并发症
这种医源性并发症可因过大剂量的胰岛素治疗而发生。可以通过遵照现行治疗方案,并频繁监测血糖和使用含葡萄糖的静脉输注液来预防。[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
这种医源性并发症可因过大剂量的胰岛素和碳酸氢钠治疗而发生。但可以通过遵照现行治疗方案,并频繁监测血钾水平和适当的补钾治疗来预防。[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [57]Hillman K. Fluid resuscitation in diabetic emergencies - a reappraisal. Intensive Care Med. 1987;13(1):4-8. http://www.ncbi.nlm.nih.gov/pubmed/3104431?tool=bestpractice.com [70]Morris LR, Murphy MB, Kitabchi AE. Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med. 1986 Dec;105(6):836-40. http://www.ncbi.nlm.nih.gov/pubmed/3096181?tool=bestpractice.com
给予这些患者低剂量肝素治疗,这种标准预防措施无疑是合理的。[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [43]Kitabchi AE. Editorial. Hyperglycemic crises: improving prevention and management. Am Fam Physician. 2005 May 1;71(9):1659-60. http://www.aafp.org/afp/2005/0501/p1659.html http://www.ncbi.nlm.nih.gov/pubmed/15887446?tool=bestpractice.com [89]Buyukasik Y, Ileri NS, Haznedaroglu IC, et al. Enhanced subclinical coagulation activation during diabetic ketoacidosis. Diabetes Care. 1998 May;21(5):868-70. http://www.ncbi.nlm.nih.gov/pubmed/9589259?tool=bestpractice.com 应用预防性治疗是基于医生对血栓栓塞事件的危险因素的临床评价。目前没有证据表明需要充分的抗凝治疗。
这种情况的发生是由于碳酸氢盐再生所需要的阴离子从尿中丢失,以及强化静脉输入含氯溶液引起氯的再吸收增加。这种酸中毒通常可以解决,不会影响治疗。这种情况更多发生于孕妇。[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [70]Morris LR, Murphy MB, Kitabchi AE. Bicarbonate therapy in severe diabetic ketoacidosis. Ann Intern Med. 1986 Dec;105(6):836-40. http://www.ncbi.nlm.nih.gov/pubmed/3096181?tool=bestpractice.com
这种情况发生在 0.7%-10% 的儿童 DKA 患者中,在成人 DKA 患者中较为罕见。5 岁以下儿童的风险更高。[84]Wolfsdorf JI, Glaser N, Agus M, et al. ISPAD Clinical practice consensus guidelines 2018: diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes. 2018 Oct;19(suppl 27):155-77. http://www.ncbi.nlm.nih.gov/pubmed/29900641?tool=bestpractice.com 临床表现为头痛、昏睡、视乳头改变和癫痫发作。死亡率较高。应该予甘露醇静脉输入和机械通气治疗。对 DKA 患者可通过避免过度水化、将患者血糖水平维持在 8.3-11.1 mmol/L(150-200 mg/dL)来预防脑水肿/脑损伤的发生。[1]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.full http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [23]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan;24(1):131-53. http://care.diabetesjournals.org/content/24/1/131.long http://www.ncbi.nlm.nih.gov/pubmed/11194218?tool=bestpractice.com [85]Duck SC, Wyatt DT. Factors associated with brain herniation in the treatment of diabetic ketoacidosis. J Pediatr. 1988 Jul;113(1 Pt 1):10-4. http://www.ncbi.nlm.nih.gov/pubmed/3133455?tool=bestpractice.com [86]Glaser N. New perspectives on the pathogenesis of cerebral edema complicating diabetic ketoacidosis in children. Pediatr Endocrinol Rev. 2006 Jun;3(4):379-86. http://www.ncbi.nlm.nih.gov/pubmed/16816806?tool=bestpractice.com 第一个评估儿童 DKA 输液方案的前瞻性研究的结果发现,静脉输液的氯化钠含量和输注速度均不会影响短期和长期的神经系统结局。[87]Kuppermann N, Ghetti S, Schunk JE,et al; PECARN DKA FLUID Study Group. Clinical trial of fluid infusion rates for pediatric diabeticketoacidosis. N Engl J Med. 2018 Jun 14;378(24):2275-87. http://www.ncbi.nlm.nih.gov/pubmed/29897851?tool=bestpractice.com
在 DKA 中,由于治疗所致胶体渗透压的下降,可能引起肺部水分积聚、肺顺应性降低以及可能有低氧血症。治疗包括通过脉搏血氧测定法监测血氧水平、减少液体摄入量并补充胶体。[23]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan;24(1):131-53. http://care.diabetesjournals.org/content/24/1/131.long http://www.ncbi.nlm.nih.gov/pubmed/11194218?tool=bestpractice.com [88]Carroll P, Matz R. Adult respiratory distress syndrome complicating severely uncontrolled diabetes mellitus: report of nine cases and a review of the literature. Diabetes Care. 1982 Nov-Dec;5(6):574-80. http://www.ncbi.nlm.nih.gov/pubmed/6821490?tool=bestpractice.com
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