Enye yezinkinga ezimbi kakhulu kodwa ezingafundiswanga kahle sikashukela yi-hyperosmolar coma. Kusenempikiswano mayelana nemishini yemvelaphi yayo nentuthuko.
Lesi sifo asisona esibi, isimo sesifo sikashukela singaba sibi kakhulu emavikini amabili ngaphambi kokulimazeka kokuqala. Imvamisa, i-coma ivela kubantu abangaphezu kweminyaka engama-50. Odokotela abahlali bakwazi ukwenza ukuxilongwa okulungile ngokushesha ngaphandle kolwazi lokuthi isiguli sinesifo sikashukela.
Ngenxa yokungeniswa esibhedlela sekwedlule isikhathi, ubunzima bokuxilongwa, ukuthikamezeka kakhulu komzimba, i-hyperosmolar coma inezinga eliphezulu lokushona kwabantu lifinyelela ku-50%.
>> Isifo sikashukela sikashukela - Izinhlobo zayo nokunakekelwa okuphuthumayo nemiphumela.
Isifo sikashukela nokucindezela kuzoba yinto yesikhathi esedlule
- Ukwehlela ushukela -95%
- Ukuqedwa kwe-vein thrombosis - 70%
- Ukuqedwa kokushaya kwenhliziyo okuqinile -90%
- Ukuqeda umfutho wegazi ophakeme - 92%
- Ukwanda kwamandla ngesikhathi sosuku, ngcono ukulala ebusuku -97%
Kuyini i-hyperosmolar coma
I-hyperosmolar coma yisimo sokulahlekelwa ukwazi kanye nokulimazeka kuwo wonke amasistimu: ingqondo, umsebenzi wenhliziyo kanye nokuphela kokuqina, umchamo uyeka ukungachazwa. Umuntu ngalesi sikhathi empeleni ulinganisa emngceleni wokuphila nokufa. Imbangela yakho konke lokhu kuphazamiseka yi-hyperosmolarity yegazi, okuwukuthi, ukwanda okuqinile kobuningi bayo (ngaphezu kwe-330 mosmol / l ngesilinganiso sama-275-295).
Lolu hlobo lwe-coma lubonakala nge-glucose ephezulu yegazi, ngaphezulu kwama-33.3 mmol / L, nokuphelelwa ngamandla komzimba. Ngasikhathi sinye, i-ketoacidosis ayikho - izidumbu ze-ketone azitholakali emchini ngezivivinyo, ukuphefumula kwesiguli sikashukela asisho iphunga le-acetone.
Ngokusho kwesigaba samazwe omhlaba, i-hyperosmolar coma ihlukaniswa njengokuphula umthetho we-metabolic usawoti wamanzi, ikhodi ngokusho kwe-ICD-10 yi-E87.0.
Isimo sehyperosmolar siholela ekhefini kunakuqabukela; ekusetshenzisweni kwezokwelapha, kwenzeka isigameko esisodwa kweziguli ezingama-3300 ngonyaka. Ngokwezibalo, unyaka ojwayelekile wesiguli uneminyaka engama-54, ugula isifo sikashukela esinga-insulin-2, kepha akasilawuli isifo sakhe, ngenxa yalokho, unezinkinga eziningi, kufaka phakathi isifo sikashukela nephropathy esine-renal. Engxenyeni yesithathu yeziguli ekhubazekile, isifo sikashukela isikhathi eside, kodwa asitholakalanga futhi, ngenxa yalokho, asikaze siphathwe sonke lesi sikhathi.
Uma kuqhathaniswa ne-ketoacidotic coma, i-hyperosmolar coma yenzeka kaningi. Imvamisa, ukubonakaliswa kwayo noma kusesimweni esilula kuyamiswa yibo abanesifo sikashukela uqobo, benganakile kodwa - bakwenza ngendlela ejwayelekile ushukela wegazi, baqale ukuphuza kakhulu, futhi baphendukele ku-nephrologist ngenxa yezinkinga zezinso.
