Hyperosmolar coma: ua, cov tsos mob, mob, kev kho mob

Hyperosmolar coma yog feem ntau paub hais tias nyob rau hauv cov neeg mob laus tshaj 50 xyoo uas raug kev txom nyem los ntawm cov ntshav qab zib rau me me mus rau mob loj tsawv degree, yog yooj yim compensated los ntawm tshwj xeeb kev noj haus thiab cov tshuaj. Degridratatsii npaj tiv thaiv lub keeb kwm ntawm lub cev raws li ib tug tshwm sim uas tau txais ib tug diuretic, vascular cov kab mob ntawm lub paj hlwb thiab ob lub raum. Lub neej no los ntawm hyperosmolar coma nce mus txog 30% lawm.

yog vim li cas

Hyperosmolar coma, cov ua uas yog txuam nrog rau cov theem ntawm qab zib, yog ib tug mob mob ntshav qab zib thiab yog cov kev tshwm sim ntawm ib tug ntse sawv nyob rau hauv cov ntshav qab zib (ntau tshaj 55,5 mmol / L) ua ke nrog hyperosmotic thiab tsis muaj kev acetone nyob rau hauv cov ntshav.

Yog vim li cas rau qhov no tshwm sim yog:

• ntse lub cev qhuav dej resulting nyob rau hauv tsausmuag ntuav, raws plab, kub nyhiab los yog thaum lub sij hawm heev kev kho mob los ntawm kev siv ntawm diuretic tshuaj;
• tsis muaj peev xwm los yog ua kom tiav tsis muaj insulin, ob qho tib si endogenous thiab exogenous (yog vim li cas rau qhov no tshwm sim tej zaum yuav tsis muaj cov insulin los yog kev kho mob regimen);
• nce coob rau insulin, uas muaj peev xwm ua tau los ntawm tag nrho cov teeb noj cov zaub mov, koom haum saib xyuas feeb meej npaj qabzib, ntawm kis kab mob (tshwj xeeb tshaj yog mob ntsws muaj dej thiab kab mob txeeb zig txhab) tom qab phais, kev raug mob, noj tshuaj, uas muaj lub thaj chaw ntawm insulin antagonists ( nyob rau hauv particular, glyukokorstikoidov thiab npaj ntawm kev sib deev cov tshuaj hormones).

pathogenesis

Tu siab, lub mechanism ntawm kev loj hlob ntawm tus kab mob xeev yog tsis qoos taub. Nws yog ntseeg hais tias cov kev loj hlob ntawm no yam tab kaum muaj feem xyuam rau blockade glucose tso tawm los ntawm ob lub raum, thiab muaj zog me nyuam ntawm cov tshuaj yeeb dej caw hauv lub cev thiab nws cov los ntawm lub siab. Thaum zoo li no tso zis yog suppressed los ntawm insulin, raws li zoo raws li thaiv cov hlab qhov siv ntawm zib los ntawm peripheral ntaub so ntswg. Qhov no yog tag nrho cov chav uas muaj lub cev qhuav dej.

Nyob rau hauv tas li ntawd, nws yog ntseeg hais tias cov muaj nyob rau hauv tus tib neeg lub endogenous (tsim sab hauv lub cev) insulin cheeb dab xws li lipolysis (neej puas muaj roj) thiab ketogenesis (lub tsim ntawm tus kab hlwb). Txawm li cas los, qhov no insulin tsis txaus los suppress tus nqi ntawm cov piam thaj uas yog ua los ntawm lub siab. Nws yog yog li ntawd tsim nyog cov thawj coj ntawm exogenous insulin.

Yog hais tias sai poob kua nyob rau hauv loj nyiaj decreases BCC (ntshav ntim), uas ua rau yus thooj ntawm cov ntshav thiab ua rau kom lub osmolarity. Qhov no tshwm sim nws yog vim ib qho kev nce rau hauv lub concentration ntawm qab zib, poov tshuaj thiab sodium ions.

cov tsos mob

Hyperosmolar coma npaj, cov tsos mob ntawm uas tshwm sim nyob rau hauv ua ntej rau ib tug ob peb hnub los lub lis piam. Nyob rau hauv cov ntaub ntawv no, tus neeg mob loj hlob tej yam tshwm sim uas yog cov yam ntxwv ntawm decompensated ntshav qab zib (cov ntshav qab zib ntau ntau yuav tsis tau tom yeeb siv tshuaj):

