..


1.

()
(O)

2.

()

()

3.

 (1)

--

1,
2
10-30%
1

 (2)

4.8-8.0/1000

2.5-9 %,
,
,

 O (1)
1.

2.

3.

 (2)

>250 [13,9]

>250

>250

>600 [33,3]

pH

7,25 7,30

7,00 7,24

<7,00

>7,30

(mEq/L)

15 18

10 15

<10

>15

(mOsm/kg)

>320

>10

>12

>12

(mg/dl) [mmol/L]


(ANION GAP)
(Na+)-[(Cl-) +HCO3 - )] mEq/ L
12 2 mEq/ L

(2 x Na+ mEq/L) + ( mg/dL / 18

+ mg/dL /6 )
285-295 mOsm/Kg

(2 x Na+ mEq/L) + ( mg/dL

/ 18)


1.
(
- )
2.


3.
( )
4.

5.

6.

7.
-
8.
(
)
9.
( ,
, ,
)

 (1)

 (2)

( >
)

stress

()

(
Kussmaul)

(
,,
)

-
(K+-Na+-Mg2+ -Po3--Cl- Ca2+)
-


(
)

HbA1c

Wbc Ht
-

pH

- (

)

(<500 kcal)

(
6 )

Monitoring

!! 2

 (1)

(NaCl
0.9%)

 (2)

-1 0.5-1L N/S
0.9 %
2 1L N/S 0.9 %
3 - 5 0.51L N/S 0.9 %
s
5 3.5-5L

 (3)

Glu <250 mg/dL
<200 mg/dL D/W
5% 250 ml/h

 (4)

HOURS

VOLUME

-1st h

1L

2nd h

1L

3rd h

500 ml-1L

4th h

500 ml-1L

Total 1st -5th h

3.5-5L

6th-12th h

250-500ml/h

(1)

iv
bolus ( 0,1iu/Kg)
iv
0,1iu/Kg/h ( 5-7 iu/h)
iv
(0,14 iu/Kg/h)
bolus

 (2)

: 50 iu
Regular Actrapid 500 ml N/S 0,9%

50-70 ml/h ( 5-7 iu /h )
1h
50-70 mg/dL
h

10%

 (3)

1.
2.

3.
4.

iv
, :

pH > 7,3

HCO3- > 18 mEq/L

Glu < 200 mg/dL

 (4)

iv , 1-2h

1 TDD 0,5-0,8 iu/Kg
(30-50% )

 (1)

- -

=> Na+

Na+ Cl-
N/S ,9%

 (2)

K+


=>
K+

K+

BG 1 h
Na,K,pH,
20-30 min
0,2,6,10,24 h
Mental status
0,2,4 h
20-30 min

0,4,8,12,18,24 h

0,4,8,12,18,24 h

0,6,12,24 h

-

ARDS

(1-2% )

Sick-day rules

 ()

1.

2.
3.
4.
5.

OEM, AEE .

.

2

(Glu >600mg/DL
>1000 mg/dL)

5-20%

, ,

,
(,
)

( >350)

stress

( >

: 7-13 mEq/kg

: 3-7 mEq/kg

: 5-15 mEq/kg

: 70-140 mmol/kg

: 50-100 mEq/kg

: 50-100 mEq/kg

: 100-200 ml/kg

Matz, Am Fam Physician 1999;60:1468-76

1.

2.

3.

1.
2.
3.

4.

5.

6.

:
Glu
Na+
Ur Cr

WBC/Ht/Hb

HCO3-

Monitoring

=Na+ + {[1,65 x (
mg/dl 100] / 100}

Na+ 145
mEq/L 900 mg/dl:
Na+ = 145 + [1,65 x (900 100)]
/100=145+13,2=158,2 mEq/L


= (2 x Na+ mEq/L) + ( mg/dL / 18)

145

mEq/L 900 mg/dL :

= (2x145) + (900/18) = 290 +
50 = 340 mOsm/kg.

FOLLOW UP-MANAGEMENT

iv -


<315 mOsm/Kg
-

1.
2.

>7 mmol /L (. <1)

2 :

 CORI

shock

()

kussmaul

pH

,


,

.

 (1)

Diabetic emergencies: Diagnosis and

clinical management

 (2)

Kitabchi et al, Hyperglycemic crises in adult

patients with diabetes:a consensus statement
from ADA, Diabetes Care 2009
Kitabchi et al, Thirthy years of personal
experience in hyperglycemic crisis :diabetic
ketoacidosis and hyperglycemic hyperosmolar
state

 :
,

.
1

. .
..

 1 :

,
,
6

 ..