Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
DKA�5'32:$6������D +)����↑ 7$6������D
KKetoacidosis↑
Triacylglycerol
Hyperlipidemia
=<�B↑
;�FFA↑
���3(↑
������↓
����(↓ ����B↑
8,31C↑
8,3↑
/�GBC !
&8
H@8
������B↑*0��8�4↓
>/
?F#
���3(I."�-%EJ
*Hyperosmolarity
++
++
/�A9��
HHSDKA
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHDFrom Diabetes Care Vol 29, Issue 12,
2006.
_C V6UHA�3�X9Q_S���%�) 2013
X9Q�����+��iDKAj�)�&) I-�)�&)B@"'$) 51����h\Xi≧250 mg/dlj�h��)\Riβ- �(�bcj����+��ipH≦7.30�dNc4L:< 18 mEq/Lj�F��O?�
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
�,`.��)�&)JS*E[ga7
� DM D^TRi20~25%j�;<P=>GRi30~40%j*Y\Wf8*AMI*;<ZM
�[0�(�&'iMARTAj*���)*&��#SGLT2 e8[*!&��+'iЌ/K[j
Kitabchi AE, et al. Diabetes Care 2001; 24:131.
DKA����]2
DKAHHS
Mild Moderate SeverePlasma glucose (mg/dL) >250 >250 >250 >600
Plasma glucose (mmol/L) >13.9 >13.9 >13.9 >33.3Arterial pH 7.25 to 7.30 7.00 to 7.24 <7.00 >7.30
Serum bicarbonate (mEq/L) 15 to 18 10 to <15 <10 >18
Urine ketones Positive Positive Positive SmallSerum ketones - Nitroprusside reaction
Positive Positive Positive ≤ Small
Serum ketones - Enzymatic assay of beta hydroxybutyrate(normal range <0.6 mmol/L)
3 to 4 mmol/L
4 to 8 mmol/L
>8 mmol/L
<0.6mmol/L
Effective serum osmolality (mOsm/kg)
Variable Variable Variable >320
Anion gap >10 >12 >12 Variable
Alteration in sensoria or mental obtundation
Alert Alert/drowsy Stupor/coma Stupor/coma
Typical laboratory characteristics of DKAFrom Diabetes Care 2009; 32:1335.
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
�8@'6��;" MHI?/G7���!!
8@-Overview
� Step 1. Fluid replacement OGrade 1AP�AE*;) �0=,-!������.��#12↑�F<:J&�BDK95%���������↓
� Step 2. KG7OGrade 1AP�DKA��KCL����+L>NG;���
� Step 3. �����3��K<3.3 mEq/L���������3��4�KG7OGrade 1BP
� Step 4. sodium bicarbonate3��PH 6.9��($3�OGrade 2 BP
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
� Step 1. Fluid replacement ZGrade 1A[
�M>AIXZ0.9%[�.J����B)S=�15 � 20 mL/kg /h (1 �1.5 L /h[�U:��-HTPE?��4M>AIX (0.45%) �4 � 14 mL/kg/h�B)�� K/,(� �Step 2�@�K�PE���� Glucose200mg+(��� ��#"�N�Q3���
� K<3.3mEq/L�85 20~40mEq/h�K�P0���� 3.3 ~5.3mEq/L�85 IX1L�K� 20~30 mEqQ3B)���� K>5.3mEq/L�85 K�B)����2CV�K/��� ����
�DKA��-1�KOT,(����!!�YGR72<���K69'*DAY�$"�!%&K
� Step 2. K�PEZGrade 1A[
FL�;W protocols
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
� Step 4. sodium bicarbonate�7$
� Step 3. �!� !7$� low-dose IV insulin:0����SGrade 1BT� KV3.3 mEq/L�.,�!� !7$�9�KJ<�()��IC200mg dL�N�����!� !7$="K3�+G ���regular insulin�Q>
"Regular insulin�IV bolus 7$�S0.1 u/kgT"��58F7$�S0.1 u/Kg/hT"IC 200 mg/dL�N���7$K3�0.02 ~ 0.05 u/kg /h�?O�"DKA-6���@#>�/;�
� insulin analogs�Q>UR'�regular insulin��2�����Q>"B>"@#>��7$=���2����
�PH 6.9&#�.,7$�SGrade 2 BT�PH7.0��EF� controversial
"H*PH�paradoxical fall�HADP1"ketogenesis�%L�Ketosis��-6M4
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
� Step 6. DKA���'.�",)91. anion gap � beta-hydroxybutyrate levels�4-#2. B76E(<315 mOsmol/kg3. I����
� Step 7. �����=�5��?C� BS<200 mg/dL �����2H>�8�*$
1. anion gap <12 mEq/L 2. Serum bicarbonate ≥15 mEq/L3. Venous pH >7.30
The American Diabetes Association (ADA) guidelines
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
� Step 5. ��F�2����F�2��3+����JGrade 1AK�G@� ��FB<J<1.0 mg/dLK�&%/;�!�:B0DB ���F2��A1���JGrade 2CK
DKA?H'!E
1. TK� KTE
2. Q@R�?H\-012~248]�#X����`G�C=%�W[�S�F7�1P�)(":bQ������3B�JL.I+5�V ���c
�<�Dd20-40%�?Hd
The 2009 American Diabetes Association (ADA) guidelines�N1�Na�>U;b9,AY*^�Z/ < 3 mOsmol/kg/hc
5 -20 mL/kg /h���9$2-38]�<50 mL/kg����������a�M6
HHS 250-300 mg/dL
3. _2&4O@R
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
CaA
H3C S
=OH3C S
CaA
=O�
2+0���#-CoAH3C
=OS
CaA
=O
����#-CoA
��!&�
CoA-SH
3-�$��#-3- �#�#�"#-
CoA"&�
3-�$��#-3- �#�#�"#-CoA
S
CaA
=OH3C
-OOC
OH3-�$��#:;���$��&�
CH3CO-S-CoANADH2+NAD+
��9;D-����$��:;
56����%�"*
NADH2+
D-�-��$�:;
= OS
CaA
=O
����#-CoA
NAD+TCA -8
� ��#CoA �� ;
56(/�34����%�"*
��9;
2+0���#-CoA
��#CoA���7'�2,����➢➢��%)�.1
Physiology of Ketone bodies
= O
CH3
=O
HO
=O
CH3
=O
HO
OH
OH
= O
OH
OH
= O
H3C
H3C H3C
?=H
����CoA↑↑
9(7J0
�� H*$F
Fasting Ketosis and Ketoacidosis
1. 9(7J03��-H*�$F�<A��/I�����CoA�6���
2. <A������CoA�G)��%�A,��"D����
3. ����CoA�B#�8C���5����&�.1����B#�8C+>����
9(7J03����&!2
4. :;K@� L�����&�����CoA�'.1����� 4��(7��
�������CoA
���&
����CoA ���H-E
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
Fasting Ketosis and Ketoacidosis
Ketosis` P9����VL�12~14C]�^_�W������ ��
� P9����#JI�45�����
� A "braking" effect ������A&*H
���������UT[A&�<),E�;/:�B
����#���UT'X�N?M <)
� FOSR��UT[@.Y9�0+
�=G������(K�0+
�fasting ketosis�"D6$K������� ��
Ketoacidosis`Ketosis�\Q-�Ketoacidosis�Z7��!8%�23�>! �1:
� no- or low-carbohydrate diet
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
Alcoholicketoacidosis
Alcoholic ketoacidosis�� ���������������������
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
���#+(�_Za ��!�( $"�ij����(CoA�j3����
�?^oh �NADH2+�,G�NADH/NADrM�,G��predox shiftq� NADH/NADrM�,G��TCA9f�E1�������[H����(CoA�dV�Ќ-j3�E1�����c`j�;2
���!�( $"��nlYO�mU�BAp8Nq87W�-LTP�4:����
�_Za�%!�)"'�Jbk=*@>XJbk=������_��&+�)5D�0g_�]\3�0g��
TCA9f
��!�( $"pCH3CHOq
��#+(pH3CH2OHq
ijpCH3COOHq
1K.e 2K.e
NAD+ NADH2+ NAD+ NADH2+
ADH ALDH
���(CoAc`j�� j3
