Hyperosmolar coma feem ntau kuaj pom hauv cov neeg mob hnub nyoog 50 xyoo uas raug mob los ntawm mob me mus rau nruab nrab mob ntshav qab zib mellitus, yooj yim them nyiaj los ntawm kev noj zaub mov thiab tshuaj tshwj xeeb. Nws tsim tawm tsam keeb kwm ntawm lub cev qhuav dej ntawm lub cev los ntawm kev noj cov tshuaj diuretics, kab mob ntawm cov hlab ntsha ntawm lub hlwb thiab ob lub raum. Kev tuag los ntawm hyperosmolar coma nce mus txog 30%.
Yog vim li cas
Glucose-related hyperosmolar coma yog ib qho teeb meem ntawm cov ntshav qab zib mellitus thiab tshwm sim los ntawm kev nce qib ntawm cov piam thaj hauv cov ntshav (ntau dua 55.5 mmol / l) ua ke nrog hyperosmolarity thiab tsis muaj acetone hauv cov ntshav.
Yog vim li cas rau qhov tshwm sim no yuav yog:
- Lub cev qhuav dej hnyav vim ntuav hnyav, raws plab, kub hnyiab, lossis kev kho mob ntev nrog cov tshuaj diuretic;
- tsis txaus lossis tsis ua tiav ntawm insulin, ob qho tib si endogenous thiabexogenous (qhov ua rau ntawm qhov tshwm sim no yuav yog qhov tsis muaj cov tshuaj insulin lossis kev kho mob tsis raug);
- xav tau insulin ntau ntxiv, uas tuaj yeem tshwm sim los ntawm kev ua txhaum tag nrho ntawm kev noj zaub mov, kev qhia txog kev npaj cov piam thaj ntau ntxiv, kev txhim kho ntawm cov kab mob sib kis (tshwj xeeb yog mob ntsws thiab kab mob urinary), tom qab ua haujlwm, raug mob, noj cov tshuaj uas muaj cov yam ntxwv ntawm cov tshuaj insulin antagonists (tshwj xeeb, glucocorticoids thiab tshuaj hormones kev sib deev).
Pathogenesis
Hmoov tsis zoo, cov txheej txheem ntawm kev txhim kho ntawm cov kab mob pathological no tsis nkag siab tag nrho. Nws ntseeg tau tias txoj kev loj hlob ntawm qhov teeb meem no cuam tshuam los ntawm kev thaiv cov piam thaj los ntawm lub raum, nrog rau kev nce ntxiv ntawm cov tshuaj no rau hauv lub cev thiab nws cov khoom tsim los ntawm lub siab. Nyob rau tib lub sijhawm, kev tsim cov tshuaj insulin raug txwv, nrog rau kev thaiv kev siv cov piam thaj los ntawm cov ntaub so ntswg peripheral. Qhov no yog tag nrho ua ke nrog lub cev qhuav dej.
Ntxiv rau, nws ntseeg tau tias muaj cov tshuaj endogenous (tsim hauv lub cev) insulin hauv tib neeg lub cev cuam tshuam nrog cov txheej txheem xws li lipolysis (fat breakdown) thiab ketogenesis (tsim cov kab mob). Txawm li cas los xij, cov tshuaj insulin no tsis txaus los txo qis cov piam thaj uas tsim los ntawm lub siab. Yog li ntawd, qhov kev taw qhia ntawm exogenous insulin yog tsim nyog.
Nrog rau qhov tsis txaus ntawm cov kua dej ntau, BCC (ntim ntawm cov ntshav ncig) txo qis, uas ua rau cov ntshav tuab thiab nce ntxiv.osmolarity. Qhov no tshwm sim meej vim qhov nce hauv cov piam thaj, potassium thiab sodium ions.
Symptoms
Hyperosmolar coma txhim kho, cov tsos mob tshwm sim ua ntej, ob peb hnub lossis ntau lub lis piam. Nyob rau tib lub sijhawm, tus neeg mob tsim cov cim qhia uas yog tus yam ntxwv ntawm decompensated ntshav qab zib mellitus (cov piam thaj tsis tuaj yeem hloov kho nrog tshuaj):
- polyuria (nce zis ntau lawm);
- nqhis dej ntau;
- nce dryness ntawm daim tawv nqaij, mucous daim nyias nyias;
- poob ceeb thawj;
- tsis muaj zog;
- qhov tshwm sim ntawm lub cev qhuav dej yog qhov ua rau muaj kev noj qab nyob zoo: txo qis ntawm daim tawv nqaij, pob muag, ntshav siab, kub.
Neurological tsos mob
Tsis tas li ntawd, cov tsos mob kuj tuaj yeem pom los ntawm lub paj hlwb:
- kev xav;
- hemiparesis (tsis muaj zog ntawm kev yeem txav);
- kev ua txhaum ntawm kev hais lus, nws yog slurred;
- ntuav tas li;
- areflexia (tsis muaj kev cuam tshuam, ib lossis ntau dua) lossis hyperlefxia (nce reflexes);
- muscle tension;
- pab tsis nco qab.
Cov tsos mob tshwm sim hnub ua ntej hyperosmolar coma tshwm sim hauv cov menyuam yaus lossis cov neeg laus.
Muaj Teeb Meem
Nrog kev pab tsis tu ncua, muaj teeb meem tshwm sim. Feem ntau yog:
- mob qaug dab peg uas tuaj yeem ua taunrog rau cov tawv muag ntawm daim tawv muag, ntsej muag (cov kev tshwm sim no yuav pom tsis tau rau lwm tus);
- deep vein thrombosis;
- pancreatitis (mob ntawm tus txiav);
- raum tsis ua haujlwm.
Kev hloov pauv kuj tshwm sim hauv plab hnyuv, uas tshwm sim los ntawm ntuav, tsam plab, mob plab, plab hnyuv motility (mob plab hnyuv yog qee zaum pom), tab sis lawv yuav luag tsis pom.
Vestibular disorders kuj pom.
Diagnosis
Yog xav tias muaj kev kuaj mob hyperosmolar coma, kev kuaj mob yog nyob ntawm kev kuaj kuaj. Tshwj xeeb, thaum kuaj ntshav, kuaj pom qhov siab ntawm glycemia thiab osmolarity. Tsis tas li ntawd, cov qib sodium siab, siab tag nrho cov whey protein, thiab cov nitrogen seem yog ua tau. Cov qib urea kuj tseem tuaj yeem nce siab. Thaum kuaj zis, ketone lub cev (acetone, acetoacetic thiab betahydroxybutyric acid) tsis kuaj.
Tsis tas li ntawd, tsis muaj qhov tsis hnov tsw ntawm acetone hauv huab cua exhaled los ntawm tus neeg mob thiab ketoacidosis (kev cuam tshuam cov carbohydrate metabolism), uas tau tshaj tawm tias hyperglycemia thiab ntshav osmolarity. Tus neeg mob muaj cov tsos mob ntawm lub paj hlwb, tshwj xeeb tshaj yog, lub pathological kos npe rau ntawm Babinski (ko taw extensor reflex), nce cov leeg nqaij, ob sab nystagmus (involuntary oscillatory qhov muag txav).
Ntawm lwm qhov kev tshawb fawbsawv tawm:
- ultrasound thiab x-ray kuaj ntawm pancreas;
- electrocardiography;
- blood glucose test.
Kev kuaj mob sib txawv yog qhov tseem ceeb tshwj xeeb. Qhov no yog vim qhov tseeb tias hypermolar coma tuaj yeem yog qhov tshwm sim ntawm tsis yog ntshav qab zib mellitus nkaus xwb, tab sis kuj yog lub raum tsis ua haujlwm thaum noj thiazide diuretics.
Kev kho mob
Yog tias kuaj pom tus mob hyperosmolar coma, kev kho mob xwm txheej ceev yog txhawm rau tshem tawm lub cev qhuav dej, hypovolemia thiab kho cov ntshav osmolarity.
Txhawm rau tiv thaiv cov dej hauv lub cev, siv cov tshuaj hypotonic sodium chloride. Taw qhia los ntawm 6 mus rau 10 litres ib hnub twg. Yog tias tsim nyog, tus nqi ntawm kev daws yog nce. Tsis pub dhau ob teev tom qab pib ntawm cov kab mob pathological, nws yuav tsum tau txhaj 2 litres ntawm sodium chloride tov intravenously, tom qab uas cov thawj coj yuav siv qhov chaw los ntawm drip ntawm tus nqi ntawm 1 l / h. Cov kev ntsuas no tau coj mus rau qhov normalization ntawm cov ntshav osmolarity thiab siab nyob rau hauv cov hlab ntsha venous. Ib qho cim ntawm kev tshem tawm ntawm lub cev qhuav dej yog qhov pom ntawm tus neeg mob lub siab nco qab.
Yog tias kuaj pom hyperosmolar coma, kev kho mob yuav tsum txo qis ntawm hyperglycemia. Rau lub hom phiaj no, cov tshuaj insulin yog muab intramuscularly thiab intravenously. Nyob rau tib lub sijhawm, kev tswj hwm nruj ntawm cov ntshav qab zib concentration yog xav tau. Thawj koob tshuaj yog 50 IU, uas tau muab faib ua ib nrab thiab nkag mus rau hauv lub cev hauv ntau txoj hauv kev. Nyob rau hauv cov ntaub ntawv ntawm hypotension, txoj kev ntawm kev tswj tsuas yog intravenous. Ntau cov tshuaj insulinnoj nyob rau hauv tib tus nqi los ntawm drip intravenously thiab intramuscularly. Cov kev ntsuas no tau ua kom txog thaum qib glycemia nce mus txog 14 mmol / l.
Cov tshuaj insulin yuav txawv:
- ib zaug 20 IU intramuscularly;
- 5-8 units txhua 60 feeb.
Yog tias cov piam thaj tau poob mus rau qib 13.88 mmol / l, cov tshuaj hypotonic sodium chloride yuav tsum tau hloov nrog cov kua qabzib.
Thaum kev kho mob hyperosmolar coma, kev saib xyuas tas li ntawm cov poov tshuaj hauv cov ntshav yog qhov tsim nyog, txij li kev qhia txog cov tshuaj potassium chloride yuav tsum tau tshem tawm ntawm lub xeev pathological.
txhawm rau tiv thaiv cerebral edema raws li qhov tshwm sim ntawm hypoxia, cov neeg mob tau txhaj cov tshuaj glutamic acid hauv qhov nyiaj ntawm 50 ml. Heparin kuj tseem xav tau, vim tias qhov kev pheej hmoo ntawm thrombosis nce ntau. Qhov no yuav tsum tau saib xyuas cov ntshav txhaws.
Raws li txoj cai, hyperosmolar coma tshwm sim hauv cov neeg mob uas mob me lossis mob ntshav qab zib mellitus, yog li peb tuaj yeem hais tias lub cev siv tshuaj insulin zoo. Yog li ntawd, nws raug pom zoo kom muab cov tshuaj me me ntawm cov tshuaj.
Kev Tiv Thaiv Kab Mob
Lub plawv plawv kuj xav tau kev tiv thaiv, uas yog, kev tiv thaiv ntawm cov hlab plawv tsis txaus. Rau lub hom phiaj no, "Kordiamin", "Strophanthin", "Korglikon" yog siv. Nrog kev txo qis, uas yog nyob rau theem tsis tu ncua, kev qhia txog kev daws teeb meem ntawm DOXA tau pom zoo, nrog rau kev tso ntshav. Kev tswj hwm ntawm plasma, gemodez, tib neeg albumin thiab tag nrho cov ntshav.
Ua tsaug…
Yog tias koj tau kuaj pom tias muaj ntshav qab zib mellitus, koj yuav tsum tau kuaj xyuas los ntawm tus kws endocrinologist tas li thiab ua raws li nws cov lus qhia, tshwj xeeb, tswj cov ntshav qab zib. Qhov no yuav zam qhov teeb meem ntawm tus kab mob.
