病史和体格检查
关键诊断因素
对于以下情况,考虑 DKA:
已知有糖尿病且身体情况不佳的患者[2]Misra S, Oliver NS. Diabetic ketoacidosis in adults. BMJ. 2015 Oct 28;351:h5660. http://www.ncbi.nlm.nih.gov/pubmed/26510442?tool=bestpractice.com [42]Joint British Diabetes Societies Inpatient Care Group. The management of diabetic ketoacidosis in adults. September 2013 [internet publication]. https://www.diabetes.org.uk/resources-s3/2017-09/Management-of-DKA-241013.pdf [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
DKA 最常见于 1 型糖尿病患者,但也可见于 2 型糖尿病患者。[42]Joint British Diabetes Societies Inpatient Care Group. The management of diabetic ketoacidosis in adults. September 2013 [internet publication]. https://www.diabetes.org.uk/resources-s3/2017-09/Management-of-DKA-241013.pdf [46]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43. https://www.doi.org/10.2337/dc09-9032 http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
具有糖尿病特征及以下任一特征的患者:[17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [48]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. November 2016 [internet publication]. https://www.nice.org.uk/guidance/ng18
恶心和呕吐
腹痛[2]Misra S, Oliver NS. Diabetic ketoacidosis in adults. BMJ. 2015 Oct 28;351:h5660. http://www.ncbi.nlm.nih.gov/pubmed/26510442?tool=bestpractice.com [49]Umpierrez G, Freire AX. Abdominal pain in patients with hyperglycemic crises. J Crit Care. 2002 Mar;17(1):63-7. http://www.ncbi.nlm.nih.gov/pubmed/12040551?tool=bestpractice.com
过度通气(Kussmaul 呼吸)[50]Whited L, Graham DD. Abnormal respirations. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2019. https://www.ncbi.nlm.nih.gov/books/NBK470309/
脱水
意识模糊。
糖尿病的特征是口渴加重、多尿、近期不明原因体重下降或过度疲劳。[17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [48]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. November 2016 [internet publication]. https://www.nice.org.uk/guidance/ng18
如果已知有糖尿病、口渴加重、多尿、近期不明原因体重下降或过度劳累的患者出现此情况,则怀疑 DKA。[17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [48]National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. November 2016 [internet publication]. https://www.nice.org.uk/guidance/ng18
检查腹部是否有 DKA 的可能病因,例如胰腺炎。[47]Evans K. Diabetic ketoacidosis: update on management. Clin Med (Lond). 2019 Sep;19(5):396-8. https://www.doi.org/10.7861/clinmed.2019-0284 http://www.ncbi.nlm.nih.gov/pubmed/31530688?tool=bestpractice.com [15]Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic crises: diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar state (HHS). In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth, MA: MDText.com, Inc.; 2018. https://www.ncbi.nlm.nih.gov/books/NBK279052/ [30]Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol. 2000 Oct;95(10):2795-800. http://www.ncbi.nlm.nih.gov/pubmed/11051350?tool=bestpractice.com DKA 可引起急腹症,也可能出现类似急腹症的表现。[49]Umpierrez G, Freire AX. Abdominal pain in patients with hyperglycemic crises. J Crit Care. 2002 Mar;17(1):63-7. http://www.ncbi.nlm.nih.gov/pubmed/12040551?tool=bestpractice.com
