Clinical Question 2017 年 5 月 15 日 分野 : 内分泌テーマ : 治療
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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 23400 15.0 35.5 1.22 2.56 72 /µl g/dl /µl mg/dl mg/dl mg/dl Alb AST ALT AMY LDH γ-gtp 4.3 58 65 1047 413 17 g/dl U/L U/L U/L U/L U/L Glu Na K Cl Ca P 967 136 4.8 91 8.3 3.7 mg/dl meq/l meq/l meq/l mg/dl mg/dl 1.005 1+ 4+ 3+ 2+ ph 7.227, pco 2 9.8mmHg, HCO 3-3.9mmol/L, Lac 3.2mmol/L, Anion gap 41.1mEq/L AG
(DKA) ICU Clinical Questions DKA n n n HHS()
DKA HHS 24 DKA Kussmaul DKA HHS Kussmaul Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis
>250mg/dL DKA DKA β () 10 Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis
Mild DKA DKA DKA Moderate DKA HHS() Severe DKA HHS >250 >250 >250 >600 ph 7.25-7.30 7.00-7.24 <7.00 >7.3 HCO 3- (mmol/l) 15-18 10-15 <10 >18 / + ± >320(mOsmol/kg) Anion gap 10 12 12 Alert Alert/drowsy Stupor/coma Stupor/coma American Diabetes Association From Diabetes Care Vol 29, Issue 12, 2006. Hyperglycemic crisis in adult pattients with diabetes. Diabetes Care, Vol 32, Issue 7, 2009.
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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): 51-59.Pocket Medicine 6 th edition SGLT-2 Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis
Na135 1520L/kg/hr Na135 250500mL/hr 150250mL/hr DKA K 3.3 0.1U/kg IV push 0.1 U/kg/hr 0.14 U/kg/h 0.020.05U/kg/h Anion gap 200 150 1 24 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, 2006. Modifications from Diabetes Care, Vol 32, Issue 7, 2009.
DKA 200mg/dL2 Up To Date : Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment 12Eq/L DKA HCO 3 15mmol/L ph7.3
200mg/dL or 0.50.8U/kg/ 12 Basal-Bolus Diabetes Care. 2009 Jul;32(7):1164-9. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial.
DKA 0.3-1.0% 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. 2009 Jul;32(7):1335-43. Hyperglycemic Crises in Adult Patients With Diabetes
DKA K(mEq/L) <3.3 3.3-5.2 >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, 2006. Modifications from Diabetes Care, Vol 32, Issue 7, 2009.Up To Date
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
2000L68kg 70.1U/kgi.v.7/hr0.1U/kg/hr ICUKCL 12200mg/dL3 36Anion gap HbA1c6.1 GAD CPR 2.1µg/day 1 () (B ) /
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: 815-820
Take Home Message l DKA l DKA DKA