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1 Clinical Question 2017 年 5 月 15 日分野 : 内分泌テーマ : 治療

2 sick contact1l

3 170cm/68.8kg, GCSE1V1M5, HR: 120/min, BP: 104/60mmHg, RR: 30/min, SpO 2 : 96%, BT: 38.0 WBC Hb PLT CRP Cr BUN /µl g/dl /µl mg/dl mg/dl mg/dl Alb AST ALT AMY LDH γ-gtp g/dl U/L U/L U/L U/L U/L Glu Na K Cl Ca P mg/dl meq/l meq/l meq/l mg/dl mg/dl ph 7.227, pco 2 9.8mmHg, HCO 3-3.9mmol/L, Lac 3.2mmol/L, Anion gap 41.1mEq/L AG

4 (DKA) ICU Clinical Questions DKA n n n HHS()

5 DKA HHS 24 DKA Kussmaul DKA HHS Kussmaul Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis

6 >250mg/dL DKA DKA β () 10 Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis

7 Mild DKA DKA DKA Moderate DKA HHS() Severe DKA HHS >250 >250 >250 >600 ph <7.00 >7.3 HCO 3- (mmol/l) <10 >18 / + ± >320(mOsmol/kg) Anion gap Alert Alert/drowsy Stupor/coma Stupor/coma American Diabetes Association From Diabetes Care Vol 29, Issue 12, Hyperglycemic crisis in adult pattients with diabetes. Diabetes Care, Vol 32, Issue 7, 2009.

8 DKA DKA

9 The I s DKA p Infection p Inflammation p InsulinⅠDM/ p IatrogenesisSGLT-2 p InfarctionIschemia p Intoxication p Infant Diabetes in the Emergency Department: Acute Care of Diabetes Patients Clinical Diabetes 2011 Apr; 29(2): Pocket Medicine 6 th edition SGLT-2 Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis

10 Na L/kg/hr Na mL/hr mL/hr DKA K U/kg IV push 0.1 U/kg/hr 0.14 U/kg/h U/kg/h Anion gap Anion gap 1) (1) 2) K 3) Na 4) P 5) orhco 3-6) 3) Na Na 2.0Eq/L /100 American Diabetes Association From Diabetes Care Vol 29, Issue 12, Modifications from Diabetes Care, Vol 32, Issue 7, 2009.

11 DKA 200mg/dL2 Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment 12Eq/L DKA HCO 3 15mmol/L ph7.3

12 200mg/dL or U/kg/ 12 Basal-Bolus Diabetes Care Jul;32(7): Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial.

13 DKA % Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment K3.3Eq/LK Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment DKA low cost Diabetes Care. 2009;32(7):1164. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. 200mg/dL Diabetes Care Jul;32(7): Hyperglycemic Crises in Adult Patients With Diabetes

14 DKA K(mEq/L) < >5.2 K 1L KCL 20-40mEq 1L KCL 20-30mEq K3.3Eq/LK Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment K K 4-5mEq/L American Diabetes Association From Diabetes Care Vol 29, Issue 12, Modifications from Diabetes Care, Vol 32, Issue 7, 2009.Up To Date

15 DKA P DKAclinical outcome CaMg A randomized study of phosphate therapy in the treatment of diabetic ketoacidosis. Fisher JN, Kitabchi AEJ Clin Endocrinol Metab. 1983;57(1):177. Up To Date P1.0mg/dL HCO 3- ( ) ph<6.9 DKA Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment

16 2000L68kg 70.1U/kgi.v.7/hr0.1U/kg/hr ICUKCL 12200mg/dL3 36Anion gap HbA1c6.1 GAD CPR 2.1µg/day 1 () (B ) /

17 1 β (2012) () 288 mg/dlhba1c (NGSP)8.7 % 10 µg/day 0.3 ng/ml( )0.5 ng/ml 98% 70% 1Ⅰ(2012) 55:

18 Take Home Message l DKA l DKA DKA

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