��!���(CoA�!)/
*fasting�6I����(CoA��!)/�<Fketosis����
SCRQ
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
�����ADH�����"���!���&'10%(
3. �%� ��MEOSCH3CH2OH ) NADPH ) H+) O2 → CH3CHO ) NADP+) 2H2O
NAD+ NADH2+
������'CH3CHO(
���'H3CH2OH(
#$'CH3COOH(
NAD+ NADH2+
ADH ALDH
1. ��������ADH'alcohol dehydrogenase(CH3CH2OH ) NAD+ → CH3CHO ) NADH ) H+
2. Peroxisome�CatalaseCH3CH2OH)H2O2 → CH3CHO ) 2H2O
H2O2 2H2O
Catalase ������'CH3CHO(
���'H3CH2OH(
NADPH2+ NADP+
MEOS ������'CH3CHO(
���'H3CH2OH(
#$'CH3COOH(
MEOS
NADP+ 2H2O
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
Alcoholic ketoacidosis�k:B=�"�%"'KHuRA ?�>[h���
`<,
1. TJ �B=�"�%"*6U�Huq8�5mt�
2. UR �.�Mw76%x$/.w73%x$_Vw62%x������"�����UR
3. Cc �_l0V$\^5$s]$va0$wLiW@fPDx
4. IGCc�aP�"�%"+$��#+��FpE�)+ 2-�4�
� )aZyvaZ��vaZ�275 mg/dL(&
� rdgS: )KaU$)!#aU$)����� aUw20%x�aPNj0GapwQ7+�eY+ 9x o5�O-=n31;b�X2-�4��
23% simple high anion gap metabolic acidosis
77% mixed high anion gap metabolic acidosis
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
K8 �Anion gap �(9 ��&-�45
�fasting ketosis 'alcoholicUdiabetic ketoacidosis�P3�FI��C='GE/'A1C
1. Anion gap����2;2. ��&-�45
G+��&-6+��&-�Nitroprusside testing ''β-��%�NO�A5������
>D Treatment
1. ���ThiamineS��!&B1T100mg 7*2. H@
���E ���&�"&2?.M��&-$ #�)��BR��Volume�H<
3. QJLH<K'P'Mg�H<
,GE:����E7*�01
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
JAMA 1958An obsolete test ?
D-��� �� ��Lactate�2���������
�L - lactate / D - lactate�
������� �� � L-lactate�������D-��� �� �D-lactate������
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
L- D-
CHAPTER 4-6
1. short bowel syndrome Ja�VR6WM:H��gG��'�+�*VR6W�Eb�;9����� short bowel���]L���?f�Ab�2`����
��'�+�*VR6W�Ab��%$lICQIcmLactobacilln���L-lactate 8� D-lactate�/e�����YX��L- / D-lactate�;9����� D-lactate /e�h��_P04D-lactate�,N���!+���<��
2. Aj propylene glycol�K-*M:�Ja�� propylene glycol�/e��D-lactate�YX��
Propylene glycol → D- lactic acid → pyruvic acid → CO2 + water�3TI*k�#I��7d=mSD5*4Od*@Zdn UB�1Z
3. ^F[I� ��!+�� Ja�DKA���� )��"!(�� )&)i�,N��_P\�D-lactate�,N��acetone / dihydroxyacetone phosphate →methylglyoxal→D-lactic acid
D-.i��!+�� 3A[>
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD
�lIc`
1. 8xL�#'3#%�q���c`2. hkc`
jh�62z?Fw2eu4Vg2sODF|�P����N�2���
�tU�vV�����8xL�#'3#%q���Wb�
1. Short bowel / other malabsorption syndrome���2. �7�M@ ��7�Y���TC���#'3#%�3. _Jf�hkc`q����4. propylene glycol �\G� �n^SA�
�Zd
1. ]}(&/ -Q5�~i�}oc2. kBRmn�+.$30�)!,�#1�*1",�#13. low-carbohydrate diet4. propylene glycol�Ky[;�{��
�propylene glycol�[H=2<Xn2Ean�\rp>=� �9a���
lI:�Zd
Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD