治疗流程
请注意药品名称和品牌、药品处方或地区之间的配方/用药途径和剂量可能有所不同。治疗建议针对患者特定群体提出： 查看免责声明
初始收缩压 <90 mmHg
确诊 DKA 后立即开始静脉输液。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
在 10-15 分钟内快速静脉给予 500 mL 生理盐水（0.9% 氯化钠）。
如果收缩压（systolic blood pressure, SBP）仍然 <90 mmHg，请再次快速大量静脉补液，并寻求上级医生的帮助。
重复大量静脉补液，立即请上级医生评估，如果第二次快速大量静脉补液后仍无改善，请考虑寻求危重症诊疗医生的支持。
考虑低血压的其他病因（例如，脓毒症、心力衰竭、急性心肌梗死）。[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
一旦 SBP >90 mmHg，请在 1 小时内给予 1 L 生理盐水。[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
对于以下患者，应更谨慎地给予静脉输液并考虑监测中心静脉压：[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
年轻人（18-25 岁），因为快速补液可能会增加这些患者脑水肿的风险
高龄或妊娠
存在心力衰竭、肾功能衰竭或其他严重合并症。
使用预混氯化钾的生理盐水在第二升静脉输液中添加钾。寻求上级医生或危重症诊疗医生的支持，因为需要大剂量补钾。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
对于体重为 70 kg 且身体状况良好的成人，典型补液方案是：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
生理盐水量（根据需要添加氯化钾） |
|---|
2 小时内 1 升 |
接下来的 2 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 6 小时内 1 升 |
如果血糖水平降至 14.0 mmol/L 以下，则除生理盐水外还要给予 10% 的葡萄糖。[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 [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
继续以这种方式输液，直至患者可正常进食进水。
特定患者群中针对所有患者的治疗建议
保护气道。
如果患者对指令无反应或持续呕吐，则插入鼻胃管并进行抽吸。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
如果出现以下情况，请确保持续进行心脏监测并寻求上级医生或危重症诊疗医生的支持：[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
即使静脉输液，仍存在持续性低血压（SBP <90 mmHg）或少尿，即尿量 <0.5 mL/(kg·h)
格拉斯哥昏迷量表评分 <12 [ 格拉斯哥昏迷量表 ]
血酮 >6 mmol/L
静脉碳酸氢根 <5 mmol/L
静脉 pH 值 <7.0
入院时钾 <3.5 mmol/L
吸入空气时血氧饱和度 <92%
脉搏 >100 次/分，或 <60 次/分
阴离子间隙 >16 [ 阴离子间隙(AG) ]
患者妊娠或患有心力衰竭、肾功能衰竭或其他严重合并症。
开始治疗 1 小时后，如果出现失禁或不排尿，则插入导尿管。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
特定患者群中针对所有患者的治疗建议
以 0.1 units/(kg·h) 的剂量或根据当地规程开始固定速率静脉胰岛素输注（fixed-rate intravenous insulin infusion, FRIII）。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
给予 FRIII 之前，确保已开始静脉输液。
如果需要 > 15 units/h 的胰岛素，请寻求糖尿病专科医生团队的意见。[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 [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
使用下表作为指导：
体重（kg） | 每小时胰岛素剂量（units） |
|---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
英国指南建议采用固定速率输注胰岛素，以抑制肝脏葡萄糖生成、生酮作用和脂解作用。
胰岛素治疗 DKA 患者的主要目的是抑制脂解作用和生酮作用，英国指南建议以基于体重的固定剂量 0.1 U/(kg·h) 开始静脉输注常规胰岛素。[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
2019 年成人急性失代偿性糖尿病临床综述强调了关于胰岛素治疗方案的指南建议存在差异。[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
根据一项纳入 37 例患者的小型试验的证据，美国糖尿病学会建议选择以下两种方案中的任意一种：以基于体重的固定剂量 0.14 units/(kg·h) 静脉输注常规胰岛素，或者快速静脉推注 0.1 units/kg 胰岛素后以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素。[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
临床综述指出，2013 年英国糖尿病学会联合住院治疗组指南中，关于不快速推注胰岛素而是以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素的建议，可能不足以抑制肝脏葡萄糖的生成和刺激外周葡萄糖的摄取，但可能足以抑制脂解作用和生酮作用。[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
一项研究针对 DKA 儿童患者比较了低剂量 0.1 units/(kg·h) 和高剂量 1 units/(kg·h) 静脉输注胰岛素方案，发现采用高剂量方案的低钾血症风险增加。[129]Burghen GA, Etteldorf JN, Fisher JN, et al. Comparison of high-dose and low-dose insulin by continuous intravenous infusion in the treatment of diabetic ketoacidosis in children. Diabetes Care. 1980 Jan-Feb;3(1):15-20. https://www.doi.org/10.2337/diacare.3.1.15 http://www.ncbi.nlm.nih.gov/pubmed/6773725?tool=bestpractice.com
DKA 消退并且患者可进食和饮水后，开始常规皮下胰岛素注射。通常应由糖尿病专科医生团队来完成，并随餐给予。[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 [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
进行皮下胰岛素注射后，继续 30-60 分钟的静脉胰岛素输注，以预防 DKA 复发。[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
如果患者不可进食进水，则继续静脉输液。[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
如果 DKA 已消退，则对这些患者开始可变速率的胰岛素静脉输注（variable rate intravenous insulin infusion, VRIII）。
定期测量血糖。
第一选择
中性胰岛素: 参考当地治疗方案中的剂量指南部分。
特定患者群中针对所有患者的治疗建议
DKA 的常见病因包括心肌梗死、脓毒症和胰腺炎。[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 [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
特定患者群中针对所有患者的治疗建议
按如下时间间隔监测生化标志物：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
酮体 | 葡萄糖 | 碳酸氢盐 | 钾 | pH | |
|---|---|---|---|---|---|
| 0 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 1 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 2 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 3 小时 | ✓ | ✓ | |||