Izizathu zokuthuthuka
I-Hyperosmolar coma iba ku-mellitus yesifo sikashukela ngaphansi kwethonya lezinto ezilandelayo:
- Ukuphelelwa ngamandla emzimbeni ngenxa yokushiswa okukhulu, ukusetshenziswa ngokweqile noma kokusebenza isikhathi eside komzimba, ubuthi nokutheleleka kwamathumbu, okuhambisana nokugabha nohudo.
- Ukushoda kwe-insulin ngenxa yokungahambelani nokudla, ukuphuma njalo kwezidakamizwa ezonciphisa ushukela, izifo ezithikamezekayo noma ukuzikhandla ngokomzimba, ukwelashwa ngezidakamizwa ze-hormonal ezivimbela ukukhiqizwa kwe-insulin uqobo.
- Isifo sikashukela esingaziwa.
- Ukutheleleka kwezinso isikhathi eside ngaphandle kokwelashwa okufanele.
- IHemodialysis noma i-intravenous glucose lapho odokotela bengazi ngesifo sikashukela esigulini.
I-Pathogenesis
Ukuqala kwe-hyperosmolar coma kuhlala kuhambisana ne-hyperglycemia enzima. I-glucose ingena egazini ivela ekudleni futhi yakhiqizwa ngasikhathi sinye isibindi, ukungena kwayo izicubu kuyinkimbinkimbi ngenxa yokumelana ne-insulin. Kulokhu, i-ketoacidosis ayenzeki, futhi isizathu sokungatholakali okwamanje asikasungulwa kahle. Abanye abacwaningi bakholelwa ukuthi uhlobo lwe-hyperosmolar of coma luba khona lapho i-insulin yanele ukuvimba ukuwohloka kwamafutha nokwakheka kwezidumbu ze-ketone, kodwa kuncane kakhulu ukucindezela ukuwohloka kwe-glycogen esibindini ukuze yakhe ushukela. Ngokuya kwenye inguqulo, ukukhishwa kwama-acid aqukethe izicubu ze-adipose kuyacindezelwa ngenxa yokuntuleka kwama-hormone ekuqaleni kokuphazamiseka kwe-hyperosmolar - somatropin, cortisol ne-glucagon.
Izinguquko ezengeziwe ze-pathological eziholela ku-hyperosmolar coma ziyaziwa kakhulu. Ngokuqhubeka kwe-hyperglycemia, umthamo womchamo uyakhuphuka. Uma izinso zisebenza ngokujwayelekile, lapho-ke umkhawulo we-10 mmol / L udluliwe, ushukela uqala ukukhishwa emchameni. Ngomsebenzi wokuphazamiseka wezinso, le nqubo ayenzeki njalo, bese ushukela uqongelela egazini, futhi inani lomchamo likhuphuka ngenxa yokutholwa kokuphazamiseka okubuyela emuva ezinso, ukuqunjelwa komzimba kuqala. I-Liquid ishiya amaseli kanye nendawo phakathi kwawo, umthamo wegazi elijikelezayo uyancipha.
Ngenxa yokuphelelwa amandla kwamangqamuzana obuchopho, kuvela izimpawu ze-neurological; ukukhuphuka kwegazi coagulation kuvuselela i-thrombosis, kuholela ekunikezelweni kwegazi okunganele ezithweni. Ekuphenduleni ukuphuma komzimba, ukwakheka kwe-aldosterone ekhuphukayo, okuvimbela i-sodium ekufinyeleleni umchamo egazini, bese kuba ne-hypernatremia. Ube esekhipha umunyu kanye nokuvuvukala ebuchosheni - kuthi ukukhululeka.
Izimpawu Nezimpawu
Ukuthuthukiswa kwe-hyperosmolar coma kuthatha isonto elilodwa kuya kwamabili. Ukuqala koshintsho kubangelwa ukuwohloka kwesinxephezelo sikashukela, bese kuba nezimpawu zokuphelelwa amanzi emzimbeni. Okokugcina, kuvela izimpawu zemizwa nemiphumela ye-osmolarity ephezulu yegazi.
