糖尿病的急性并發(fā)癥課件

糖尿病的急性并發(fā)癥Morbidityreport糖尿病的急性并發(fā)癥Name:曾XAge:81y/oGender:maleAdmissiondate:92-08-07Married,MinnanTaiwanerOccupation:unknownBW:59kgwBH:165cmBMI:21.6Smoking(-)糖尿病的急性并發(fā)癥ChiefcomplaintSuddenonsetofgeneralweaknessthismorningabout10:00Am糖尿病的急性并發(fā)癥Presentillness

Thispatientisacaseof(1)COPDwithregularmedicinecontrol(2)hypertensionforseveralyearsanddiscontinuedmedicinetherapyfor2-3monthsrecently.(3)type2DMnotedfor3yearswithoutcontrolforseveralmonths.Hewaswellbeforethisadmission.Inrecent3days,hebegantohaveslurredspeech.Acuteonsetofgeneralweakness,righteye-lidptosisandmotorweaknessnotedbyfamilyon8/7.HewassenttoourERandhyperglycemiawasnoted.ThenhewasadmittedundertheimpressionofNKHS.

糖尿病的急性并發(fā)癥PhysicalexaminationConsciousness:E4V5M6BP:164/84mmHg220/90mmHg,HR:70RR:20/min,Bodytemperature:36.4Neck:supple,noLAP,thyroid–impalpableHeartsound:RegularheartbeatBreathsound:clearAbdomen:soft,notenderness,hyperactivebowelsound,distensionL/L:noedema,nocyanosisDryskinturgor糖尿病的急性并發(fā)癥NeurologicalexaminationConsciousness:clear,alert,orientation:fairVerbaloutput:fairwithdysarthriaEye:lightreflex+/+,2.5/2.5EOM:righteyemildlimitation,-1~-2deviationtoleftsideDiplopia(-),choking(+),UvuladeviatedtorightsideMusclepower:RUL:4+,RLL:4+,LUL:4-,LLL:4-Barbinskisign:negativeUrineincontinence(+)Sensory:impairmentoflowerlegs,bilateral糖尿病的急性并發(fā)癥Labdata-1Bloodgas---pH:7.436,PO2:86,PCO2:36.2,HCO3:24.6

Glucose(spot):732Cr:1.8Na:128,K:4.8Effectiveosmolality–306.2糖尿病的急性并發(fā)癥Labdata-2Hemogram---WBC:13100/ul,Hgb:14.6g/dl,platelet:232000/uLUrinalysis---glucose:1.0,ketone-,protein:-,WBCesterase-,WBC0-1HbA1c:11.5%

Cholesterol:237,HDL:48,TG:435糖尿病的急性并發(fā)癥Hospitalcourse8/7–admissiontype2DM,poorcontrolHydration+insulinpumphypertensionDiovan+Hytrin+NorvascsuspectCVABrainCT:nofindingConsultneurologistR/obrainsteminfarction--AspirinEEG–normal糖尿病的急性并發(fā)癥Hospitalcourse8/11–Dyspnea,highfever,respiratoryfailureaspirationpneumoniaTransfertoICUEmpiricantibioticswithUnasynUGIbleedingsuspectstressulcer糖尿病的急性并發(fā)癥HospitalcourseBrainMRI(8/13)–HighT2signallesionlocatedinrightcoronaradiataandrightbasalgangliaacuteinfarctionMildreperfusionhemorrhageintheinfarctionNeckdoppler(8/14)–mild(10%)homogeneousplaquesofleftbifurcation,normalechoflowofbil.CCA,ICAandvertebralartery糖尿病的急性并發(fā)癥HospitalcourseBrainCTscan(8/18)–Lowdensitylesioninvolvingrightcoronaradiataandrightbasalganglia8/25–tracheostomywasperformed9/9–successfulweaning9/15–transfertotheclinicsforchroniccare糖尿病的急性并發(fā)癥糖尿病的急性并發(fā)癥糖尿病的急性并發(fā)癥FLAREPICTURE糖尿病的急性并發(fā)癥糖尿病的急性并發(fā)癥HyperdenseofMCAsign