| 4 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 5 小时 | ✓ | ✓ | |||
| 6 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 12 个小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
如果可以检测血酮，力争使血酮水平下降 0.5 mmol/(L·h)。
如果无法检测血酮，则检测静脉碳酸氢根或血糖。
争取使静脉碳酸氢根增加 3.0 mmol/(L·h) 或使血糖减少 3.0 mmol/(L·h)。
如果未达到血酮、血糖和静脉碳酸氢根目标改善速率：[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
检查胰岛素输注泵是否功能正常且连接良好，并检查胰岛素余量是否正确（以检查胰岛素泵是否出现故障）
每小时增加 1 u 胰岛素输注剂量（若无胰岛素泵故障），直至达到目标血酮、血糖以及碳酸氢根水平。
评估 DKA 消退情况。定义为：[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
静脉 pH 值>7.3 且
血酮水平 <0.6 mmol/L，且
碳酸氢根 >15 mmol/L
2013 年英国糖尿病学会联合住院治疗组指南建议应继续予以 FRIII，直到碳酸氢根 >18 mmol/L。[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
特定患者群中针对所有患者的治疗建议
在 DKA 的整个治疗过程中，应定期监测并发症。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
每小时使用格拉斯哥昏迷量表进行评估，以监测是否发生脑水肿。[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 [ 格拉斯哥昏迷量表 ]
如果怀疑有脑水肿，请立即寻求上级医生和危重症诊疗医生的支持。
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
若格拉斯哥昏迷量表评分恶化或者患者新发头痛或头痛恶化，应考虑进行头颅 CT 检查。[137]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
根据当地规程密切监测生命体征。
如果血氧饱和度下降，请申请胸部 X 线检查，该体征可能提示肺水肿。考虑进行动脉血气检查。
特定患者群中针对部分患者的治疗建议
仅在静脉 pH 值 <6.9 并与上级顾问医师讨论后，才考虑给予碳酸氢盐治疗。在危重症诊疗环境中监测患者。[131]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
特定患者群中针对部分患者的治疗建议
考虑对老年患者或高风险患者使用低分子肝素预防血栓，除非存在相关禁忌证。[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 请参阅 VTE 预防专题。
确诊 DKA 后立即开始静脉输液。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
在 10-15 分钟内快速静脉给予 500 mL 生理盐水（0.9% 氯化钠）。
如果 SBP 保持 <90 mmHg，请再次快速大量静脉补液，并寻求上级医生的帮助。
重复大量静脉补液，立即请上级医生评估，如果第二次快速大量静脉补液后仍无改善，请考虑寻求危重症诊疗医生的支持。
考虑低血压的其他病因（例如，脓毒症、心力衰竭、急性心肌梗死）。[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
一旦 SBP >90 mmHg，请在 1 小时内给予 1 L 生理盐水。[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
对于以下患者，应更谨慎地给予静脉输液并考虑监测中心静脉压：[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
年轻人（18-25 岁），因为快速补液可能会增加这些患者脑水肿的风险
高龄或妊娠
存在心力衰竭、肾功能衰竭或其他严重合并症。
使用预混氯化钾的生理盐水在第二升静脉输液中添加 40 mmol/L 钾。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
对于体重为 70 kg 且身体状况良好的成人，典型补液方案是：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
生理盐水量（根据需要添加氯化钾） |
|---|
2 小时内 1 升 |
接下来的 2 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 6 小时内 1 升 |
如果血糖水平降至 14.0 mmol/L 以下，则除生理盐水外还要给予 10% 的葡萄糖。[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 [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
继续以这种方式输液，直至患者可正常进食进水。
特定患者群中针对部分患者的治疗建议
保护气道。
如果患者对指令无反应或持续呕吐，则插入鼻胃管并进行抽吸。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
如果出现以下情况，请确保持续进行心脏监测并寻求上级医生或危重症诊疗医生的支持：[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
即使静脉输液，仍存在持续性低血压（SBP <90 mmHg）或少尿，即尿量 <0.5 mL/(kg·h)
格拉斯哥昏迷量表评分 <12 [ 格拉斯哥昏迷量表 ]
血酮 >6 mmol/L
静脉碳酸氢根 <5 mmol/L
静脉 pH 值 <7.0
吸入空气时血氧饱和度 <92%
脉搏 >100 次/分，或 <60 次/分
阴离子间隙 >16 [ 阴离子间隙(AG) ]
患者妊娠或患有心力衰竭、肾功能衰竭或其他严重合并症。
开始治疗 1 小时后，如果出现失禁或不排尿，则插入导尿管。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
特定患者群中针对所有患者的治疗建议
以 0.1 units/(kg·h) 的剂量或根据当地规程开始固定速率静脉胰岛素输注（fixed-rate intravenous insulin infusion, FRIII）。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
给予 FRIII 之前，确保已开始静脉输液。
如果需要 > 15 units/h 的胰岛素，请寻求糖尿病专科医生团队的意见。[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 [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
使用下表作为指导：
体重（kg） | 每小时胰岛素剂量（units） |
|---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
英国指南建议采用固定速率输注胰岛素，以抑制肝脏葡萄糖生成、生酮作用和脂解作用。
胰岛素治疗 DKA 患者的主要目的是抑制脂解作用和生酮作用，英国指南建议以基于体重的固定剂量 0.1 units/(kg·h) 开始静脉输注常规胰岛素。[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
2019 年成人急性失代偿性糖尿病临床综述强调了关于胰岛素治疗方案的指南建议存在差异。[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
根据一项纳入 37 例患者的小型试验的证据，美国糖尿病学会建议选择以下两种方案中的任意一种：以基于体重的固定剂量 0.14 units/(kg·h) 静脉输注常规胰岛素，或者快速静脉推注 0.1 units/kg 胰岛素后以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素。[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
临床综述指出，2013 年英国糖尿病学会联合住院治疗组指南中，关于不快速推注胰岛素而是以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素的建议，可能不足以抑制肝脏葡萄糖的生成和刺激外周葡萄糖的摄取，但可能足以抑制脂解作用和生酮作用。[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
