shock (Hours 12 to 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 \(110\text{ to }199\text{ mg/dL}\)).

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¶

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. Severe dehydration blocks subcutaneous insulin absorption, then dumps it all at once¶

When a patient in DKA or HHS is dehydrated by 5 to 10 liters, blood vessels in the skin and subcutaneous fat constrict to preserve blood flow to the heart and brain. Multiple doses of rapid-acting insulin injected under the skin sit trapped in an unperfused subcutaneous depot. Once paramedics start intravenous saline and skin circulation returns, that pooled depot rushes into the bloodstream simultaneously, triggering severe hypoglycemic shock.

2. Driving potassium into cells before checking blood labs causes cardiac arrest¶

During DKA and HHS, osmotic diuresis drains massive quantities of potassium (\(\text{K}^+\)) into the urine. Although total body potassium is depleted, serum potassium initially looks normal because acidosis pushes potassium out of cells. Insulin forces potassium from the bloodstream back inside cells. If high-dose insulin is given before a hospital checks serum potassium (and before intravenous potassium chloride is added when \(\text{K}^+ < 5.0\text{ to }5.2\text{ mmol/L}\), or while insulin is held if \(\text{K}^+ < 3.5\text{ mmol/L}\)), blood potassium plummets within minutes, causing hypokalemic ventricular arrhythmias and cardiac arrest.

3. Dropping blood sugar too fast in HHS or Pediatric DKA causes Cerebral Edema and Vascular Collapse¶

• In HHS: High blood sugar is the main osmotic force holding water inside shrunken arteries, and brain cells have adapted over days to extreme osmolality (\(> 320\text{ mOsm/kg}\)). Hospital guidelines (UK JBDS and ADA/EASD 2024 consensus) state that the first hour of HHS treatment is \(0.9\%\) normal saline fluid resuscitation ALONE, which lowers blood sugar safely by \(2.8\text{ to }4.2\text{ mmol/L/hr}\) (\(50\text{ to }75\text{ mg/dL/hr}\)). Giving large insulin doses first sucks water out of arteries (causing circulatory collapse) and into brain cells, causing cerebral edema or osmotic demyelination.
• In Pediatric DKA: Children and adolescents are uniquely vulnerable to DKA-associated cerebral edema, which carries a 20 to 25 percent mortality rate. Lowering blood glucose too rapidly with insulin boluses (or giving intravenous sodium bicarbonate) dramatically increases the risk of fatal brain swelling.

Recognizing cerebral edema (brain swelling) in children and young adults¶

Watch every child, teenager, or young adult with DKA closely for signs of rising intracranial pressure (cerebral edema), which can begin before hospital arrival or 4 to 12 hours after treatment starts:

Red flag signs of cerebral edema (Immediate neurocritical emergency)¶

• New or worsening severe headache (especially after initial improvement).
• Sudden change in behavior: Unusual irritability, agitation, restlessness, or sudden drowsiness and inability to wake up.
• Slowing heart rate (bradycardia) paired with rising blood pressure (Cushing's triad): In a dehydrated DKA patient, heart rate is normally fast (\(110\text{ to }150\text{ bpm}\)). If a child's heart rate suddenly drops to \(60\text{ to }70\text{ bpm}\) while they become drowsy, suspect brain herniation immediately.
• Recurrent vomiting, unequal pupils, crossed eyes, abnormal posturing, or incontinence.
• Immediate action: Elevate the head of the bed to 30 degrees, keep the neck midline, and alert clinicians immediately so they can administer intravenous hypertonic \(3\%\) saline (\(3\text{ to }5\text{ mL/kg}\)) or mannitol (\(0.5\text{ to }1.0\text{ g/kg}\)).

Special emergency scenario: Insulin pump failure and the "Pen First" rule¶

Patients who use a continuous subcutaneous insulin infusion (CSII) insulin pump carry a unique vulnerability to rapid-onset DKA: - Unlike injection users who take daily long-acting basal insulin (glargine, degludec, or detemir) that stays active under the skin for 24 to 42 hours, an insulin pump contains ONLY rapid-acting insulin (lispro, aspart, or glulisine). - If the Teflon cannula under the skin kinks, dislodges, or blocks, circulating insulin drops to zero within 2 to 3 hours, and full-blown DKA can develop in 4 to 6 hours.

Step-by-step insulin pump ketone troubleshooting checklist¶

• Step 1: If blood glucose is \(\ge 13.9\text{ mmol/L}\) (\(250\text{ mg/dL}\)) and blood ketones are \(\ge 1.5\text{ mmol/L}\), assume the pump infusion site has failed, even without an occlusion alarm.
• Step 2: Do NOT deliver the correction bolus through the pump. Use a back-up disposable insulin pen or syringe to inject the prescribed rapid-acting correction dose into a fresh anatomical area.
• Step 3: Remove the old cannula/pod, inspect the skin for redness or leaking insulin odor, and insert a brand-new infusion set, reservoir, and fresh insulin in a new site.
• Step 4: Drink 250 to 500 milliliters (8 to 16 fluid ounces) of water and re-check blood glucose and ketones in 90 to 120 minutes. If ketones rise or vomiting begins, call 911 / 112 / 999 or go to the emergency room.

Golden rules of home Sick Day Management to prevent DKA and HHS¶

Over half of all hospital admissions for DKA and HHS are triggered by common illnesses (urinary tract infections, pneumonia, flu, COVID-19, or gastroenteritis) where a medication mistake occurs. Follow these five universal Sick Day Rules endorsed by the American Diabetes Association (ADA), Diabetes UK, and ISPAD:

1. Rule 1: NEVER stop taking your basal (long-acting) insulin, even if you are vomiting and eating zero food.
2. During fever or infection, stress hormones cause your liver to pour glucose and ketones into your blood continuously, even on an empty stomach. Stopping daily long-acting insulin (Lantus, Toujeo, Tresiba, Levemir) because you are not eating is a primary cause of DKA.
3. Rule 2: Check blood glucose and blood ketones every 2 to 4 hours around the clock (including overnight).
4. Do not rely solely on a Continuous Glucose Monitor (CGM) during dehydration, and always check ketones when blood sugar exceeds \(13.9\text{ mmol/L}\) (\(250\text{ mg/dL}\)) or whenever nauseated.
5. 3ይ ሕጊ፡ ኣብ ነፍሲ ወከፍ 30 ክሳብ 60 ደቓይቕ ካብ 100 ክሳብ 250 ሚሊሊተር (ካብ 3.5 ክሳብ 8 ፈሳሲ ኦውንስ) ፈሳሲ ምስታይ፡ ዓይነት ፈሳሲ ምስ ሽኮር ደምካ ብምትእስሳር።
6. Blood glucose above \(10.0\text{ to }11.1\text{ mmol/L}\) (\(180\text{ to }200\text{ mg/dL}\)): Drink sugar-free fluids (plain water, sugar-free electrolyte solutions, or clear salty broth).
7. ትሕቲ \(10.0\text{ mmol/L}\) (\(180\text{ mg/dL}\)) ዘለዎ ግሉኮስ ደም ምስ ረስኒ ወይ ልዑል ኬቶን: ካርቦሃይድሬት ዝሓዘ ፈሳሲ (ዝተቐልቀለ ጽማቝ ፍረታት፡ ስሩዕ ኣፋዊ ኣፋዊ ሪሃይድሬሽን ፍታሕ፡ ወይ በረድ ፖፕ) ጎኒ ጎኒ ዝተኣዘዘ ናይ ሕማም መዓልቲ ኢንሱሊን ምሕንባስ ምእንቲ ጸላም ከብዲ ምፍራይ ኬቶን የቋርጽ።
8. Rule 4: Follow your endocrinologist's written Sick Day Supplemental Insulin Chart (typically 10% to 20% of Total Daily Dose).
9. Most clinics provide a chart based on your Total Daily Dose (TDD) of insulin. When blood glucose is elevated with mild-to-moderate ketones (\(0.6\text{ to }2.9\text{ mmol/L}\)), patients typically take an extra 10 to 20 percent of their TDD as rapid-acting insulin every 2 to 4 hours, guided by their written care plan.
10. Rule 5: Pause "SADMANS" medications during acute dehydration or vomiting.
11. Diabetes organizations use the "SADMANS" acronym for daily pills that must be temporarily paused during severe vomiting, diarrhea, or dehydration to prevent Euglycemic DKA, acute kidney injury, and lactic acidosis:
    • Sulfonylureas (glipizide, gliclazide, glimepiride: cause hypoglycemia if not eating)
    • ACE inhibitors (lisinopril, ramipril, enalapril: impair kidney filtration when dehydrated)
    • Diuretics / water pills (furosemide, hydrochlorothiazide: worsen dehydration and HHS)
    • Metformin (causes lactic acidosis if dehydrated kidneys cannot clear it)
    • 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)

ብተደጋጋሚ ዝሕተቱ ሕቶታት¶

How can I tell the difference between low blood sugar (hypoglycemia) and high blood sugar (DKA or HHS) if I do not have a meter handy?¶

Hypoglycemia comes on within minutes and causes shaking, cold clammy sweat, pale skin, and sudden confusion. In contrast, DKA and HHS develop over hours to days and cause extreme thirst, frequent urination, dry flushed skin, vomiting, and deep rapid sighing breaths with fruity breath; if you cannot test blood sugar, treat for suspected hypoglycemia first because low blood sugar damages the brain within minutes, whereas 15 grams of sugar will not meaningfully worsen DKA or HHS.

Can someone who has never been diagnosed with diabetes suddenly develop DKA?¶

Yes, roughly 20 to 40 percent of children, teenagers, and young adults newly diagnosed with Type 1 diabetes only discover their condition when rushed to the emergency room in Diabetic Ketoacidosis. Always suspect new-onset Type 1 diabetes and DKA if a child or adult has had 1 to 3 weeks of unexplained weight loss, constant thirst, and frequent urination (or new bedwetting) followed by vomiting, abdominal pain, and deep rapid breathing.

Why is it dangerous for someone with an insulin pump to use the pump to fix high blood sugar and ketones?¶

Because an insulin pump uses only rapid-acting insulin and zero long-acting basal insulin, high blood sugar paired with elevated ketones (1.5 mmol/L or higher) usually means the cannula under the skin is kinked or blocked. Pushing a correction bolus through a blocked cannula delivers no insulin while wasting hours; inject the correction dose using a manual insulin pen or syringe into a fresh body site and change the entire pump infusion set.

What does it mean when a home blood glucose meter displays "HI" instead of a number?¶

On most consumer blood glucose meters, "HI" means capillary blood sugar exceeds the maximum readable limit of the device, typically above 27.8 to 33.3 mmol/L (500 to 600 mg/dL). A "HI" reading warns of Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycemic State (HHS); check blood ketones immediately, and if the person is confused, drowsy, vomiting, or has ketones above 1.5 to 3.0 mmol/L, call emergency medical services right away.

ምንጭታት ተፈቲሾም¶

• 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), and Diabetes Technology Society (DTS): Hyperglycemic Crises in Adults: A Consensus Report (Umpierrez et al., Diabetes Care / Diabetologia, 2024).
• 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): Type 1 Diabetes in Adults: Diagnosis and Management (NG17) and Diabetes (Type 1 and Type 2) in Children and Young People: Diagnosis and Management (NG18, including cerebral edema and fluid resuscitation protocols).
• Joint British Diabetes Societies for Inpatient Care (JBDS-IP, United Kingdom): The Management of Diabetic Ketoacidosis in Adults and The Management of the Hyperosmolar Hyperglycaemic State (HHS) in Adults.
• 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" & "STOP DKA" Protocols).

ተዛመድቲ መምርሒታት¶

• Diabetic emergencies: hypoglycemia and immediate glucose rescue
• ኣፍልጦ ስንባደን ምሕደራ ቀዳማይ ረድኤትን
• መርዛም መግቢ፡ ሕዱር ሕማም ከስዐ፡ ከምኡ’ውን ምውሓድ ማይ
• ሴፕሲስን ሴፕቲክ ሾክን ምልላይ
• ምልላይ ወቕዒ (FAST)ን ህጹጽ ምላሽን።