糖尿病的急性并發(fā)癥糖尿病的急性并發(fā)癥FinalDiagnosisacutehemorrhagicinfarctionoverrightputamenareaType2DM,poorglycemiacontrolHypertensionHyperlipidemiaRLLpneumoniawithrespiratoryfailures/ptracheostomywithsuccessfulweaningUGIbleeding糖尿病的急性并發(fā)癥DischargeMedication---

HM(70/30):36-16bidNootropil1#bidBisolvon1#tidLipitor1#qd

Zanidip1#qdPhyllocontin1#tidMeptin-mini1#bidStilnox1#hsEmetrol1#tidThrough2#hsLosec1#qdDiovan1#qd糖尿病的急性并發(fā)癥Discussion糖尿病的急性并發(fā)癥糖尿病的急性併發(fā)癥DKA(糖尿病酮酸血癥)NKHS(HHNS,HHNK)高血糖高滲透壓非酮體性昏迷/癥候群

Hypoglycemia(低血糖)糖尿病的急性并發(fā)癥NKHS通常發(fā)生於年老的type2DM病人多尿，體重減輕姿勢性低血壓心跳快速意識障礙，嗜睡，抽筋，昏迷沒有噁心嘔吐或是腹痛，亦無Kussmaulrespiration10-20%mortalityrate糖尿病的急性并發(fā)癥DKA胰島素缺乏葡萄糖攝取蛋白質(zhì)異化作用脂肪分解甘油醇游離脂肪酸

酮生成

酮血癥

尿酮

電解質(zhì)減少脫水酸中毒

滲透性利尿低張性流失高血糖

葡萄糖新生氨基酸氮流失糖尿病的急性并發(fā)癥致病機(jī)轉(zhuǎn)NKHS的病理生理學(xué)大致上和DKA相同有下列幾點(diǎn)不同insulindeficiency較不嚴(yán)重，所以不會(huì)使lipolysis增加，沒有ketosis,acidosisprolonghyperglycemia,造成嚴(yán)重脫水，腎前氮血癥

plasmaosmolality增加

consciousdisturbance較常見糖尿病的急性并發(fā)癥促發(fā)因子-1Massivefluidlossosmoticdiuresis(hyperglycemia)severeburnseverediarrheahemodialysis,peritonealdialysisthiazide,otherdiureticsOthersinfectionAMI,StrokeGIhemorrhageuremia糖尿病的急性并發(fā)癥促發(fā)因子-2HypertonicfeedingprolongedparenteralnutritionhighproteintubefeedingPharmacologicagentsThiazidePropranolol(Inderal)DilantinSteroidLasix糖尿病的急性并發(fā)癥NKHSDiagnosis---markedhyperglycemia(>600mg/dL)hyperosmolality(>320mosmol/L)prerenalazotemia,profounddehydrationabsenceofketoacidosisneurologicalsigns(focal)糖尿病的急性并發(fā)癥LaboratoryvaluesinNKHSglucose600~1200

Sodium135~145PotassiumnormalMagnesiumnormalChloridenormalPhosphatenormalCreatinemoderatelyOsmolality330-380Plasmaketone+/-SerumbicarbonatenormaltoslightlyArterialpH>7.3ArterialPco2normal糖尿病的急性并發(fā)癥NKHSInNKHS,thevolumedepletion,freewaterdeficit,andhyperosmolalityaregreaterthaninDKAWaterdeficient---9~10LInitially:1~3L0.9%salinetostabilizethehomodynamicstatusifsodium>150meq/lhalfsalineshouldbeused糖尿病的急性并發(fā)癥HHNKwithstroke

Intensiveinsulintherapy?Insulinpump?Mortalityrate??Glycerolormannitolused?CentrallineforadequatehydrationAntihypertensiveagent的選擇Consciousnessdisturbance如何D.DPrognosticfactor??糖尿病的急性并發(fā)癥Stroke糖尿病的急性并發(fā)癥DifferentialDiagnosisofStroke-LikeSymptomsNeurologicalDifferentialCraniocerebral/cervicaltraumaDissectionMeningitis/encephalitisIntracranialmassTumorSubduralhematomaSeizurewithpersistentneurologicalsignsMigrainewithpersistentneurologicalsigns糖尿病的急性并發(fā)癥DifferentialDiagnosisofStroke-LikeSymptomsMetabolicDifferentialHyperglycemia(nonketotichyperosmolarcoma)HypoglycemiaDrug/narcoticoverdoseWithdrawalHypoxia糖尿病的急性并發(fā)癥BloodVesselsintheBrain糖尿病的急性并發(fā)癥DMchroniccomplication--

MacrovascularDiseaseCoronaryHeartDiseaseCerebrovascularDiseasePeripheralVascularDiseaseHypertensionDyslipidemiaSmokingFamilyhistoryHyperglycemia糖尿病的急性并發(fā)癥PreventionofMacrovascularDiseaseWeightreductionExerciseImprovelipidprofileSmokingcessationTreatHypertensionControlglycemiaDailysalicylatetherapy糖尿病的急性并發(fā)癥糖尿病的急性并發(fā)癥CVARiskfactors:NonmodifiableAgeMalesexRaceHeredityModifiableHypertensionDiabetesHeartdiseaseHyperlipidemiaSmokingExcessAlcoholOralcontraceptivesHypercoagulability.糖尿病的急性并發(fā)癥

Hyperosmolarnon-ketoticcomaindiabetic

strokepatients.

ActaMedicaScandinavica.212(6):407-11,1982.糖尿病的急性并發(fā)癥610episodesofdiabeticketoacidosis(pH,7.30orlower)orhyperosmolar

coma(osmolality>350mOsmol/kgmortalityrate:6.2%4.9%ofdiabeticketoacidosisand14.6%ofhyperosmolarcomabacterialpneumonia(12),aspirationpneumonia(2),mesentericandiliacthromboses(6cases),myocardialinfarction(8cases)andcerebralhaemorrhage(2cases)Mortalityinpatientswithhyperosmolarcomadidnotrelatetoage,initialblood-glucoselevelorosmolality.Eightofthe12hyperosmolar-coma-associateddeathsoccurredinnewlyrecognizeddiabeticpatientsinwhomtherewereavoidabledelaysindiagnosisimprovementsinoutcome--earlierdiagnosisofdiabetesandtheearlierrecognitionandtreatmentofassociatedacutepulmonaryandvascularcomplications.糖尿病的急性并發(fā)癥

Courseandprognosisof132patientswithdiabeticnonketotic

hyperosmolarstate.

DiabeteetMetabolisme.20(1):43-8,1994Jan-Feb.

糖尿病的急性并發(fā)癥osmolaritywasthemostinfluentialvariableinboththelevelofconsciousnessandtheadmissionlevelofdehydration

Twentytwopatientsdied(16.9%)

Septicshockwasthemostfrequentcauseofdeath(31%)andmortalitywashigherinpatientswithcardiovasculardisease(acutemyocardialinfarctionorstroke)astheprecipitatingfactorfordiabetichyperosmolarstate糖尿病的急性并發(fā)癥Olderage,lowbloodpressure,lowsodium,pHandbicarbonateplasmalevels,andhighureaplasmalevelswererelatedtomortalityInmultipleregressionanalysis,ureawasthemostinfluentialmortalityriskfactoritisnotthehyperosmolarityitself,butthehemodynamicalstateofthepatients,whichisthemostinfluentialfactorontheprognosisofadiabetichyperosmolarstate糖尿病的急性并發(fā)癥Deathsassociatedwithdiabeticketoacidosisand

hyperosmolarcoma.1973-1988

MedicalJournalofAustralia.151(8):439,441-2,444,1989Oct16.

糖尿病的急性并發(fā)癥Causeofdeath--extensivethrombusformationincerebralarteriesandmultipleembolitothelungsenhancedendogenousglucoseproductionandreducedrenalclearanceofglucosemaycontributetoprecipitatehyperosmolarnon-ketoticcomainDMstrokepatientsAclosemonitoringoffluidanddextroseadministrationseemsmandatoryindiabeticstrokepatients,inparticularifrenalfunctionisimpairedorifdiureticsaregivenInsulintreatmentshouldbeconsideredinalldiabeticpatientsduringthefirstdaysafterastroke糖尿病的急性并發(fā)癥Low-dosedopaminetreatmentofpatientsinnonketotic

hyperosmolar

hyperglycemic

coma.[Japanese]

NeurologiaMedico-Chirurgica.29(10):890-4,1989Oct.

糖尿病的急性并發(fā)癥mortalityofNKHSisreportedlyveryhigh

duetoacuterenaland/orcardiacfailure.low-dosedopamine(1to5micrograms/kg/min)therapyThetotalnetintakevolumeforthenormalizationofserumosmolaritywassmallandthedurationoftreatmentwasmuchshorternotassociatedwithcomplications,suchasaggravationofcerebraledema,renalfailure,orcardiacfailureresultsinbeta-effectofcatecholamine,sodiumdiuresis,andincreasedrenalbloodflow,isapracticalmeansofmanagingacuteneurosurgicalcasescomplicatedbyNHC糖尿病的急性并發(fā)癥Braincatecholamineconcentrationsinhyperosmolardiabetic

anddiabeticrats

DiabetesResearch.19(1):1-7,1992Jan糖尿病的急性并發(fā)癥Diabeteswasinducedwithstreptozotocinhyperosmolarity

deprivationofwaterfor50hoursDopamine,norepinephrineandepinephrineconcentrationsweremeasuredintheleftcerebralcortex,hypothalamic-thalamicarea,cerebellumandmedullaoblongataDopamineandnorepinephrineconcentrationsweresignificantlyelevatedinthecerebralcortex,hypothalamic-thalamicareaandcerebellumofthedehydratedhyperosmolar-diabeticratsrelativetothoseofnormalcontrolschangesinbraincatecholaminesmaybeinvolvedinthenervoussystemdisturbancesthatoccurinthedehydratedhyperosmolar-diabetesandseverediabetes糖尿病的急性并發(fā)癥

Prognosticfactorsofhyperglycemic

hyperosmolar

nonketoticstate.

ChangGungMedicalJournal.24(6):345-51,2001Jun.

糖尿病的急性并發(fā)癥KaohsiungVeteransGeneralHospital(1992to1998),119patientsfulfillingthecriteriaofHHNKmeanagewas67.8+/-11.7yearswithmalepredominanceTwenty-ninepatientsdiedwhichproducedafatalityrateof24.4%

Eighty-six(72.3%)casesoccurredinpatientswithknowndiabetichistory,whileanotherthirty-three(27.7%)occurredinpatientswithnodiabetichistoryTheleadingprecipitatingfactor–infection(57.1%),

poorcomplianceofmedication(21.0%)undiagnoseddiabetes(10.9%)Fiftypatients(42%)hadahistoryofstroke

糖尿病的急性并發(fā)癥TheriskfactorsfordeathincludedprecipitationofHHNKbyinfectionandlowGlasgowcomascale(GCS)onadmissionOldageitselfdidnotcontributetodeath.SeverityofhyperglycemiaorhyperosmolaritywasalsonotanimportantprognosticfactorlowGCSonadmissionwasthemostinfluentialfactorofleadingtodeathNeitheragenorosmolarity,butunderlyingprecipitatingfactorsandstateofconsciousnesswerethemostinfluentialfactorsaffectingtheprognosisofHHNK.糖尿病的急性并發(fā)癥SulfonylureaDrugsDoNotInfluenceInitialStrokeSeverityandIn-HospitalOutcomeinStrokePatientsWithDiabetes