一项研究针对 DKA 儿童患者比较了低剂量 0.1 units/(kg·h) 和高剂量 1 units/(kg·h) 静脉输注胰岛素方案，发现采用高剂量方案的低钾血症风险增加。[129]Burghen GA, Etteldorf JN, Fisher JN, et al. Comparison of high-dose and low-dose insulin by continuous intravenous infusion in the treatment of diabetic ketoacidosis in children. Diabetes Care. 1980 Jan-Feb;3(1):15-20. https://www.doi.org/10.2337/diacare.3.1.15 http://www.ncbi.nlm.nih.gov/pubmed/6773725?tool=bestpractice.com
DKA 消退并且患者可进食和饮水后，开始常规皮下胰岛素注射。通常应由糖尿病专科医生团队来完成，并随餐给予。[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 [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
进行皮下胰岛素注射后，继续 30-60 分钟的静脉胰岛素输注，以预防 DKA 复发。[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
如果患者不可进食进水，则继续静脉输液。[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
如果 DKA 已消退，则对这些患者开始可变速率的胰岛素静脉输注（variable rate intravenous insulin infusion, VRIII）。
定期测量血糖。
第一选择
中性胰岛素: 参考当地治疗方案中的剂量指南部分。
特定患者群中针对所有患者的治疗建议
DKA 的常见病因包括心肌梗死、脓毒症和胰腺炎。[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 [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
特定患者群中针对所有患者的治疗建议
按如下时间间隔监测生化标志物：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
酮体 | 葡萄糖 | 碳酸氢盐 | 钾 | pH | |
|---|---|---|---|---|---|
| 0 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 1 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 2 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 3 小时 | ✓ | ✓ | |||
| 4 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 5 小时 | ✓ | ✓ | |||
| 6 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 12 个小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
如果可以检测血酮，力争使血酮水平下降 0.5 mmol/(L·h)。
如果无法检测血酮，则检测静脉碳酸氢根或血糖。
争取使静脉碳酸氢根增加 3.0 mmol/(L·h) 或使血糖减少 3.0 mmol/(L·h)。
如果未达到血酮、血糖和静脉碳酸氢根目标改善速率：[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
检查胰岛素输注泵是否功能正常且连接良好，并检查胰岛素余量是否正确（以检查胰岛素泵是否出现故障）
每小时增加 1 u 胰岛素输注剂量（若无胰岛素泵故障），直至达到目标血酮、血糖以及碳酸氢根水平。
评估 DKA 消退情况。定义为：[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
静脉 pH 值>7.3 且
血酮水平 <0.6 mmol/L，且
碳酸氢根 >15 mmol/L
2013 年英国糖尿病学会联合住院治疗组指南建议应继续予以 FRIII，直到碳酸氢根 >18 mmol/L。[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
特定患者群中针对所有患者的治疗建议
在 DKA 的整个治疗过程中，应定期监测并发症。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
每小时使用格拉斯哥昏迷量表进行评估，以监测是否发生脑水肿。[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 [ 格拉斯哥昏迷量表 ]
如果怀疑有脑水肿，请立即寻求上级医生和危重症诊疗医生的支持。
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
若格拉斯哥昏迷量表评分恶化或者患者新发头痛或头痛恶化，应考虑进行头颅 CT 检查。[137]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
根据当地规程密切监测生命体征。
如果血氧饱和度下降，请申请胸部 X 线检查，该体征可能提示肺水肿。考虑进行动脉血气检查。
特定患者群中针对部分患者的治疗建议
仅在静脉 pH 值 <6.9 并与上级顾问医师讨论后，才考虑给予碳酸氢盐治疗。在危重症诊疗环境中监测患者。[131]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
特定患者群中针对部分患者的治疗建议
考虑对老年患者或高风险患者使用低分子肝素预防血栓，除非存在相关禁忌证。[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 请参阅 VTE 预防专题。
确诊 DKA 后立即开始静脉输液。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
在 10-15 分钟内快速静脉给予 500 mL 生理盐水（0.9% 氯化钠）。
如果 SBP 保持 <90 mmHg，请再次快速大量静脉补液，并寻求上级医生的帮助。
重复大量静脉补液，立即请上级医生评估，如果第二次快速大量静脉补液后仍无改善，请考虑寻求危重症诊疗医生的支持。
考虑低血压的其他病因（例如，脓毒症、心力衰竭、急性心肌梗死）。[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
一旦 SBP >90 mmHg，请在 1 小时内给予 1 L 生理盐水。[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
对于以下患者，应更谨慎地给予静脉输液并考虑监测中心静脉压：[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
年轻人（18-25 岁），因为快速补液可能会增加这些患者脑水肿的风险
高龄或妊娠
存在心力衰竭、肾功能衰竭或其他严重合并症。
输注第一升液体后，继续给予补液。在钾 ≤5.5 mmol/L 之前，不要添加氯化钾。
对于体重为 70 kg 且身体状况良好的成人，典型补液方案是：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
生理盐水量（根据需要添加氯化钾） |
|---|
2 小时内 1 升 |
接下来的 2 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 6 小时内 1 升 |
如果血糖水平降至 14.0 mmol/L 以下，则除生理盐水外还要给予 10% 的葡萄糖。[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 [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
继续以这种方式输液，直至患者可正常进食进水。
特定患者群中针对部分患者的治疗建议
保护气道。
如果患者对指令无反应或持续呕吐，则插入鼻胃管并进行抽吸。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
如果出现以下情况，请确保持续进行心脏监测并寻求上级医生或危重症诊疗医生的支持：[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
即使静脉输液，仍存在持续性低血压（SBP <90 mmHg）或少尿，即尿量 <0.5 mL/(kg·h)
格拉斯哥昏迷量表评分 <12 [ 格拉斯哥昏迷量表 ]
血酮 >6 mmol/L
静脉碳酸氢根 <5 mmol/L
静脉 pH 值 <7.0
吸入空气时血氧饱和度 <92%
脉搏 >100 次/分，或 <60 次/分
阴离子间隙 >16 [ 阴离子间隙(AG) ]
患者妊娠或患有心力衰竭、肾功能衰竭或其他严重合并症。
开始治疗 1 小时后，如果出现失禁或不排尿，则插入导尿管。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
特定患者群中针对所有患者的治疗建议
以 0.1 units/(kg·h) 的剂量或根据当地规程开始固定速率静脉胰岛素输注（fixed-rate intravenous insulin infusion, FRIII）。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
给予 FRIII 之前，确保已开始静脉输液。
如果需要 > 15 units/h 的胰岛素，请寻求糖尿病专科医生团队的意见。[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 [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
使用下表作为指导：
体重（kg） | 每小时胰岛素剂量（units） |
|---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
英国指南建议采用固定速率输注胰岛素，以抑制肝脏葡萄糖生成、生酮作用和脂解作用。
胰岛素治疗 DKA 患者的主要目的是抑制脂解作用和生酮作用，英国指南建议以基于体重的固定剂量 0.1 units/(kg·h) 开始静脉输注常规胰岛素。[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
2019 年成人急性失代偿性糖尿病临床综述强调了关于胰岛素治疗方案的指南建议存在差异。[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
根据一项纳入 37 例患者的小型试验的证据，美国糖尿病学会建议选择以下两种方案中的任意一种：以基于体重的固定剂量 0.14 units/(kg·h) 静脉输注常规胰岛素，或者快速静脉推注 0.1 units/kg 胰岛素后以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素。[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
临床综述指出，2013 年英国糖尿病学会联合住院治疗组指南中，关于不快速推注胰岛素而是以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素的建议，可能不足以抑制肝脏葡萄糖的生成和刺激外周葡萄糖的摄取，但可能足以抑制脂解作用和生酮作用。[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
一项研究针对 DKA 儿童患者比较了低剂量 0.1 units/(kg·h) 和高剂量 1 units/(kg·h) 静脉输注胰岛素方案，发现采用高剂量方案的低钾血症风险增加。[129]Burghen GA, Etteldorf JN, Fisher JN, et al. Comparison of high-dose and low-dose insulin by continuous intravenous infusion in the treatment of diabetic ketoacidosis in children. Diabetes Care. 1980 Jan-Feb;3(1):15-20. https://www.doi.org/10.2337/diacare.3.1.15 http://www.ncbi.nlm.nih.gov/pubmed/6773725?tool=bestpractice.com
DKA 消退并且患者可进食和饮水后，开始常规皮下胰岛素注射。通常应由糖尿病专科医生团队来完成，并随餐给予。[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 [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
进行皮下胰岛素注射后，继续 30-60 分钟的静脉胰岛素输注，以预防 DKA 复发。[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
如果患者不可进食进水，则继续静脉输液。[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
如果 DKA 已消退，则对这些患者开始可变速率的胰岛素静脉输注（variable rate intravenous insulin infusion, VRIII）。
定期测量血糖。
第一选择
中性胰岛素: 参考当地治疗方案中的剂量指南部分。
特定患者群中针对所有患者的治疗建议
DKA 的常见病因包括心肌梗死、脓毒症和胰腺炎。[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 [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
特定患者群中针对所有患者的治疗建议
按如下时间间隔监测生化标志物：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
酮体 | 葡萄糖 | 碳酸氢盐 | 钾 | pH | |
|---|---|---|---|---|---|
| 0 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 1 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 2 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 3 小时 | ✓ | ✓ | |||
| 4 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 5 小时 | ✓ | ✓ | |||
| 6 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 12 个小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
如果可以检测血酮，力争使血酮水平下降 0.5 mmol/(L·h)。
如果无法检测血酮，则检测静脉碳酸氢根或血糖。
争取使静脉碳酸氢根增加 3.0 mmol/(L·h) 或使血糖减少 3.0 mmol/(L·h)。
如果未达到血酮、血糖和静脉碳酸氢根目标改善速率：[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
检查胰岛素输注泵是否功能正常且连接良好，并检查胰岛素余量是否正确（以检查胰岛素泵是否出现故障）
每小时增加 1 u 胰岛素输注剂量（若无胰岛素泵故障），直至达到目标血酮、血糖以及碳酸氢根水平。
评估 DKA 消退情况。定义为：[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
静脉 pH 值>7.3 且
血酮水平 <0.6 mmol/L，且
碳酸氢根 >15 mmol/L
2013 年英国糖尿病学会联合住院治疗组指南建议应继续予以 FRIII，直到碳酸氢根 >18 mmol/L。[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
特定患者群中针对所有患者的治疗建议
一旦血钾 ≤5.5 mmol/L，则使用预混氯化钾的生理盐水在静脉输液中添加钾。[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
特定患者群中针对所有患者的治疗建议
在 DKA 的整个治疗过程中，应定期监测并发症。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
每小时使用格拉斯哥昏迷量表进行评估，以监测是否发生脑水肿。[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 [ 格拉斯哥昏迷量表 ]
如果怀疑有脑水肿，请立即寻求上级医生和危重症诊疗医生的支持。
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
若格拉斯哥昏迷量表评分恶化或者患者新发头痛或头痛恶化，应考虑进行头颅 CT 检查。[137]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
根据当地规程密切监测生命体征。
如果血氧饱和度下降，请申请胸部 X 线检查，该体征可能提示肺水肿。考虑进行动脉血气检查。
特定患者群中针对部分患者的治疗建议
仅在静脉 pH 值 <6.9 并与上级顾问医师讨论后，才考虑给予碳酸氢盐治疗。在危重症诊疗环境中监测患者。[131]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
特定患者群中针对部分患者的治疗建议
考虑对老年患者或高风险患者使用低分子肝素预防血栓，除非存在相关禁忌证。[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 请参阅 VTE 预防专题。