| Izimbangela zezimpawu | Ukuboniswa kwangaphandle okwedlule kwe-hyperosmolar coma |
| Isikweletu Sikashukela | Ukoma, ukuchama kaningi, owomile, isikhumba esikhanyayo, ukungakhululeki kulwelwesi lwama-mucous, ubuthakathaka, ukukhathala okungapheli. |
| Ukomisa | Ukwehla kwesisindo nokucindezela, izindebe ziqine, kubuye kube nomlomo owomile, isikhumba siphuzi futhi sipholile, ukuqina kwaso kuyalahleka - ngemuva kokungena esibayeni ngeminwe emibili, isikhumba sithukululwa kancane kancane kunokujwayelekile. |
| Ukulimazeka kobuchopho | Ubuthakathaka emaqenjini emisipha, kuze kufike okokukhubazeka, ukucindezelwa kwe-reflexes noma i-hyperreflexia, imihuzuko, ukukhishwa kwemizwa, ukubanjwa okufana nokuqaqanjelwa. Isiguli siyayeka ukuphendula imvelo, bese silahlekelwa ukwazi. |
| Ukwehluleka kwezinye izitho zomzimba | Ukuqunjelwa, i-arrhythmia, ukushaya ngamandla, ukuphefumula okungashonile. Ukukhishwa kwe-urine kuyehla bese kuyeka ngokuphelele. Ukushisa kungakhuphuka ngenxa yokuphulwa kwe-thermoregulation, ukushaya kwenhliziyo, imivimbo, ama-thromboses kungenzeka. |
Ngenxa yokuthi ukusebenza kwazo zonke izitho kuphulwa nge-hyperosmolar coma, lesi simo singavikeleka ngokuhlaselwa yisifo senhliziyo noma izimpawu ezifana nokukhula kwesifo esibi. I-encephalopathy eyinkimbinkimbi ingahle isolwe ngenxa ye-edema yamakhemikhali. Ukwenza ngokushesha ukuxilongwa okuyikho, udokotela kufanele azi ngesifo sikashukela emlandweni wesiguli noma ngesikhathi sokukuhlonza ngokuya ngokuhlaziywa.
Izindlela zokuxilonga ezidingekayo
Ukuxilongwa kusekelwe kwizimpawu, ukuxilongwa kwelabhoratri, kanye nesifo sikashukela. Naphezu kweqiniso lokuthi lesi simo sivame kakhulu kubantu asebekhulile abanesifo sohlobo 2, i-hyperosmolar coma ingakhula ngohlobo 1, kungakhathalekile ubudala.
Imvamisa, ukuhlolwa okuphelele kwegazi nomchamo kuyadingeka ukuthola ukuxilongwa:
| Ukuhlaziywa | Ukuphazamiseka kwe-Hyperosmolar | |
| Ushukela wegazi | Kukhuliswe kakhulu - kusuka ku-30 mmol / l kuya ezinombolweni ezikhudlwana, kwesinye isikhathi kuze kufike ku-110. | |
| I-Plasma osmolarity | Kunamandla ngokweqile okujwayelekile ngenxa ye-hyperglycemia, hypernatremia, ukwanda kwe-nitrogen kusuka ku-25 kuye kuma-90 mg%. | |
| IGlucose emchameni | Kuyatholwa uma ukwehluleka kakhulu kwe-reso engekho. | |
| Izidumbu zeKetone | Akutholakali ku-serum noma umchamo. | |
| Ama-electrolyte e-Plasma | i-sodium | Inani lenyuka uma ukomisa kakhulu sekuvele kuthuthukile; Kujwayelekile noma kwehle kancane esigabeni esiphakathi sokuphelelwa ngamandla, lapho uketshezi lushiya izicubu zingena egazini. |
| potaziyamu | Isimo sihlukile: lapho amanzi eshiya amangqamuzana, kwanele, khona-ke ukuntuleka kukhula - i-hypokalemia. | |
| Isibalo segazi esiphelele | IHemoglobin (Hb) ne-hematocrit (Ht) zivame ukuphakanyiswa, amaseli amhlophe egazi (i-WBC) angaphezulu kokujwayelekile uma kungekho zimpawu ezisobala zokutheleleka. | |
Ukuthola ukuthi inhliziyo ilimale kangakanani, nokuthi ingakwazi ukubekezelela ukuvuselelwa, kwenziwa i-ECG.