检查是否存在腹胀,腹胀可能提示肠梗阻。[83]Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008 Apr 1;77(7):971-8. http://www.ncbi.nlm.nih.gov/pubmed/18441863?tool=bestpractice.com
触诊腹部,检查是否存在腹膜刺激引起的反跳痛和肌卫。[83]Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008 Apr 1;77(7):971-8. http://www.ncbi.nlm.nih.gov/pubmed/18441863?tool=bestpractice.com
听诊闻及肠鸣音。[84]Jackson PG, Raiji MT. Evaluation and management of intestinal obstruction. Am Fam Physician. 2011 Jan 15;83(2):159-65. http://www.ncbi.nlm.nih.gov/pubmed/21243991?tool=bestpractice.com
早期肠梗阻可能出现频急高亢的肠鸣音。
晚期肠梗阻、内脏穿孔、腹腔积血或任何腹膜炎病因可能表现为肠鸣音减弱或消失。
进行直肠检查。[83]Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008 Apr 1;77(7):971-8. http://www.ncbi.nlm.nih.gov/pubmed/18441863?tool=bestpractice.com
确保携带一名行为监督人。
评估隐性或显性出血、疼痛或肿块。
检查是否有脱水征象。包括:[17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
黏膜干燥
皮肤张力降低或皮肤皱缩
毛细血管再充盈缓慢
心动过速伴脉搏微弱
低血压。
这是 DKA 的晚期体征,并伴有更严重的酸中毒。[17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [50]Whited L, Graham DD. Abnormal respirations. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2019. https://www.ncbi.nlm.nih.gov/books/NBK470309/
特征表现为缓慢或正常速率的叹息样深呼吸。[17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [50]Whited L, Graham DD. Abnormal respirations. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2019. https://www.ncbi.nlm.nih.gov/books/NBK470309/
每小时使用格拉斯哥昏迷量表评估意识水平,以监测是否发生脑水肿。意识水平降低与更严重的 DKA 和更差的预后密切相关。[67]Nyenwe EA, Razavi LN, Kitabchi AE, et al. Acidosis: the prime determinant of depressed sensorium in diabetic ketoacidosis. Diabetes Care. 2010 Aug;33(8):1837-9. http://care.diabetesjournals.org/content/33/8/1837.long http://www.ncbi.nlm.nih.gov/pubmed/20484127?tool=bestpractice.com [42]Joint British Diabetes Societies Inpatient Care Group. The management of diabetic ketoacidosis in adults. September 2013 [internet publication]. https://www.diabetes.org.uk/resources-s3/2017-09/Management-of-DKA-241013.pdf [ 格拉斯哥昏迷量表 ]
精神状态可从轻度 DKA 的警觉状态到重度 DKA 的昏迷状态。[53]Trachtenbarg DE. Diabetic ketoacidosis. Am Fam Physician. 2005 May 1;71(9):1705-14. http://www.ncbi.nlm.nih.gov/pubmed/15887449?tool=bestpractice.com
在 DKA 治疗期间,快速纠正高血糖时可能出现脑水肿。[42]Joint British Diabetes Societies Inpatient Care Group. The management of diabetic ketoacidosis in adults. September 2013 [internet publication]. https://www.diabetes.org.uk/resources-s3/2017-09/Management-of-DKA-241013.pdf
相关征象包括头痛、易激惹、脉搏减慢、血压升高、意识水平降低。这些征象可能发生于开始治疗后数小时。[51]British Society for Paediatric Endocrinology and Diabetes. BSPED interim guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis. January 2020 [internet publication]. https://www.bsped.org.uk/media/1712/new-dka-guideline-v6-final.pdf [61]Kitabchi AE, Wall BM. Management of diabetic ketoacidosis. Am Fam Physician. 1999 Aug;60(2):455-64. http://www.ncbi.nlm.nih.gov/pubmed/10465221?tool=bestpractice.com
视乳头水肿是脑水肿的晚期体征。[51]British Society for Paediatric Endocrinology and Diabetes. BSPED interim guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis. January 2020 [internet publication]. https://www.bsped.org.uk/media/1712/new-dka-guideline-v6-final.pdf