初始收缩压 ≥90 mmHg
确诊 DKA 后立即开始静脉输液。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
在 1 小时内给予 1 L 生理盐水（0.9% 氯化钠）。[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
对于以下患者，应更谨慎地给予静脉输液并考虑监测中心静脉压：[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
年轻人（18-25 岁），因为快速补液可能会增加这些患者脑水肿的风险
高龄或妊娠
存在心力衰竭、肾功能衰竭或其他严重合并症。
使用预混氯化钾的生理盐水在第二升静脉输液中添加钾。寻求上级医生或危重症诊疗医生的支持，因为需要大剂量补钾。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
对于体重为 70 kg 且身体状况良好的成人，典型补液方案是：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
生理盐水量（根据需要添加氯化钾） |
|---|
2 小时内 1 升 |
接下来的 2 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 6 小时内 1 升 |
如果血糖水平降至 14.0 mmol/L 以下，则除生理盐水外还要给予 10% 的葡萄糖。[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 [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
继续以这种方式输液，直至患者可正常进食进水。
特定患者群中针对所有患者的治疗建议
保护气道。
如果患者对指令无反应或持续呕吐，则插入鼻胃管并进行抽吸。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
如果出现以下情况，请确保持续进行心脏监测并寻求上级医生或危重症诊疗医生的支持：[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
即使静脉输液，仍存在持续性低血压（SBP <90 mmHg）或少尿，即尿量 <0.5 mL/(kg·h)
格拉斯哥昏迷量表评分 <12 [ 格拉斯哥昏迷量表 ]
血酮 >6 mmol/L
静脉碳酸氢根 <5 mmol/L
静脉 pH 值 <7.0
入院时钾 <3.5 mmol/L
吸入空气时血氧饱和度 <92%
脉搏 >100 次/分，或 <60 次/分
阴离子间隙 >16 [ 阴离子间隙(AG) ]
患者妊娠或患有心力衰竭、肾功能衰竭或其他严重合并症。
开始治疗 1 小时后，如果出现失禁或不排尿，则插入导尿管。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
特定患者群中针对所有患者的治疗建议
以 0.1 units/(kg·h) 的剂量或根据当地规程开始固定速率静脉胰岛素输注（fixed-rate intravenous insulin infusion, FRIII）。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
给予 FRIII 之前，确保已开始静脉输液。
如果需要 > 15 units/h 的胰岛素，请寻求糖尿病专科医生团队的意见。[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 [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
使用下表作为指导：
体重（kg） | 每小时胰岛素剂量（units） |
|---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
英国指南建议采用固定速率输注胰岛素，以抑制肝脏葡萄糖生成、生酮作用和脂解作用。
胰岛素治疗 DKA 患者的主要目的是抑制脂解作用和生酮作用，英国指南建议以基于体重的固定剂量 0.1 units/(kg·h) 开始静脉输注常规胰岛素。[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
2019 年成人急性失代偿性糖尿病临床综述强调了关于胰岛素治疗方案的指南建议存在差异。[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
根据一项纳入 37 例患者的小型试验的证据，美国糖尿病学会建议选择以下两种方案中的任意一种：以基于体重的固定剂量 0.14 units/(kg·h) 静脉输注常规胰岛素，或者快速静脉推注 0.1 units/kg 胰岛素后以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素。[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
临床综述指出，2013 年英国糖尿病学会联合住院治疗组指南中，关于不快速推注胰岛素而是以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素的建议，可能不足以抑制肝脏葡萄糖的生成和刺激外周葡萄糖的摄取，但可能足以抑制脂解作用和生酮作用。[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
一项研究针对 DKA 儿童患者比较了低剂量 0.1 units/(kg·h) 和高剂量 1 units/(kg·h) 静脉输注胰岛素方案，发现采用高剂量方案的低钾血症风险增加。[129]Burghen GA, Etteldorf JN, Fisher JN, et al. Comparison of high-dose and low-dose insulin by continuous intravenous infusion in the treatment of diabetic ketoacidosis in children. Diabetes Care. 1980 Jan-Feb;3(1):15-20. https://www.doi.org/10.2337/diacare.3.1.15 http://www.ncbi.nlm.nih.gov/pubmed/6773725?tool=bestpractice.com
DKA 消退并且患者可进食和饮水后，开始常规皮下胰岛素注射。通常应由糖尿病专科医生团队来完成，并随餐给予。[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 [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
进行皮下胰岛素注射后，继续 30-60 分钟的静脉胰岛素输注，以预防 DKA 复发。[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
如果患者不可进食进水，则继续静脉输液。[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
如果 DKA 已消退，则对这些患者开始可变速率的胰岛素静脉输注（variable rate intravenous insulin infusion, VRIII）。
定期测量血糖。
第一选择
中性胰岛素: 参考当地治疗方案中的剂量指南部分。
特定患者群中针对所有患者的治疗建议
DKA 的常见病因包括心肌梗死、脓毒症和胰腺炎。[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 [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
特定患者群中针对所有患者的治疗建议
按如下时间间隔监测生化标志物：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
酮体 | 葡萄糖 | 碳酸氢盐 | 钾 | pH | |
|---|---|---|---|---|---|
| 0 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 1 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 2 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 3 小时 | ✓ | ✓ | |||
| 4 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 5 小时 | ✓ | ✓ | |||
| 6 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 12 个小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
如果可以检测血酮，力争使血酮水平下降 0.5 mmol/(L·h)。
如果无法检测血酮，则检测静脉碳酸氢根或血糖。
争取使静脉碳酸氢根增加 3.0 mmol/(L·h) 或使血糖减少 3.0 mmol/(L·h)。
如果未达到血酮、血糖和静脉碳酸氢根目标改善速率：[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
检查胰岛素输注泵是否功能正常且连接良好，并检查胰岛素余量是否正确（以检查胰岛素泵是否出现故障）
每小时增加 1 u 胰岛素输注剂量（若无胰岛素泵故障），直至达到目标血酮、血糖以及碳酸氢根水平。
评估 DKA 消退情况。定义为：[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
静脉 pH 值>7.3 且
血酮水平 <0.6 mmol/L，且
碳酸氢根 >15 mmol/L
2013 年英国糖尿病学会联合住院治疗组指南建议应继续予以 FRIII，直到碳酸氢根 >18 mmol/L。[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
特定患者群中针对所有患者的治疗建议
在 DKA 的整个治疗过程中，应定期监测并发症。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
每小时使用格拉斯哥昏迷量表进行评估，以监测是否发生脑水肿。[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 [ 格拉斯哥昏迷量表 ]
如果怀疑有脑水肿，请立即寻求上级医生和危重症诊疗医生的支持。
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
若格拉斯哥昏迷量表评分恶化或者患者新发头痛或头痛恶化，应考虑进行头颅 CT 检查。[137]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
根据当地规程密切监测生命体征。
如果血氧饱和度下降，请申请胸部 X 线检查，该体征可能提示肺水肿。考虑进行动脉血气检查。
特定患者群中针对部分患者的治疗建议
仅在静脉 pH 值 <6.9 并与上级顾问医师讨论后，才考虑给予碳酸氢盐治疗。在危重症诊疗环境中监测患者。[131]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
特定患者群中针对部分患者的治疗建议
考虑对老年患者或高风险患者使用低分子肝素预防血栓，除非存在相关禁忌证。[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 请参阅 VTE 预防专题。
确诊 DKA 后立即开始静脉输液。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
在 1 小时内给予 1 L 生理盐水（0.9% 氯化钠）。[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
对于以下患者，应更谨慎地给予静脉输液并考虑监测中心静脉压：[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
年轻人（18-25 岁），因为快速补液可能会增加这些患者脑水肿的风险
高龄或妊娠
存在心力衰竭、肾功能衰竭或其他严重合并症。
使用预混氯化钾的生理盐水在第二升静脉输液中添加 40 mmol/L 的钾。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
对于体重为 70 kg 且身体状况良好的成人，典型补液方案是：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
生理盐水量（根据需要添加氯化钾） |
|---|
2 小时内 1 升 |
接下来的 2 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 6 小时内 1 升 |
如果血糖水平降至 14.0 mmol/L 以下，则除生理盐水外还要给予 10% 的葡萄糖。[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 [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
继续以这种方式输液，直至患者可正常进食进水。
特定患者群中针对部分患者的治疗建议
保护气道。
如果患者对指令无反应或持续呕吐，则插入鼻胃管并进行抽吸。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
如果出现以下情况，请确保持续进行心脏监测并寻求上级医生或危重症诊疗医生的支持：[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
即使静脉输液，仍存在持续性低血压（SBP <90 mmHg）或少尿，即尿量 <0.5 mL/(kg·h)
格拉斯哥昏迷量表评分 <12 [ 格拉斯哥昏迷量表 ]
血酮 >6 mmol/L
静脉碳酸氢根 <5 mmol/L
静脉 pH 值 <7.0
吸入空气时血氧饱和度 <92%
脉搏 >100 次/分，或 <60 次/分
阴离子间隙 >16 [ 阴离子间隙(AG) ]
患者妊娠或患有心力衰竭、肾功能衰竭或其他严重合并症。
开始治疗 1 小时后，如果出现失禁或不排尿，则插入导尿管。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
特定患者群中针对所有患者的治疗建议
以 0.1 units/(kg·h) 的剂量或根据当地规程开始固定速率静脉胰岛素输注（fixed-rate intravenous insulin infusion, FRIII）。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
给予 FRIII 之前，确保已开始静脉输液。
如果需要 > 15 units/h 的胰岛素，请寻求糖尿病专科医生团队的意见。[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 [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
使用下表作为指导：
体重（kg） | 每小时胰岛素剂量（units） |
|---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
英国指南建议采用固定速率输注胰岛素，以抑制肝脏葡萄糖生成、生酮作用和脂解作用。
胰岛素治疗 DKA 患者的主要目的是抑制脂解作用和生酮作用，英国指南建议以基于体重的固定剂量 0.1 units/(kg·h) 开始静脉输注常规胰岛素。[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
2019 年成人急性失代偿性糖尿病临床综述强调了关于胰岛素治疗方案的指南建议存在差异。[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
根据一项纳入 37 例患者的小型试验的证据，美国糖尿病学会建议选择以下两种方案中的任意一种：以基于体重的固定剂量 0.14 units/(kg·h) 静脉输注常规胰岛素，或者快速静脉推注 0.1 units/kg 胰岛素后以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素。[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
临床综述指出，2013 年英国糖尿病学会联合住院治疗组指南中，关于不快速推注胰岛素而是以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素的建议，可能不足以抑制肝脏葡萄糖的生成和刺激外周葡萄糖的摄取，但可能足以抑制脂解作用和生酮作用。[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
一项研究针对 DKA 儿童患者比较了低剂量 0.1 units/(kg·h) 和高剂量 1 units/(kg·h) 静脉输注胰岛素方案，发现采用高剂量方案的低钾血症风险增加。[129]Burghen GA, Etteldorf JN, Fisher JN, et al. Comparison of high-dose and low-dose insulin by continuous intravenous infusion in the treatment of diabetic ketoacidosis in children. Diabetes Care. 1980 Jan-Feb;3(1):15-20. https://www.doi.org/10.2337/diacare.3.1.15 http://www.ncbi.nlm.nih.gov/pubmed/6773725?tool=bestpractice.com
DKA 消退并且患者可进食和饮水后，开始常规皮下胰岛素注射。通常应由糖尿病专科医生团队来完成，并随餐给予。[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 [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