I-algorithm ephuthumayo
Uma isiguli sikashukela soma noma sesimweni esanele, into yokuqala okufanele siyenze ukubiza i-ambulensi. Ukunakekelwa okuphuthumayo kwe-hyperosmolar coma kunganikezwa kuphela ophikweni lokunakekela olunzulu. Lapho isiguli sihanjiswa ngokushesha, kuphakama nethuba lokusinda, izitho ezingaphansi zizolimala, futhi izokwazi ukululama ngokushesha.
Ngenkathi ulinde i-ambulensi oyidingayo:
- Beka isiguli eceleni kwakhe.
- Uma kunokwenzeka, bopha ukuze unciphise ukulahleka kokushisa.
- Gada ukuphefumula kanye ne-palpitations, uma kunesidingo, qala ukuphefumula kokufakelwa kanye nokuzivocavoca kwenhliziyo okungaqondile.
- Kala ushukela wegazi. Uma kwenzeka ukweqiwa okunamandla, juba i-insulin emfushane. Awukwazi ukufaka i-insulin uma ingekho i-glucometer futhi nedatha ye-glucose ayitholakali, lesi senzo singavusa ukufa kwesiguli uma ine-hypoglycemia.
- Uma kunethuba namakhono, faka i-dropper enosawoti. Izinga lokuphatha lehla ngomzuzwana.
Lapho isifo sikashukela singena ekunakekelweni okukhulu, uvivinya ngokushesha ukuthola ukuthi yisiphi isifo, uma kunesidingo, xhuma kwi-ventilator, ubuyisele ukuphuma komchamo, faka i-catheter emthanjeni wokulawulwa kwezidakamizwa isikhathi eside.
Isimo sesiguli siqashwa njalo:
- I-glucose ilinganiswa ngehora.
- Njalo emahoreni ayi-6 - amazinga e-potassium ne-sodium.
- Ukuvimbela i-ketoacidosis, imizimba ye-ketone kanye ne-acid acidity kuyabhekwa.
- Inani lomchamo okhishwe libalwa sonke isikhathi lapho ama-ruble afakiwe.
- Imvamisa hlola ukushaya ngamandla, ingcindezi kanye nokushisa.
Izinkomba eziphambili zokwelashwa ukubuyiselwa kwemali esele kasawoti-amanzi, ukuqedwa kwe-hyperglycemia, ukwelashwa kwezifo ezihlobene kanye nokuphazamiseka.
Ukulungiswa kokuphelelwa ngamanzi emzimbeni kanye nokwenza kabusha kwama-electrolyte
Ukubuyisela uketshezi emzimbeni, kwenziwa i-volumetric intravenous infusions - kuze kufike kumalitha ayi-10 ngosuku, ihora lokuqala - kuze kufike kumalitha ayi-1.5, khona-ke ivolumu yesisombululo esikhishwe ngehora incishiswa kancane kancane ibe amalitha angu-0,3-0,5.
Umuthi ukhethwa ngokuya ngezinkomba ze-sodium ezitholakala ngesikhathi sokuhlolwa kwelebhu:
| I-Sodium, meq / L | Isixazululo sokuvuselela amanzi emzimbeni | Ukuqondiswa% |
| Ngaphansi kuka-145 | I-Sodium Chloride | 0,9 |
| 145 kuya ku-165 | 0,45 | |
| Bangaphezu kuka-165 | Isixazululo se-glucose | 5 |
Ngokulungiswa kokuphelelwa ngamanzi emzimbeni, ngaphezu kokubuyisa ukugcinwa kwamanzi kumaseli, umthamo wegazi nawo uyakhuphuka, ngenkathi isimo se-hyperosmolar siqedwa futhi izinga likashukela wegazi liyancipha. Ukuvuselelwa komzimba kwenziwa ngokulawulwa okuphoqelekile kwe-glucose, ngoba ukwehla kwayo okubukhali kungaholela ekwehleni ngokushesha kwengcindezi noma i-edema yamakhemikhali.