立即寻求危重症诊疗医生的意见并给予甘露醇。[62]Meaden CW, Kushner BJ, Barnes S. A rare and lethal complication: cerebral edema in the adult patient with diabetic ketoacidosis. Case Rep Emerg Med. 2018 Mar 21;2018:5043752. https://www.doi.org/10.1155/2018/5043752 http://www.ncbi.nlm.nih.gov/pubmed/29755797?tool=bestpractice.com
脑水肿的死亡率为 70%。常见于儿童和青少年,也可见于成人。[2]Misra S, Oliver NS. Diabetic ketoacidosis in adults. BMJ. 2015 Oct 28;351:h5660. http://www.ncbi.nlm.nih.gov/pubmed/26510442?tool=bestpractice.com
感染
这是最常见的 DKA 病因。[46]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43. https://www.doi.org/10.2337/dc09-9032 http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com [42]Joint British Diabetes Societies Inpatient Care Group. The management of diabetic ketoacidosis in adults. September 2013 [internet publication]. https://www.diabetes.org.uk/resources-s3/2017-09/Management-of-DKA-241013.pdf [53]Trachtenbarg DE. Diabetic ketoacidosis. Am Fam Physician. 2005 May 1;71(9):1705-14. http://www.ncbi.nlm.nih.gov/pubmed/15887449?tool=bestpractice.com [26]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 [33]Alavi IA, Sharma BK, Pillay VK. Steroid-induced diabetic ketoacidosis. Am J Med Sci. 1971 Jul;262(1):15-23. http://www.ncbi.nlm.nih.gov/pubmed/4327634?tool=bestpractice.com [71]Wachtel TJ, Silliman RA, Lamberton P. Predisposing factors for the diabetic hyperosmolar state. Arch Intern Med. 1987 Mar;147(3):499-501. http://www.ncbi.nlm.nih.gov/pubmed/3827427?tool=bestpractice.com [35]Newcomer JW. Second generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs. 2005;19(suppl 1):1-93. http://www.ncbi.nlm.nih.gov/pubmed/15998156?tool=bestpractice.com [36]Nyenwe EA, Loganathan RS, Blum S, et al. Active use of cocaine: an independent risk factor for recurrent diabetic ketoacidosis in a city hospital. Endocr Pract. 2007 Jan-Feb;13(1):22-9. http://www.ncbi.nlm.nih.gov/pubmed/17360297?tool=bestpractice.com
最常见病因为肺炎和泌尿道感染。
停用胰岛素(非故意或故意)
这是 DKA 的第二大常见病因。[17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com [53]Trachtenbarg DE. Diabetic ketoacidosis. Am Fam Physician. 2005 May 1;71(9):1705-14. http://www.ncbi.nlm.nih.gov/pubmed/15887449?tool=bestpractice.com [26]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
谨慎询问故意停用胰岛素的原因,其中可能包括担心体重增加或低血糖、经济障碍以及心理因素(例如,针头恐惧症和心理压力)。[2]Misra S, Oliver NS. Diabetic ketoacidosis in adults. BMJ. 2015 Oct 28;351:h5660. http://www.ncbi.nlm.nih.gov/pubmed/26510442?tool=bestpractice.com [17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
较年轻的 1 型糖尿病患者可能会因为担心低血糖、体重增加、进食障碍,或慢性病带来的压力而停用胰岛素。这些因素可能是 20% 复发性 DKA 的原因。[72]Polonsky WH, Anderson BJ, Lohrer PA, et al. Insulin omission in women with IDDM. Diabetes Care. 1994 Oct;17(10):1178-85. http://www.ncbi.nlm.nih.gov/pubmed/7821139?tool=bestpractice.com
胰岛素使量不足
常见原因有:
胰岛素笔或泵故障[54]Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014 Jun 30;7:255-64. http://www.ncbi.nlm.nih.gov/pubmed/25061324?tool=bestpractice.com [55]Pryce R. Diabetic ketoacidosis caused by exposure of insulin pump to heat and sunlight. BMJ. 2009 Jan 5;338:a2218. http://www.ncbi.nlm.nih.gov/pubmed/19124546?tool=bestpractice.com
储存于不正确的温度下,导致胰岛素降解。[55]Pryce R. Diabetic ketoacidosis caused by exposure of insulin pump to heat and sunlight. BMJ. 2009 Jan 5;338:a2218. http://www.ncbi.nlm.nih.gov/pubmed/19124546?tool=bestpractice.com
新发糖尿病[17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
DKA 的常见病因。
急症
常见病因包括心肌梗死、脓毒症和胰腺炎[15]Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic crises: diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar state (HHS). In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth, MA: MDText.com, Inc.; 2018. https://www.ncbi.nlm.nih.gov/books/NBK279052/ [30]Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol. 2000 Oct;95(10):2795-800. http://www.ncbi.nlm.nih.gov/pubmed/11051350?tool=bestpractice.com
糖尿病患者的症状常不典型,因此应对心肌梗死保持高度怀疑。
实用小贴士
一些糖尿病患者可能存在“隐匿性心肌梗死”(无胸痛或只有轻微胸痛)。这种情况可能是心脏自主神经功能障碍所致。[75]Khafaji HA, Suwaidi JM. Atypical presentation of acute and chronic coronary artery disease in diabetics. World J Cardiol. 2014 Aug 26;6(8):802-13. https://www.doi.org/10.4330/wjc.v6.i8.802 http://www.ncbi.nlm.nih.gov/pubmed/25228959?tool=bestpractice.com [76]Junghans C, Sekhri N, Zaman MJ, et al. Atypical chest pain in diabetic patients with suspected stable angina: impact on diagnosis and coronary outcomes. Eur Heart J Qual Care Clin Outcomes. 2015 Jul 1;1(1):37-43. https://www.doi.org/10.1093/ehjqcco/qcv003 http://www.ncbi.nlm.nih.gov/pubmed/29474566?tool=bestpractice.com
生理应激
包括妊娠、创伤和手术。
一些女性在月经期间可能会出现 DKA。[73]Jamshed N, Banavaliker B, Aggarwal P. Catamenial diabetic ketoacidosis - a diagnostic dilemma in ED. Am J Emerg Med. 2013 Feb;31(2):464.e1-3. http://www.ncbi.nlm.nih.gov/pubmed/23107348?tool=bestpractice.com [74]Ovalle F, Vaughan TB 3rd, Sohn JE, et al. Catamenial diabetic ketoacidosis and catamenial hyperglycemia: case report and review of the literature. Am J Med Sci. 2008 Apr;335(4):298-303. http://www.ncbi.nlm.nih.gov/pubmed/18414069?tool=bestpractice.com
实用小贴士
妊娠期 DKA 的诊断常常被延误,因为妊娠期 DKA 可发生在血糖水平较低时,并且相较于非妊娠患者,其发病速度更快。[77]Kamalakannan D, Baskar V, Barton DM, et al. Diabetic ketoacidosis in pregnancy. Postgrad Med J. 2003 Aug;79(934):454-7. https://www.doi.org/10.1136/pmj.79.934.454 http://www.ncbi.nlm.nih.gov/pubmed/12954957?tool=bestpractice.com
DKA 常见于妊娠中期和晚期,因为此时胰岛素抵抗增加。[77]Kamalakannan D, Baskar V, Barton DM, et al. Diabetic ketoacidosis in pregnancy. Postgrad Med J. 2003 Aug;79(934):454-7. https://www.doi.org/10.1136/pmj.79.934.454 http://www.ncbi.nlm.nih.gov/pubmed/12954957?tool=bestpractice.com
既往病史
糖尿病史:
DKA 最常见于 1 型糖尿病患者中,但也可见于 2 型糖尿病患者。[46]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43. https://www.doi.org/10.2337/dc09-9032 http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
用药史[17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com
可能导致 DKA 的药物包括:
皮质类固醇(增加胰岛素抵抗)[57]Cağdaş DN, Paç FA, Cakal E. Glucocorticoid-induced diabetic ketoacidosis in acute rheumatic fever. J Cardiovasc Pharmacol Ther. 2008 Dec;13(4):298-300. http://www.ncbi.nlm.nih.gov/pubmed/19087951?tool=bestpractice.com
噻嗪类药物(病因不明,但可能会增加胰岛素抵抗、抑制葡萄糖摄取以及减少胰岛素释放)
拟交感神经药(改变葡萄糖代谢)[26]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
第二代抗精神病药物(改变葡萄糖代谢)[58]Vuk A, Kuzman MR, Baretic M, et al. Diabetic ketoacidosis associated with antipsychotic drugs: case reports and a review of literature. Psychiatr Danub. 2017 Jun;29(2):121-35. http://www.ncbi.nlm.nih.gov/pubmed/28636569?tool=bestpractice.com
免疫检查点抑制剂(导致胰岛素缺乏)[59]Kotwal A, Haddox C, Block M, et al. Immune checkpoint inhibitors: an emerging cause of insulin-dependent diabetes. BMJ Open Diabetes Res Care. 2019 Feb 13;7(1):e000591. https://www.doi.org/10.1136/bmjdrc-2018-000591 http://www.ncbi.nlm.nih.gov/pubmed/30899528?tool=bestpractice.com
可卡因、大麻和急性酒精中毒(DKA 与可卡因的使用有关,但机制尚不清楚)[56]Umpierrez GE, Kitabchi AE. Diabetic ketoacidosis: risk factors and management strategies. Treat Endocrinol. 2003;2(2):95-108. http://www.ncbi.nlm.nih.gov/pubmed/15871546?tool=bestpractice.com [60]Kinney GL, Akturk HK, Taylor DD, et al. Cannabis use is associated with increased risk for diabetic ketoacidosis in adults with type 1 diabetes: findings from the T1D Exchange Clinic Registry. Diabetes Care. 2020 Jan;43(1):247-9. http://www.ncbi.nlm.nih.gov/pubmed/31628116?tool=bestpractice.com
SGLT2 抑制剂(防止葡萄糖重吸收并促进其通过尿液排泄)。[21]Kalra S. Sodium glucose co-transporter-2 (SGLT2) inhibitors: a review of their basic and clinical pharmacology. Diabetes Ther. 2014 Dec;5(2):355-66. https://www.doi.org/10.1007/s13300-014-0089-4 http://www.ncbi.nlm.nih.gov/pubmed/25424969?tool=bestpractice.com [22]Hampp C, Swain RS, Horgan C, et al. Use of sodium-glucose cotransporter 2 inhibitors in patients with type 1 diabetes and rates of diabetic ketoacidosis. Diabetes Care. 2020 Jan;43(1):90-7. http://www.ncbi.nlm.nih.gov/pubmed/31601640?tool=bestpractice.com
严重低体温与 30%-60% 的死亡率相关。[68]Goldberger ZD. Severe hypothermia with Osborn waves in diabetic ketoacidosis. Respir Care. 2008 Apr;53(4):500-2. http://www.ncbi.nlm.nih.gov/pubmed/18364063?tool=bestpractice.com 可能观察到一些 DKA 患者由于外周血管扩张出现轻度低体温。[46]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43. https://www.doi.org/10.2337/dc09-9032 http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com
实用小贴士
发热不是 DKA 的特征,但 DKA 可能由脓毒症引起。如果出现发热或低体温、低血压、难治性酸中毒或乳酸酸中毒,则怀疑脓毒症是 DKA 的病因。[51]British Society for Paediatric Endocrinology and Diabetes. BSPED interim guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis. January 2020 [internet publication]. https://www.bsped.org.uk/media/1712/new-dka-guideline-v6-final.pdf
其他诊断因素
患者的呼吸闻起来像梨子糖或洗甲液。[17]Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ. 2019 May 29;365:l1114. https://www.doi.org/10.1136/bmj.l1114 http://www.ncbi.nlm.nih.gov/pubmed/31142480?tool=bestpractice.com 这是由于血酮水平高。
实用小贴士
很大一部分患者即使呼出丙酮,也闻不到丙酮气味。
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