• polyuria (nce tso zis tsim);
• nce nqhis dej;
• nce dryness ntawm daim tawv nqaij, txheej week;
• cia li poob;
• qhov tsis muaj zog;
• Nws yog ib qho tsim nyog tau lub cev qhuav dej deteriorating noj qab haus huv: txo cov laus ntawm daim tawv nqaij, eyeballs, cov ntshav siab thiab kub.

neurological cov tsos mob

Nyob rau hauv tas li ntawd, cov tsos mob tej zaum yuav muaj cai nyob rau hauv lub paj hlwb:

• hallucinations;
• hemiparesis (weakening ntawm kev yeem taw);
• hais lus ntshawv siab, nws yog muab slurred;
• pheej qaug dab peg;
• areflexia (reflexes tsis tuaj kawm ntawv ntawm ib tug los yog ntau tshaj) los yog giperlefksiya (nce reflexes);
• nqaij sab;
• impaired nco qab.

Cov tsos mob yuav tshwm sim li ob peb hnub ua ntej nws yuav pib tsim hyperosmolar coma nyob rau hauv cov me nyuam los yog cov neeg laus.

tau teeb meem

Nyob rau hauv cov ntaub ntawv ntawm untimely pab tej zaum yuav tsim teeb meem. Common yog:

• qaug dab peg, uas tej zaum yuav tsum tau nrog los ntawm laim muag daj, lub ntsej muag (cov tsos mob no tej zaum yuav pom tsis tau lwm tus neeg);
• sib sib zog nqus cov hlab ntsha thrombosis;
• pancreatitis (o ntawm lub pancreas);
• raum insufficiency.

Cov kev hloov tseem tshwm sim nyob rau hauv lub mob huam, uas yuav tshwm sim ntuav, tsam plab, mob plab, impaired plab hnyuv kom (tej zaum kuj yog cov hnyuv rhuav txhua), tab sis lawv tej zaum yuav zoo unnoticeable.

Tsis tas li ntawd, muaj vestibular ntshawv siab.

diagnostics

Yog hais tias koj xav tias ib tug mob ntawm hyperosmolar coma, mob yog raws li nyob rau hauv laboratory kev ntsuam xyuas. Nyob rau hauv kev, txoj kev tshawb nrhiav tau ib theem siab ntawm cov ntshav piam thaj thiab osmolarity. Nyob rau hauv tas li ntawd, tau kom ntau ntau cov sodium, siab cov ntsiab lus ntawm tag nrho cov ntshiab protein thiab residual nitrogen. urea theem yuav tau muab ntau zog. Nyob rau hauv qhov kev tshawb nrhiav ntawm cov zis ketone lub cev (acetone, acetoacetic acid thiab betaoksimaslyanaya) nws tsis yog txiav txim.

Nyob rau hauv tas li ntawd, muaj yog tsis muaj tsw ntawm acetone nyob rau hauv cov huab cua exhaled los ntawm tus neeg mob thiab ketoacidosis (disturbance ntawm carbohydrate metabolism) uas hais giperoglikemiey thiab cov ntshav osmolarity. Tus neeg mob yog tam sim no neurological cov tsos mob, xws li kev txawv txav Babinski (Khiav extension reflex), muaj zog nqaij laus, ob sab sib dho nystagmus (tsis tuaj yeem oscillatory zog ntawm lub qhov muag).

sawv tawm ntawm lwm cov kev tshawb fawb:

• Ultrasound thiab X-ray kev soj ntsuam ntawm lub pancreas;
• electrocardiography;
• kev txiav txim theem ntawm qab zib nyob rau hauv cov ntshav.

Ntawm kev tseem ceeb yog lub differential mob. Qhov no yog vim lub fact tias gipersmolyarnaya coma tej zaum yuav tshwm sim tsis tau tsuas yog mob ntshav qab zib tab sis kuj thiab hepatic raum insufficiency raug txais thiazide diuretics.

kev kho mob

Yog hais tias paub hais tias hyperosmolar coma, thaum muaj xwm ceev kho mob yog mus tshem tawm degidrotatsii, hypovolemia thiab restore ntshav osmolarity.

