21
CHAPTER 4-4 Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD

仙台市医療センター 仙台オープン病院〈消化器・循環器・呼 …Ja propylene glycol /e D-lactate YX Propylene glycol → D-lactic acid → pyruvic acid → CO2

  • Upload
    others

  • View
    3

  • Download
    0

Embed Size (px)

Citation preview

����������

CHAPTER 4-4

Sendai City Medical Center, Emergency Room Y.Moizumi.MD,PHD

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

������ �����

���

��� ��

CHAPTER 4-5

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