Szrama Jakub, Smuszkiewicz Piotr
Department of Anaesthesiology, Intensive Therapy and Pain Management, University Hospital no. 2 in Poznań, Poland.
Anaesthesiol Intensive Ther. 2013 Oct-Dec;45(4):230-4. doi: 10.5603/AIT.2013.0044.
This case report presents a 49 year-old female with type 1 diabetes admitted to the intensive care unit with acute respiratory failure and severe diabetic ketoacidosis with an initial measurement of blood glucose level of 1,200 mg L⁻¹, pH 6.78, serum HCO₃ ⁻ 3.2 mmoL L⁻¹ and BE -31.2 mmoL L⁻¹. Analysis of the blood gasometric parameters with the Stewart approach and the traditional Henderson-Hasselbalch concept enabled the discovery of metabolic acidosis caused by unidentified anions (mainly ketons). A treatment protocol with intensive fluid management with 0.9% NaCl, intensive intravenous insulin therapy, and potassium supplementation was administered. Analysis of the gasometric parameters after 12 hours of treatment according to the Stewart approach compared to the Henderson-Hasselbalch concept disclosed that metabolic acidosis caused by the unidentified anions has resolved almost completely and been replaced by metabolic hyperchloremic acidosis. The hyperchloremic acidosis was caused by the intensive fluid resuscitation with 0.9% NaCl, which contains a high chloride load, exceeding the chloride levels observed in human serum. Fluid management with balanced fluids other than saline was continued, together with intravenous insulin infusion, potassium supplementation, and 5% glucose administration. Analysis of this case study revealed the advantages of the Stewart approach to acid base abnormalities compared to the traditional Henderson-Hasselbalch concept. The Stewart approach allows the diagnosis of the exact causes of severe life-threatening metabolic acidosis and the appropriate modification of the therapeutic mangement of patients with diabetic ketoacidosis.
本病例报告介绍了一名49岁的1型糖尿病女性患者，因急性呼吸衰竭和严重糖尿病酮症酸中毒入住重症监护病房，初始血糖水平为1200 mg L⁻¹，pH值为6.78，血清HCO₃ ⁻为3.2 mmoL L⁻¹，碱剩余为 -31.2 mmoL L⁻¹。采用斯图尔特方法和传统的亨德森 - 哈塞尔巴尔赫概念对血气参数进行分析，发现了由不明阴离子（主要是酮体）引起的代谢性酸中毒。实施了一项治疗方案，包括用0.9%氯化钠进行强化液体管理、强化静脉胰岛素治疗和补钾。根据斯图尔特方法与亨德森 - 哈塞尔巴尔赫概念对治疗12小时后的血气参数进行分析，结果显示由不明阴离子引起的代谢性酸中毒几乎已完全缓解，并被代谢性高氯性酸中毒所取代。高氯性酸中毒是由用0.9%氯化钠进行强化液体复苏导致的，该溶液含氯量高，超过了人血清中观察到的氯水平。继续使用除生理盐水外的平衡液进行液体管理，同时静脉输注胰岛素、补钾并给予5%葡萄糖。对该病例研究的分析揭示了与传统的亨德森 - 哈塞尔巴尔赫概念相比，斯图尔特方法在诊断酸碱异常方面的优势。斯图尔特方法能够诊断严重危及生命的代谢性酸中毒的确切原因，并对糖尿病酮症酸中毒患者的治疗管理进行适当调整。