Yuav kom tshwj kom txhob co kab siv hypotonic tov ntawm sodium tshuaj dawb. Tswv yim los ntawm 6 mus rau 10 liv ib hnub twg. Yog hais tias tsim nyog tus nqi ntawm cov tshuaj yuav tsub kom. Tsis pub dhau ob xuaj moos tom qab qhov pib ntawm ib tug pathological mob yuav tsum tau ua kom paub 2 liv ntawm sodium tshuaj dawb tov i.v., ua raws li los ntawm cov kev taw qhia ntawm mob kis ntawm ib tus nqi ntawm 1 l / h. Cov kev ntsuas coj mus txog rau normalization osmolarity thiab cov ntshav siab nyob rau hauv lub venous hlab ntsha. Ib tug kos npe rau ntawm lub cev qhuav dej yog mus tshem tawm cov tsos ntawm cov neeg mob pem.

Yog hais tias paub hais tias hyperosmolar coma, kev kho mob yuav tsum tau ib tug yuav txo tau giperoglikemii. Rau lub hom phiaj no, intramuscularly thiab intravenously muab insulin. Nws yuav tsum tau nqa tawm nruj tswj ntawm cov ntshav qab zib concentration. Thawj koob tshuaj yog 50 units, uas yog muab faib nyob rau hauv ib nrab thiab nkag tau rau hauv lub cev nyob rau hauv ntau txoj kev. Nyob rau hauv cov ntaub ntawv ntawm hypotension thawj coj txoj kev tsuas intravenously. Ntxiv mus, insulin yog muab nyob rau hauv tus nqi qub nrog intravenously thiab intramuscularly. Cov kev ntsuas yog nqa tawm kom txog thaum lub theem ntawm qab zib 14 mmol / l.

Scheme ntawm koom haum saib xyuas ntawm insulin tej zaum yuav sib txawv:

• ib tug ib-lub sij hawm 20 IU intramuscularly;
• 5-8 U txhua txhua 60 feeb.

Nyob rau hauv cov kev tshwm sim hais tias cov piam thaj tshem tawm mus rau 13,88 mmol / l, hypotonic tov ntawm sodium tshuaj dawb tsim nyog yuav hloov tau lub zib tov.

Thaum lub sij hawm kev kho mob hyperosmolar coma yuav tsum tau tas li xyuas ntawm cov ntshav potassium, txij li thaum tshem tawm ntawm lub pathological mob yuav tsum tau muab poov tshuaj tshuaj dawb.

Rau lub hom phiaj ntawm kev tiv thaiv ntawm lub hlwb edema uas ua los ntawm hypoxia cov neeg mob intravenously muab glutamic acid nyob rau hauv ib tug npaum li ntawm 50 ml. Tsis tas li ntawd tau txais heparin yog yuav tsum tau, vim hais tias cov kev pheej hmoo ntawm thrombosis nce dramatically. Qhov no yuav tsum tau cov kev tswj ntawm cov ntshav txhaws.

Raws li ib tug txoj cai, hyperosmolar coma muaj nyob rau hauv cov neeg mob uas me me los yog muaj mob loj tsawv theem ntawm cov ntshav qab zib, ces peb yuav xyuam xim hais tias lub cev perceives cov insulin zoo. Yog li ntawd, nws yog pom zoo rau txhaj koob tshuaj me me ntawm cov tshuaj.

Profilatika teeb meem

Nyob rau hauv cov kev tiv thaiv ntawm kev xav tau, thiab cov hlab plawv system, uas yog, tus tiv thaiv ntawm tus kab mob plawv. Nrog lub hom phiaj no yog ib tug "Kordiamin", "Strofantin", "Korglikon". Nyob rau hauv luv siab uas yog ntawm qhov theem, nws yog pom zoo kom koom haum saib xyuas Dox tshuaj, thiab tso dej ntshav gemodeza, tib neeg albumin thiab tag nrho cov ntshav.

Faj seeb ...

Yog hais tias koj muaj ib tug mob ntawm cov ntshav qab zib yuav tsum lossi dhau soj ntsuam nyob rau endocrinologist thiab ua raws li tag nrho nws cov uas yuav tsum tau, nyob rau hauv particular, los tswj cov ntshav qab zib. Qhov no yuav tsis txhob muaj cov teeb meem ntawm tus kab mob.