Hyperosmolar chikomine mu matenda a shuga (pathogenesis, mankhwala)

Chimodzi mwazinthu zovuta kwambiri koma zophunziridwa bwino za matenda ashuga ndi hyperosmolar coma. Pali kutsutsanabe pamakina omwe adachokera ndikukula kwake.

Matendawa alibe pachimake, mkhalidwe wa odwala matenda ashuga amatha kukhala wowopsa kwa masabata awiri isanayambike kufooka koyamba. Nthawi zambiri, chikomokere chimapezeka mwa anthu opitilira zaka 50. Madokotala nthawi zambiri samatha kudzipangitsa kuti adziwe ngati wodwala ali ndi matenda ashuga.

>> Matenda a shuga - mitundu yake ndi chisamaliro chadzidzidzi ndi zotsatira zake.

Matenda a shuga ndi kupsinjika kudzakhala chinthu chakale

• Matenda a shuga -95%
• Kuthetsa kwa mitsempha thrombosis - 70%
• Kuthetsa kwa kugunda kwamtima kwamphamvu -90%
• Kuthana ndi kuthamanga kwa magazi - 92%
• Kuwonjezeka kwa mphamvu masana, kukonza kugona usiku -97%

Kodi Hyperosmolar coma ndi chiyani?

Kusekerera kwa hyperosmolar ndi vuto lotha kuzindikira m'machitidwe amtundu uliwonse: Mphamvu, ntchito za mtima ndi kuzimiririka, mkodzo umasiya kutulutsidwa. Munthu panthawiyi amakhala ndi malire pam moyo ndi imfa. Choyambitsa mavuto onsewa ndi hyperosmolarity yamagazi, ndiko kuti, kuwonjezeka kwamphamvu mu kupsinjika kwake (kuposa 330 mosmol / l wokhala ndi chizolowezi 275-295).

Mtundu wamtunduwu umadziwika ndi shuga wamagazi ambiri, pamwamba pa 33.3 mmol / L, komanso kutopa kwambiri. Nthawi yomweyo, ketoacidosis kulibe - matupi a ketone samapezeka mkodzo ndi mayeso, kupuma kwa wodwala matenda ashuga sikufungo la acetone.

Malinga ndi gulu lapadziko lonse lapansi, hyperosmolar coma imatchulidwa kuti ndikuphwanya kagayidwe kamchere wamadzi, khodi malinga ndi ICD-10 ndi E87.0.

Matenda a hyperosmolar amayamba kutsokomola kawirikawiri; muzochita zamankhwala, 1 yokhudza odwala 3300 pachaka imachitika. Malinga ndi ziwerengero, pafupifupi odwala ali ndi zaka 54, akudwala matenda ashuga a 2 osadalira insulin, koma samawongolera matendawa, chifukwa chake ali ndi zovuta zingapo, kuphatikizapo matenda ashuga a nephropathy omwe amalephera. Mu gawo limodzi mwa magawo atatu a odwala omwe ali ndi chikomokere, matenda a shuga ndiwotalika, koma sanapezeke ndipo, motero, sanalandiridwe nthawi yonseyi.

Poyerekeza ndi ketoacidotic coma, hyperosmolar coma imachitika kangapo ka 10. Nthawi zambiri, mawonetseredwe ake ngakhale osavuta amasiyidwa ndi odwala matenda ashuga okha, osazindikira ngakhale pang'ono - amasintha shuga m'magazi, amayamba kumwa kwambiri, ndikuyamba kuchipatala chifukwa cha zovuta za impso.

Zifukwa zachitukuko

Hyperosmolar coma imayamba matenda a shuga mellitus mothandizidwa ndi izi:

1. Kuthetsa madzi m'thupi kwambiri chifukwa cha kupsa kwambiri, kugwiritsa ntchito bongo mopitirira muyeso, poyizoni ndi matenda am'matumbo, omwe amayenda ndi kusanza komanso kutsegula m'mimba.
2. Kuperewera kwa insulini chifukwa chosagwirizana ndi zakudya, kuchotsera pafupipafupi kwa mankhwala ochepetsa shuga, matenda owopsa kapena kulimbitsa thupi, chithandizo cha mankhwala osokoneza bongo omwe amalepheretsa kupanga insulin.
3. Matenda a shuga osadziwika.
4. Matenda a impso nthawi yayitali osalandira chithandizo choyenera.
5. Hemodialysis kapena glucose wamitsempha pamene madokotala sakudziwa shuga m'm wodwala.

Pathogenesis

Kukhazikika kwa hyperosmolar coma nthawi zonse kumayendera limodzi ndi hyperglycemia. Glucose imalowa m'magazi kuchokera mu chakudya ndipo imapangidwa nthawi yomweyo ndi chiwindi, kulowa kwake mu minofu ndizovuta chifukwa chotsutsana ndi insulin. Pankhaniyi, ketoacidosis sichimachitika, ndipo chifukwa chakusowekaku sichinadziwike molondola. Ofufuza ena amakhulupirira kuti mtundu wa hyperosmolar wa coma umayamba pamene insulin ikukwanira kuletsa kuwonongeka kwa mafuta ndi mapangidwe a matupi a ketone, koma ochepa kwambiri kuti athe kutsekereza kuchepa kwa glycogen m'chiwindi ndikupanga shuga. Malinga ndi mtundu wina, kumasulidwa kwamafuta acids kuchokera ku minofu ya adipose kumapanikizika chifukwa chosowa kwamahomoni kumayambiriro kwa vuto la hyperosmolar - somatropin, cortisol ndi glucagon.

Kusintha kwina kwa pathological komwe kumayambitsa hyperosmolar coma kumadziwika bwino. Ndi kupita patsogolo kwa hyperglycemia, kuchuluka kwa mkodzo kumawonjezeka. Ngati impso imagwira ntchito mwachizolowezi, ndiye kuti malire a 10 mmol / L akapitilira, shuga amayamba kuthiridwa mkodzo. Ndi vuto laimpso, matendawa samachitika nthawi zonse, ndiye kuti shuga amadziunjikira m'magazi, ndipo kuchuluka kwa mkodzo kumawonjezeka chifukwa cha kusowetsedwa bwino kwa impso, kuperewera kwa madzi kumayamba. Madzi amasiya maselo ndi malo pakati pawo, kuchuluka kwa magazi omwe amayendayenda kumachepa.

Chifukwa cha kuchepa mphamvu kwa maselo aubongo, zizindikiro zamanjenje zimachitika; kuchuluka magazi coagulation amakwiya thrombosis, kumabweretsa osakwanira magazi ziwalo. Potengera kuchepa kwa madzi, mapangidwe a mahomoni aldosterone amawonjezereka, omwe amalepheretsa sodium kufika pamkodzo kuchokera m'magazi, ndipo hypernatremia imayamba. Iyenso amakwiya ndipo amatupa m'matumbo - mumakhala chikomokere.

Zizindikiro zake

Kukula kwa vuto la hyperosmolar kumatenga sabata limodzi kapena awiri. Kusintha kumachitika chifukwa chakuwonongeka pakubwezeredwa kwa matenda ashuga, kenako zizindikiro za kuchepa thupi. Pomaliza, zizindikiro zamitsempha ndi zotsatira za kuthamanga kwa magazi zimachitika.

Chifukwa chakuti kugwira ntchito kwa ziwalo zonse kumaphwanyidwa ndi chikomokere (Hyperosmolar coma), izi zitha kutsekedwa ndi vuto la mtima kapena zizindikiro zofanana ndi kukula kwa matenda opatsirana. Encephalopathy yovuta ikhoza kukayikiridwa chifukwa cha edema ya ubongo. Kuti adziwe matenda ake mwachangu, adotolo ayenera kudziwa za matenda ashuga m'mbiri ya wodwalayo kapena kuti adziwe nthawi yoyenera.

