重症糖尿病酮症酸中毒的诊治体会

目的：探讨重症糖尿病酮症酸中毒（DKA）的救治方法。方法对20例重症DKA患者的临床资料进行回顾性分析。探讨其起病诱因及治疗方法。结果20例重症DKA中,发病诱因不是单一的,最常见的诱因是感染。均采用小剂量胰岛素持续静脉滴注,积极纠正水、电解质紊乱及加强抗感染治疗,16例（80%）患者在24 h内临床症状缓解,血糖降至8.0～10.0 mmol·L-1,尿酮、血酮转阴,pH＞7.3,电解质恢复正常,神志转清,能正常进餐;2例（10%）于治疗后第2天达到上述标准。18例患者均治愈出院。2例死亡（均合并重症肺炎）,病死率为10.0%。结论积极防治诱因、综合治疗,是防治重症DKA的关键;对急性脑水肿、急性呼吸窘迫综合征等要及早预防。     

New Test,Old Disease: A Case Series of Diabetic Ketoalkalosis

BackgroundDiabetic ketoalkalosis (DKAlk) was first described in 1967 as a rare complication of diabetic ketoacidosis with normal or elevated pH/bicarbonate and elevated anion gap (AG) from high β-hydroxybutyrate (BHB).ObjectiveWe report a case series of patients with DKAlk to show how venous blood gas (VBG) electrolytes alone may misdiagnose these patients.MethodsThis was a case series of DKAlk patients with concomitant VBG and basic metabolic panel (BMP) electrolytes who met the following criteria for DKAlk: BMP hyperglycemia (glucose >250 mg/dL), elevated AG (>15 mEq/L), elevated BHB (>1.2 mmol/L), and high Delta (Δ) gap (>6 mEq/L [bicarbonate gap (BG): measured bicarbonate – 24] – [AG – 12]). Data are reported as median with interquartile range (IQR) (25%, 75%) and group comparisons utilized Mann-Whitney U test (two-tailed, α = 0.05).ResultsWe found 10 patients with DKAlk in 2 months. Patients ranged in age from 13 to 77 years, 50% were male, and all were African American. Most patients (8 of 10) were vomiting with hyperglycemia (350 to >600 mg/dL). DKAlk BMP AG ranged from 18 to 34 mmol/L and BHB from 1.74 to 9.09 mmol/L. For bicarbonate, we found no significant difference between VBG (24 mmol/L) and BMP (22 mmol/L) (p = 0.796). VBG chloride (98 mmol/L) was significantly higher than BMP chloride (88 mmol/L) (p < 0.005). This falsely elevated VBG chloride resulted in undervaluing of all VBG AGs, missing almost all of the patients with DKAlk.ConclusionsWe found that DKAlk is more common than previously reported. We recommend screening with BMP electrolytes and BHB levels for hyperglycemic ED patients who are vomiting or suspected of hypovolemia.     

小剂量胰岛素联合电解质补充治疗儿童糖尿病酮症酸中毒的临床价值研究

目的：研究小剂量胰岛素联合电解质补充治疗儿童糖尿病酮症酸中毒的临床疗效。方法以该院2012年5月-2014年5月收治的30例糖尿病酮症酸中毒患儿为研究对象,均接受小剂量胰岛素、电解质补充等治疗,统计患儿酸中毒纠正时间、住院时间,同时比较治疗前后患儿血糖、钠、钾水平及主要血清炎症因子变化。结果治疗后患儿病情均稳定,平均酸中毒纠正时间、平均住院时间分别为(13.50±1.12)、(14.00±1.05)d。治疗前后患儿血糖[(38.66±2.37)VS(12.07±2.85)]mmol/L、血钾[(5.52±0.81)VS(4.70±0.78)]mmol/L、血钠[(133.27±10.41)VS(142.68±9.98)]mmol/L比较差异有统计学意义(P<0.01)。另外,治疗前后IL-6、IL-12、IL-18及TNF-α水平比较差异有统计学意义(P<0.01)。结论小剂量胰岛素联合电解质补充治疗能明显改善患儿高血糖、高血酮症状,安全有效,可作为儿童糖尿病酮症酸中毒治疗的重要手段。     

Extrapontine myelinolysis in a 4 year old with diabetic ketoacidosis

Extrapontine and central pontine myelinolysis (EPM/CPM) are rare events in pediatric neurology but can have devastating consequences. They are most commonly associated with rapid correction of hyponatremia but have been reported in other situations as well. This condition is relatively more common in adult neurology, not surprisingly, as alcoholism and associated malnutrition are often predisposing conditions. There have been few case reports in children with regards to this. We describe a 4-year old who presented with focal neurological deficits in the setting of diabetic ketoacidosis and the ensuing underlying osmotic imbalances. The patient made a remarkable recovery with no deficits of note-cognitive or motor. To our knowledge this is the youngest case reported so far of EPM in a child with diabetic ketoacidosis. The history of the condition, early animal experiments, clinicopathologic correlates, previous case reports and other scenarios in which this unusual event can occur are discussed--though the exact pathogenesis of this condition still remains unclear. We hope to bring to the attention of clinicians caring for children in the acute care setting, the importance of gradual correction of serum osmolality to reduce morbidity and mortality.     