Lapho kuvela umchamo, ukugcwaliswa kabusha kwezindawo zokugcina i-potassium emzimbeni kuqala. Imvamisa yi-potassium chloride, lapho ingekho khona ukwehluleka kwezinso - i-phosphate. Ukuhlushwa kanye nenani lokuphatha kukhethwa ngokuya ngemiphumela yokuhlolwa kwegazi okuvamisile kwe-potassium.
Hyperglycemia Ukulawula
I-glucose yegazi ilungiswa ukwelashwa kwe-insulin, i-insulin ilawulwa ngokusebenza okufushane, ngemithamo emincane, kahle ngokufakwa okuqhubekayo. Nge-hyperglycemia ephezulu kakhulu, ukujova okufakwa ngaphakathi kwe-hormone esilinganisweni esifinyelela kumayunithi angama-20 kwenziwa kuqala.
Ngokuphelelwa ngamandla, i-insulin ingahle isetshenziswe kuze kubuyiswe ibhalansi yamanzi, ushukela ngaleso sikhathi wehla ngokushesha okukhulu. Uma isifo sikashukela ne-hyperosmolar coma kuyinkimbinkimbi ngezifo ezihlangana, i-insulin ingadingeka ngaphezu kokujwayelekile.
Ukwethulwa kwe-insulin kulesi sigaba sokwelashwa akusho ukuthi isiguli kuzodingeka siguqule ekutholeni kwayo impilo yaso yonke. Imvamisa, ngemuva kokuqina kwesimo, uhlobo 2 sikashukela lunganxephezelwa ngokudla (ukudla uhlobo lwesifo sikashukela sesibili) nokudla izidakamizwa ezinciphisa ushukela.
Ukwelapha Ukuphazamiseka Okuhambelanayo
Kanye nokubuyiselwa kwe-osmolarity, ukulungiswa kokwephuka okuvele kwenzeka noma okusolwayo kuyenziwa:
- I-Hypercoagulation iyaqedwa futhi i-thrombosis ivinjelwe ngokuphatha i-heparin.
- Uma ukwehluleka kwezinso kukhulu, kwenziwa i-hemodialysis.
- Uma i-hyperosmolar coma icasulwa ukutheleleka kwezinso noma ezinye izitho, kunqunywa imithi elwa namagciwane.
- I-Glucocorticoids isetshenziswa njenge-anti-shock therapy.
- Ekupheleni kokwelashwa, amavithamini kanye namaminerali anqunyelwe ukuthi akwenzele ukulahleka kwawo.
Ongakulindela - isibikezeli
Ukuqashelwa kwe-hyperosmolar coma ikakhulu kuya ngesikhathi sokuqala ukunakekelwa kwezokwelapha. Ngokulashwa okufika ngesikhathi, ukwazi ukungasebenzi kahle kungavinjelwa noma kubuyiswe ngesikhathi. Ngenxa yokwelashwa okubambezelekile, ama-10% eziguli ezinalolu hlobo lwama-coma ayafa. Isizathu samacala abulalayo asele sithathwa njengokuguga, isifo sikashukela esingahlawulwanga isikhathi eside, “isixhaxu” sezifo ezinqwabelene ngalesi sikhathi - ukuhluleka kwenhliziyo nezinso, i-angiopathy.
Ukufa nge-hyperosmolar coma kwenzeka kaningi ngenxa ye-hypovolemia - ukwehla kwethamo legazi. Emzimbeni, kubangela ukungapheleli kwezitho zangaphakathi, ngokuyinhloko izitho ezinezinguquko ezivele zivele zenzeka. Futhi, i-edema yamakhorali kanye ne-thromboses enkulu ebulalayo ingaphetha ngokufa.
Uma ukwelashwa bekufika ngesikhathi futhi kusebenza ngempumelelo, isiguli sikashukela siphinda sazi, izimpawu zokwethisa ziyanyamalala, ushukela kanye ne-osmolality yegazi kuvamile. Ama-pathologies we-Neurological lapho eshiya i-coma angahlala ezinsukwini ezimbalwa kuya ezinyangeni ezimbalwa. Kwesinye isikhathi ukubuyiselwa okuphelele kwemisebenzi akwenzeki, ukukhubazeka, izinkinga zokukhuluma, ukuphazamiseka kwengqondo kungaqhubeka.