Zoyenera kudziwa

Kuzindikira kumakhazikika pazizindikiro, matenda a labotale, komanso matenda ashuga. Ngakhale kuti matendawa amafala kwambiri kwa anthu achikulire omwe ali ndi matenda a 2, hyperosmolar coma imatha kukhala mtundu 1, ngakhale utakhala ndi zaka zingati.

Nthawi zambiri, kuyezetsa magazi ndi mkodzo kokwanira kumafunikira kuti mudziwe matenda:

Kuti mudziwe momwe mtima umawonongekera, komanso ngati ungapirire kutulutsa, ECG yachitika.

Algorithm mwadzidzidzi

Wodwala wodwala matenda ashuga akamwalira kapena vuto lakelo, chinthu choyamba kuchita ndi kuyitanira ambulansi. Thandizo ladzidzidzi la hyperosmolar coma lingaperekedwe kokha kumalo osamalira odwala. Wodwalayo akapulumutsidwa mwachangu, mwayi wake wopulumuka, ziwalo zochepa zimawonongeka, ndipo adzachira mwachangu.

Mukuyembekezera ambulansi yomwe mukufuna:

1. Mugoneke wodwala pambali pake.
2. Ngati ndi kotheka, kukulani kuti muchepetse kutentha.
3. Muyang'anirani kupuma ndi maukwati, ngati kuli kotheka, yambani kupuma movutikira komanso kutikita minofu yamtima mwachindunji.
4. Pimani shuga. Ngati muli ndi mphamvu zochulukirapo, jekesani insulin yochepa. Simungathe kulowetsa insulini ngati palibe glucometer ndipo kuchuluka kwa glucose kulibe, izi zimatha kupangitsa wodwalayo kufa ngati ali ndi hypoglycemia.
5. Ngati pali mwayi ndi luso, ikani dontho ndi saline. Mulingo wa makonzedwe ndi dontho mphindi.

Wodwala matenda ashuga akayamba kuthandizidwa, amapita kuchipatala mofulumira kuti adziwe ngati kuli koyenera, kulumikizana ndi mpweya wabwino, kubwezeretsa kutuluka kwa mkodzo, kukhazikitsa catheter mu mtsempha kwa nthawi yayitali.

Nthawi zonse wodwala amayang'aniridwa:

• Glucose amayeza limodzi ndi ola limodzi.
• Maola 6 aliwonse - potaziyamu ndi sodium.
• Popewa ketoacidosis, matupi a ketone ndi acidity magazi amayang'aniridwa.
• Kuchulukitsa kwa mkodzo kumawerengeredwa nthawi yonse yomwe ma dontho amaikidwa.
• Nthawi zambiri yang'anani kukoka, kuthamanga ndi kutentha.

Njira zazikulu zochizira ndikubwezeretsa kuchuluka kwa mchere wamchere, kuchotsedwa kwa hyperglycemia, chithandizo cha matenda ophatikizika ndi zovuta.

Kukonza madzi am'madzi ndi kubwezeretsanso kwa ma elekitirodi

Kubwezeretsa madzimadzi m'thupi, infusions ya intravenous imachitika - mpaka malita 10 patsiku, ora loyamba - mpaka malita 1.5, ndiye kuchuluka kwa yankho lomwe limayendetsedwa pa ola limachepetsedwa pang'onopang'ono mpaka malita 0,3-0,5.

Mankhwala amasankhidwa malinga ndi zigawo za sodium zomwe zimapezeka pa mayeso a zasayansi:

Ndi kukonzanso kwam'madzi, kuphatikiza pakubwezeretsa malo osungiramo madzi m'maselo, kuchuluka kwa magazi kumawonjezerekanso, pomwe dziko la hyperosmolar limachotsedwa ndipo shuga ya magazi imachepa. Kukonzanso madzi mkaka kumachitika ndi kulamulidwa kwa glucose, chifukwa kuchepa kwake kothamanga kumatha kubweretsa kugwa kwakanthawi kwa mavuto kapena matenda a edema.