进行皮下胰岛素注射后，继续 30-60 分钟的静脉胰岛素输注，以预防 DKA 复发。[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
如果患者不可进食进水，则继续静脉输液。[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
如果 DKA 已消退，则对这些患者开始可变速率的胰岛素静脉输注（variable rate intravenous insulin infusion, VRIII）。
定期测量血糖。
第一选择
中性胰岛素: 参考当地治疗方案中的剂量指南部分。
特定患者群中针对所有患者的治疗建议
DKA 的常见病因包括心肌梗死、脓毒症和胰腺炎。[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 [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
特定患者群中针对所有患者的治疗建议
按如下时间间隔监测生化标志物：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
酮体 | 葡萄糖 | 碳酸氢盐 | 钾 | pH | |
|---|---|---|---|---|---|
| 0 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 1 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 2 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 3 小时 | ✓ | ✓ | |||
| 4 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 5 小时 | ✓ | ✓ | |||
| 6 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 12 个小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
如果可以检测血酮，力争使血酮水平下降 0.5 mmol/(L·h)。
如果无法检测血酮，则检测静脉碳酸氢根或血糖。
争取使静脉碳酸氢根增加 3.0 mmol/(L·h) 或使血糖减少 3.0 mmol/(L·h)。
如果未达到血酮、血糖和静脉碳酸氢根目标改善速率：[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
检查胰岛素输注泵是否功能正常且连接良好，并检查胰岛素余量是否正确（以检查胰岛素泵是否出现故障）
每小时增加 1 u 胰岛素输注剂量（若无胰岛素泵故障），直至达到目标血酮、血糖以及碳酸氢根水平。
评估 DKA 消退情况。定义为：[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
静脉 pH 值>7.3 且
血酮水平 <0.6 mmol/L，且
碳酸氢根 >15 mmol/L
2013 年英国糖尿病学会联合住院治疗组指南建议应继续予以 FRIII，直到碳酸氢根 >18 mmol/L。[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
特定患者群中针对所有患者的治疗建议
在 DKA 的整个治疗过程中，应定期监测并发症。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
每小时使用格拉斯哥昏迷量表进行评估，以监测是否发生脑水肿。[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 [ 格拉斯哥昏迷量表 ]
如果怀疑有脑水肿，请立即寻求上级医生和危重症诊疗医生的支持。
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
若格拉斯哥昏迷量表评分恶化或者患者新发头痛或头痛恶化，应考虑进行头颅 CT 检查。[137]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
根据当地规程密切监测生命体征。
如果血氧饱和度下降，请申请胸部 X 线检查，该体征可能提示肺水肿。考虑进行动脉血气检查。
特定患者群中针对部分患者的治疗建议
仅在静脉 pH 值 <6.9 并与上级顾问医师讨论后，才考虑给予碳酸氢盐治疗。在危重症诊疗环境中监测患者。[131]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
特定患者群中针对部分患者的治疗建议
考虑对老年患者或高风险患者使用低分子肝素预防血栓，除非存在相关禁忌证。[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 请参阅 VTE 预防专题。
确诊 DKA 后立即开始静脉输液。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
在 1 小时内给予 1 L 生理盐水（0.9% 氯化钠）。[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
对于以下患者，应更谨慎地给予静脉输液并考虑监测中心静脉压：[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
年轻人（18-25 岁），因为快速补液可能会增加这些患者脑水肿的风险
高龄或妊娠
存在心力衰竭、肾功能衰竭或其他严重合并症。
输注第一升液体后，继续给予补液。在钾 ≤5.5 mmol/L 之前，不要添加氯化钾。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
对于体重为 70 kg 且身体状况良好的成人，典型补液方案是：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
生理盐水量（根据需要添加氯化钾） |
|---|
2 小时内 1 升 |
接下来的 2 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 4 小时内给予 1 升 |
接下来的 6 小时内 1 升 |
如果血糖水平降至 14.0 mmol/L 以下，则除生理盐水外还要给予 10% 的葡萄糖。[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 [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
继续以这种方式输液，直至患者可正常进食进水。
特定患者群中针对部分患者的治疗建议
保护气道。
如果患者对指令无反应或持续呕吐，则插入鼻胃管并进行抽吸。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
如果出现以下情况，请确保持续进行心脏监测并寻求上级医生或危重症诊疗医生的支持：[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
即使静脉输液，仍存在持续性低血压（SBP <90 mmHg）或少尿，即尿量 <0.5 mL/(kg·h)
格拉斯哥昏迷量表评分 <12 [ 格拉斯哥昏迷量表 ]
血酮 >6 mmol/L
静脉碳酸氢根 <5 mmol/L
静脉 pH 值 <7.0
吸入空气时血氧饱和度 <92%
脉搏 >100 次/分，或 <60 次/分
阴离子间隙 >16 [ 阴离子间隙(AG) ]
患者妊娠或患有心力衰竭、肾功能衰竭或其他严重合并症。
开始治疗 1 小时后，如果出现失禁或不排尿，则插入导尿管。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
特定患者群中针对所有患者的治疗建议
以 0.1 units/(kg·h) 的剂量或根据当地规程开始固定速率静脉胰岛素输注（fixed-rate intravenous insulin infusion, FRIII）。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
给予 FRIII 之前，确保已开始静脉输液。
如果需要 > 15 units/h 的胰岛素，请寻求糖尿病专科医生团队的意见。[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 [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
使用下表作为指导：
体重（kg） | 每小时胰岛素剂量（units） |
|---|---|
60-69 | 6 |
70-79 | 7 |
80-89 | 8 |
90-99 | 9 |
100-109 | 10 |
110-119 | 11 |
120-129 | 12 |
130-139 | 13 |
140-149 | 14 |
>150 | 15 |
英国指南建议采用固定速率输注胰岛素，以抑制肝脏葡萄糖生成、生酮作用和脂解作用。
胰岛素治疗 DKA 患者的主要目的是抑制脂解作用和生酮作用，英国指南建议以基于体重的固定剂量 0.1 units/(kg·h) 开始静脉输注常规胰岛素。[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
