糖尿病急性併發症

DKA(Diabetic ketoacidosis)

Insulin deficiency® 肝lipolysis® FFA® Acetoacetate® Acetone脂溶性由肺呼出

b -hydroxybutyrate最酸

　

治療：

  1. restoration of volume
  2. appropriate electrolyte management
  3. reversal of acidosis and ketogenesis
  4. control of blood glucose

診斷：

  1. nausea,vomiting, vague abdominal pain
  2. hyperventilation( Kussmaul's respiration)
  3. shock or coma

實驗評估：

  1. metabolic acidosis
  2. elevated anion gap
  3. presence of serum ketones, ketouria
  4. elevated plasma glucose

-- hyponatremia(glucose­ 100mg/dl,Na+‾ 1.6mEq/L), hyperkalemia, increase BUN and creatinine, hyperosmolarity, elevated serum amylase

誘發因子：

insufficient or interrupted insulin therapy, infection, stress, myocardial infarction, pregnancy

體液的偵測：assessment of the HR, BP, urine output

治療：

Bicarbonate therapy :

1.DKA伴隨shock or coma 2.arterial pH <7.1 3.severe hyperkalemia

Potassium replacement：

Hyperkalemia initially due to metabolic acidosis(pH‾ 0.1,K+­ 0.6mEq/L)

Life-threatening hypokalemia can develop during insulin treatment

Insulin treatment： adjustments of insulin dosage

Initial dose: 0.15units/kg, then 0.1 units/kg

Dextrose administration may be necessary during therapy

maintain blood glucose at 200-300 mg/dl

Phosphate administration: routine use of phosphate should be avoided.

Complication of DKA:

  1. Lactic acidosis(pH<7.25,anion gap>20 mmol/L)
  2. Cerebral edema
  3. Arterial thrombosis

　

NKHS(Nonketotic hyperosmolar syndrome)

--DM type 2, dehydration, severe hyperglycemia without ketoacidosis

Severe stress, stroke, excessive carbohydrate intake, antecedent renal insufficiency, prerenal azotemia

診斷：obtundation(遲緩), coma, severe dehydration, an underlying illness

實驗評估：

  1. hyperglycemia, often>600mg/dl
  2. absence of ketonemia
  3. plasma osmolarity>320 mOsm/liter --severe azotemia, lactic acidosis

Electrolyte management: similar to those for DKA

Hypoglycemia

診斷：Whipple's Triad:

  1. Symptoms and signs of hypoglycemia: irritability(刺激性), tremulousness(震顫), diaphoresis(出汗), tachycardia, confusion(精神混亂)--seizure, stupor, coma, focal neurologic findings

    2. 　
  2. Associated with plasma glucose equal to or less than 45 mg/dl
  3. Reversibility of symptoms after glucose administration:

(方糖2~3塊、半杯橘子汁、可樂、汽水、二茶匙糖)

BW<30kg Glucagon 0.5mg IM

BW>30kg Glucagon 1mg IM

Adjustments of drug therapy

Adjustments of diet and physical activity

Hypoglycemia unawareness

不經Neurogenic symptoms而直接進入Neuroglycopenic symptoms

Spontaneous hypoglycemia

Fasting hypoglycemia

可能起因於 endogeneous insulin excess, severe hepatic insufficiency, alcohol intoxication, adrenocortical insufficiency, hypothyroidism, or GH deficiency

Postprandial hypoglycemia: insulin induced hypoglycemia