Pamene mkodzo umawonekera, kubwezeretsanso kwa potaziyamu m'mimba kumayamba. Nthawi zambiri amakhala potaziyamu mankhwala enaake, pakakhala kulephera kwa aimpso - phosphate. Ndende ndi kuchuluka kwa kayendetsedwe amasankhidwa malinga ndi zotsatira za kuyesedwa kwa magazi pafupipafupi kwa potaziyamu.

Hyperglycemia Control

Mwazi wamagazi umakonzedwa ndi insulin, insulin imayendetsedwa mwachidule, muyezo wochepetsetsa, moyenera mwa kulowetsedwa kosalekeza. Ndi hyperglycemia wokwera kwambiri, jakisoni wambiri wamadzi am'magawo mpaka 20 umachitika kale.

Ndikusowa kwamadzi kwambiri, insulini singagwiritsidwe ntchito kufikira madzi atabwezeretsedwa, shuga panthawiyo amachepetsa msanga. Ngati matenda ashuga ndi hyperosmolar coma ali ovuta kwambiri ndi matenda omwe amakhala nawo, insulin ingafunike mopitilira masiku onse.

Kukhazikitsidwa kwa insulin panthawiyi yamankhwala sikutanthauza kuti wodwalayo asinthana ndikuyamba moyo wake wonse. Nthawi zambiri, mutakhazikika, shuga yachiwiri imatha kulipidwa ndi chakudya (mtundu 2 shuga) komanso mankhwala ochepetsa shuga.

Chithandizo cha Matenda Olumikizana

Pamodzi ndi kubwezeretsa kwa osmolarity, kukonza komwe kudachitika kale kapena kumayikiridwa akutsutsana kumachitika:

1. Hypercoagulation imachotsedwa ndipo thrombosis imalepheretsedwa ndikupereka heparin.
2. Ngati kulephera kwa impso kukukulirakulira, hemodialysis imachitika.
3. Ngati hyperosmolar chikomokere chikukwiyitsidwa ndi matenda a impso kapena ziwalo zina, maantibayotiki ndi omwe amapereka.
4. Glucocorticoids amagwiritsidwa ntchito ngati anti-shock mankhwala.
5. Pamapeto pa chithandizo, mavitamini ndi michere amaikidwa kuti apange zotayika zawo.

Zomwe ungayembekezere - kuneneratu

Kukula kwa hyperosmolar coma makamaka kumatengera nthawi yakuyamba chithandizo chamankhwala. Ndi chithandizo cha panthawi yake, chikumbumtima chitha kupewetsa kapena kubwezeretsa nthawi. Chifukwa chachedwa kuchira, 10% ya odwala omwe ali ndi chikomokereyi amafa. Zomwe zimapangitsa kuti milandu yotsala imphedwe imawonedwa kuti ndi nkhalamba, matenda osawerengeka a shuga, "maluwa" amatenda omwe anasonkhana panthawiyi - kulephera kwa mtima ndi impso, angiopathy.

Imfa ndi hyperosmolar coma imachitika nthawi zambiri chifukwa cha Hypovolemia - kuchepa kwa magazi. Mthupi, zimapangitsa kusowa kwa ziwalo zamkati, makamaka ziwalo zosintha kale. Komanso, edema yam'mimba komanso zopweteka zazikulu zakufa zitha kufa.

Ngati mankhwalawa adakwaniritsidwa komanso atakwaniritsidwa, wodwalayo amayambiranso kudziwa, zizindikiro za chikomokere zimatha, shuga ndi magazi osinthika. Matenda am'mitsempha pakusiya chikomokere amatha masiku angapo mpaka miyezi ingapo. Nthawi zina kubwezeretsa kwathunthu kwa ntchito sikuchitika, ziwalo, vuto la kulankhula, matenda amisala amatha kupitilira.