Cardoso Luís, Vicente Nuno, Rodrigues Dírcea, Gomes Leonor, Carrilho Francisco
Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
Metabolism. 2017 Mar;68:43-54. doi: 10.1016/j.metabol.2016.11.010. Epub 2016 Nov 25.
Hyperglycaemic emergencies are associated with significant morbi-mortality and healthcare costs. Management consists on fluid replacement, insulin therapy, and electrolyte correction. However, some areas of patient management remain debatable. In patients without respiratory failure or haemodynamic instability, arterial and venous pH and bicarbonate measurements are comparable. Fluid choice varies upon replenishment phase and patient's condition. If patient is severely hypovolaemic, normal saline solution should be the first option. However, if patient has mild/moderate dehydration, fluid choice must take in consideration sodium concentration. Insulin therapy should be guided by β-hydroxybutyrate normalization and not by blood glucose. Variations of conventional insulin infusion protocols emerged recently. Priming dose of insulin may not be required, and fixed rate insulin infusion represents the best option to suppress hepatic glucose production, ketogenesis, and lipolysis. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycaemia. Simpler protocols using subcutaneous rapid-acting insulin analogues for mild/moderate diabetic ketoacidosis treatment have proven to be safe and effective, but further studies are required to confirm these results. Treatment with bicarbonate, phosphate, and low-molecular-weight heparin is still disputable, and randomized controlled trials are urgently needed to optimize patient management and decrease the morbi-mortality of hyperglycaemic emergencies.
高血糖急症与显著的病残率和死亡率以及医疗成本相关。治疗包括补液、胰岛素治疗和电解质纠正。然而，患者管理的一些方面仍存在争议。在没有呼吸衰竭或血流动力学不稳定的患者中，动脉血和静脉血的pH值及碳酸氢盐测量结果相当。补液的选择因补液阶段和患者状况而异。如果患者严重低血容量，生理盐水应作为首选。然而，如果患者有轻度/中度脱水，补液选择必须考虑钠浓度。胰岛素治疗应以β-羟丁酸恢复正常为指导，而非血糖。最近出现了传统胰岛素输注方案的变体。可能不需要胰岛素负荷剂量，固定速率胰岛素输注是抑制肝糖生成、酮体生成和脂肪分解的最佳选择。基础胰岛素类似物与常规胰岛素输注联合使用可加速酮症酸中毒的缓解并预防血糖反跳。使用皮下速效胰岛素类似物治疗轻度/中度糖尿病酮症酸中毒的更简单方案已被证明是安全有效的，但需要进一步研究来证实这些结果。使用碳酸氢盐、磷酸盐和低分子量肝素治疗仍存在争议，迫切需要进行随机对照试验以优化患者管理并降低高血糖急症的病残率和死亡率。