1型糖尿病酮症酸中毒患儿缺氧诱导因子-1α与血管内皮细胞生长因子mRNA表达水平的变化

目的探讨1型糖尿病(T1DM)酮症酸中毒(DKA)患儿缺氧诱导因子-1α(HIF-1α)与血管内皮细胞生长因子(VEGF)mRNA水平的变化。方法天津市儿童医院住院T1DM并DKA患儿30例,于确诊24 h内(DKA 1组)及DKA纠正后10 d(DKA 2组)采血,另选取同期住院的不伴感染、缺氧、肿瘤或结缔组织病的同年龄同性别患儿30例为对照组。实时荧光定量PCR(Real-time PCR)法测定其外周血CD4+T淋巴细胞HIF-1α与VEGF mRNA的相对表达水平。PCR产物行琼脂糖凝胶电泳鉴定特异性。采用SPSS 13.0软件进行统计学分析。结果 3组HIF-1α及VEGF mRNA相对表达水平比较差异均有统计学意义(Pa<0.01)。DKA1组HIF-1α及VEGF水平明显高于对照组,差异有统计学意义(Pa<0.01);DKA纠正后HIF-1α及VEGF水平恢复,差异有统计学意义(P<0.05,0.01),但直至DKA纠正后10 d(DKA2组)仍未恢复至对照组水平,差异有统计学意义(P<0.01,0.05)。Real-timePCR产物行琼脂糖凝胶电泳,产物位于预期位置,确定产物特异性。结论 T1DM并DKA患儿CD4+T淋巴细胞HIF-1α与VEGFmRNA水平升高,且DKA纠正后HIF-1α与VEGF mRNA水平不能恢复至正常,这可能与T1DM并发症的发生发展有关。     

妊娠合并酮症酸中毒

妊娠合并酮症酸中毒是一种可危及孕妇与胎儿生命的严重并发症,由于妊娠期的生理改变,发生酮症的易感性增加。本文主要阐述了妊娠期发生酮症酸中毒的发生机制、诱因、对母儿的风险及处理。     

妊娠合并糖尿病酮症酸中毒的识别和处理

妊娠合并糖尿病酮症酸中毒是产科严重的合并症,如未能及时诊断及处理,会造成母儿严重的不良结局.本文就妊娠合并DKA的临床识别及处理进行讨论.     

Diabetic coma: Serum growth hormone before and during treatment

Summary Serum growth hormone values in 37 patients with diabetic ketoacidosis were 5.4±0.8 ng/ml (S.E.M.) in males and 6.7±1.1 ng/ml in females before treatment; while in five hyperosmolar non-ketotic patients the HGH concentration was 3.9±0.5 ng/ml. One hour after insulin 90% of patients showed a rise in HGH, to a mean of 33.7±9.8 ng/ml for males and 25.5±6.0 ng/ml for females in ketoacidosis; and to 27.1±9.9 ng/ml for hyperosmolar coma patients. The rise, which was transient, was inversely correlated with pretreatment plasma glucose, the l h plasma glucose concentration and plasma urea, and directly proportional to the % fall in blood glucose after 1 h. When the ketoacidosis patients were divided into two groups according to HGH response, those with a small response had the greater disturbances of plasma glucose, blood ketone bodies, blood lactate, plasma urea, blood pH, and blood pressure, the smaller 1 h fall in blood glucose, and the higher mortality. Thus the most severely ketoacidotic patients had the poorest growth hormone response. Growth hormone is probably of little importance as an insulin antagonist in diabetic coma.Presented in part at the Spring Meeting of the British Diabetic Association, York, April 1972.     

胰岛素泵治疗糖尿病酮症酸中毒伴发肾功能不全的临床研究

目的比较胰岛素泵持续皮下胰岛素输注法（CSⅡ）与传统小剂量胰岛素静脉点滴法治疗糖尿病酮症酸中毒（DKA）伴发肾功能不全的短期疗效。方法DKA并发肾功能不全患者36例,随机均分为CSⅡ组（用胰岛素泵经导管持续皮下输注短效生物合成人胰岛素）和对照组（给予小剂量短效生物合成人胰岛素静滴）。结果CSⅡ组酮体平均消失时间为（22．94±7．89）h,显著短于对照组（38．22±12．29）h,P〈0．05]。CSⅡ组肾功能恢复时间（4．11±2．05）d,显著短于对照组[（6．72±2．87）d,P〈0．051。CSⅡ组调整期各时点（除凌晨3点）的空腹血糖值均低于对照组（均P〈0．05）。CSⅡ组低血糖事件发生次数明显少于对照组（P〈0．05）。结论CSⅡ能更有效地治疗DKA,能更快地改善肾功能,使血酮体转阴,降低低血糖发生率。     

Diabetic ketoacidosis and rhabdomyolysis following excessive intake of a weight reducing diet

With the awareness of health problems related to obesity, weight reducing diets have become very popular. However, if these meal supplements are not taken as recommended, they can cause considerable harm in high risk individuals. We report a case of a young obese man who developed diabetic ketoacidosis (DKA) followed by rhabdomyolysis and acute renal failure (ARF) after excessive intake of a high carbohydrate containing weight-reducing meal. DKA associated with excessive intake of weight reducing diets has not been reported previously. In people with obesity and insulin resistance improper use of these supplements can cause severe metabolic complications.