2019 年成人急性失代偿性糖尿病临床综述强调了关于胰岛素治疗方案的指南建议存在差异。[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
根据一项纳入 37 例患者的小型试验的证据，美国糖尿病学会建议选择以下两种方案中的任意一种：以基于体重的固定剂量 0.14 units/(kg·h) 静脉输注常规胰岛素，或者快速静脉推注 0.1 units/kg 胰岛素后以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素。[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
临床综述指出，2013 年英国糖尿病学会联合住院治疗组指南中，关于不快速推注胰岛素而是以基于体重的固定剂量 0.1 units/(kg·h) 静脉输注胰岛素的建议，可能不足以抑制肝脏葡萄糖的生成和刺激外周葡萄糖的摄取，但可能足以抑制脂解作用和生酮作用。[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
一项研究针对 DKA 儿童患者比较了低剂量 0.1 units/(kg·h) 和高剂量 1 units/(kg·h) 静脉输注胰岛素方案，发现采用高剂量方案的低钾血症风险增加。[129]Burghen GA, Etteldorf JN, Fisher JN, et al. Comparison of high-dose and low-dose insulin by continuous intravenous infusion in the treatment of diabetic ketoacidosis in children. Diabetes Care. 1980 Jan-Feb;3(1):15-20. https://www.doi.org/10.2337/diacare.3.1.15 http://www.ncbi.nlm.nih.gov/pubmed/6773725?tool=bestpractice.com
DKA 消退并且患者可进食和饮水后，开始常规皮下胰岛素注射。通常应由糖尿病专科医生团队来完成，并随餐给予。[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 [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
进行皮下胰岛素注射后，继续 30-60 分钟的静脉胰岛素输注，以预防 DKA 复发。[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
如果患者不可进食进水，则继续静脉输液。[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
如果 DKA 已消退，则对这些患者开始可变速率的胰岛素静脉输注（variable rate intravenous insulin infusion, VRIII）。
定期测量血糖。
第一选择
中性胰岛素: 参考当地治疗方案中的剂量指南部分。
特定患者群中针对所有患者的治疗建议
DKA 的常见病因包括心肌梗死、脓毒症和胰腺炎。[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 [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
特定患者群中针对所有患者的治疗建议
按如下时间间隔监测生化标志物：[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
酮体 | 葡萄糖 | 碳酸氢盐 | 钾 | pH | |
|---|---|---|---|---|---|
| 0 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 1 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 2 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 3 小时 | ✓ | ✓ | |||
| 4 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 5 小时 | ✓ | ✓ | |||
| 6 小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
| 12 个小时 | ✓ | ✓ | ✓ | ✓ | ✓ |
如果可以检测血酮，力争使血酮水平下降 0.5 mmol/(L·h)。
如果无法检测血酮，则检测静脉碳酸氢根或血糖。
争取使静脉碳酸氢根增加 3.0 mmol/(L·h) 或使血糖减少 3.0 mmol/(L·h)。
如果未达到血酮、血糖和静脉碳酸氢根目标改善速率：[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
检查胰岛素输注泵是否功能正常且连接良好，并检查胰岛素余量是否正确（以检查胰岛素泵是否出现故障）
每小时增加 1 u 胰岛素输注剂量（若无胰岛素泵故障），直至达到目标血酮、血糖以及碳酸氢根水平。
评估 DKA 消退情况。定义为：[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
静脉 pH 值>7.3 且
血酮水平 <0.6 mmol/L，且
碳酸氢根 >15 mmol/L
2013 年英国糖尿病学会联合住院治疗组指南建议应继续予以 FRIII，直到碳酸氢根 >18 mmol/L。[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
特定患者群中针对所有患者的治疗建议
一旦血钾 ≤5.5 mmol/L，则使用预混氯化钾的生理盐水在静脉输液中添加钾。[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
特定患者群中针对所有患者的治疗建议
在 DKA 的整个治疗过程中，应定期监测并发症。[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 [105]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. July 2016 [internet publication]. https://www.nice.org.uk/guidance/ng17
每小时使用格拉斯哥昏迷量表进行评估，以监测是否发生脑水肿。[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 [ 格拉斯哥昏迷量表 ]
如果怀疑有脑水肿，请立即寻求上级医生和危重症诊疗医生的支持。
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
若格拉斯哥昏迷量表评分恶化或者患者新发头痛或头痛恶化，应考虑进行头颅 CT 检查。[137]Dixon AN, Jude EB, Banerjee AK, et al. Simultaneous pulmonary and cerebral oedema, and multiple CNS infarctions as complications of diabetic ketoacidosis: a case report. Diabet Med. 2006 May;23(5):571-3. http://www.ncbi.nlm.nih.gov/pubmed/16681567?tool=bestpractice.com
根据当地规程密切监测生命体征。
如果血氧饱和度下降，请申请胸部 X 线检查，该体征可能提示肺水肿。考虑进行动脉血气检查。
特定患者群中针对部分患者的治疗建议
仅在静脉 pH 值 <6.9 并与上级顾问医师讨论后，才考虑给予碳酸氢盐治疗。在危重症诊疗环境中监测患者。[131]Hsieh HC, Wu SH, Chiu CC, et al. Excessive sodium bicarbonate infusion may result in osmotic demyelination syndrome during treatment of diabetic ketoacidosis: a case report. Diabetes Ther. 2019 Apr;10(2):765-71. https://www.doi.org/10.1007/s13300-019-0592-8 http://www.ncbi.nlm.nih.gov/pubmed/30843157?tool=bestpractice.com
特定患者群中针对部分患者的治疗建议
考虑对老年患者或高风险患者使用低分子肝素预防血栓，除非存在相关禁忌证。[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 请参阅 VTE 预防专题。
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