Stroke.2001;32:2029

糖尿病的急性并發(fā)癥BackgroundandPurposeSulfonylureadrugsinhibitATP-dependentpotassiumchannelsandmayincreasemortalityaftermyocardialinfarction.Sulfonylureadrugsalsoinhibitischemicpreconditioninginexperimentalmodelsofbrainischemiaandinclinicalstudiesinthehumanheart.糖尿病的急性并發(fā)癥Methodstheimpactofsulfonylureadrugsonin-hospitalmortalityandtheimmediateneurologicaldeficitofdiabeticstrokepatients.146diabeticpatientswithacutehemisphericischemicstroke.Sixtypatientswereusingsulfonylureadrugs糖尿病的急性并發(fā)癥ResultsMajorbaselinecharacteristicssuchasage,bloodpressure,admissionglucoselevel,HbA1c,distributionofcardiovascularriskfactors,andpresumedstrokeetiologywerenotdifferent.Mortality(15%versus14%;P=0.86)andinitialstrokeseveritywerenotsignificantlydifferentbetweenpatientswithandwithoutsulfonylureadrugs.FurtherendpointssuchasRankinScalescore,deterioratingstroke,durationofhospitalstay,typeofinfarctsonCT/MRI,requirementofintensivecare,andcomplicationswerenotdifferent.Inastepwiselogisticregressionmodel,sulfonylureadrugswerenotindependentpredictorsforincreasedmortality,deterioratingstroke,orstrokeseverity.糖尿病的急性并發(fā)癥Effectsofadmissionhyperglycemiaonmortalityandcostsinacuteischemia

Neurology,59(1)67-71,2002,Jul

糖尿病的急性并發(fā)癥Hyperglycemiapatientshadlongerhospitalstay(7vs6days),higherinpatienthospitalchargesHyperglycemiaindependentlyincreasedtheriskfordeathat30days,1year,and6yearsafterstrokeIntensivetreatmentofhyperglycemiashouldbeconsidered糖尿病的急性并發(fā)癥Reducingtheriskofstrokeindiabetes:whathavewelearnedthatisnew?

Diabetes,Obesity,metabolism4suppl,S27~34,2002Jan糖尿病的急性并發(fā)癥AntihypertensiveACEIRamipril(HOPE)LipidloweringtherapyAntiplatelettherapy糖尿病的急性并發(fā)癥糖尿病的急性并發(fā)癥EffectofRamiprilonCVEventsinPatientsWithDiabetes0510152025CVeventsCVdeathMIStrokePatients(%)19.815.39.76.212.910.26.14.2PrimaryendpointPlacebo(n=1770)Ramipril(n=1808)糖尿病的急性并發(fā)癥Abenefit-riskassessmentofagentsusedinthesecondarypreventionofstroke

Drugsafety:25(13),943~63糖尿病的急性并發(fā)癥AntiplateletAspirin,aspirin+Dipyridamole,ticlopidine,clopidogrelAnticoagulantWarfarincoexistinggatrialfibrillationAntihypertensiveACEILipidloweringagentStatinPharmacologicagentsforsmokingcessationOHA/insulin糖尿病的急性并發(fā)癥Diabetes

mellitusandstroke

ItalianHeartJournal:OfficialJournaloftheItalianFederationof

Cardiology.3(5Suppl):471-7,2002May糖尿病的急性并發(fā)癥Severalstudies(Framingham,CopenhagenStrokeStudy,NorthernSwedenMONICA,NHANES)showedahigherprevalence,recurrencerateandworseprognosisofstrokeindiabeticsubjectsthepathogeneticroleofacutehyperglycemiaasadirectneuronaldamagemediatorandnegativeprognosticmarker糖尿病的急性并發(fā)癥Theinfluenceofdiabetes

mellitusand

hyperglycaemiaonstrokeincidenceandoutcome.

JournalofClinicalNeuroscience.9(6):618-26,2002Nov.

糖尿病的急性并發(fā)癥Theincidenceandseverityofischaemicstrokeareincreasedbythepresenceofdiabetes,andoutcomefromstrokeispoorerMorethanonethirdofpatientsadmittedwithacutestrokearehyperglycaemicReasonsforthealteredprogn