..

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]

(mg/dl) [mmol/L]

pH 7,25 7,30 7,00 7,24 <7,00 >7,30

(mEq/L)
15 18 10 15 <10 >15

>320
(mOsm/kg)

>10 >12 >12

, , ,


(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 0.5-
1L 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)

iv
, :

1. pH > 7,3
2.

3. HCO3- > 18 mEq/L
4. 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. OEM, AEE .
3.
4. .
5.

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. :
1. Glu
2. 2. Na+
3. Ur Cr
3.
4.
WBC/Ht/Hb
5.


6. 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
-

>7 mmol /L (. <1)

2 :
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




 ..