2022ISPAD指南:糖尿病酮症酸中毒和高血糖高渗状态:更新和执行摘要

指南共识 l 2022ISPAD指南:糖尿病酮症酸中毒和高血糖高渗状态:更新和执行摘要**


指南共识 l 2022 l ISPAD
糖尿病酮症酸中毒和高血糖高渗状态
临床实践共识指南
更新和执行摘要
 
1 | 新信息或不同点概述

1 | SUMMARY OF WHAT IS NEW OR DIFFERENT

对以往推荐的更改包括:

Changes to previous recommendations include:

  • 诊断糖尿病酮症酸中毒(DKA)的生化标准纳入血清碳酸氢盐< 18 mmol/L

    Biochemical criteria to diagnose diabetic ketoacidosis (DKA) include serum bicarbonate <18 mmol/L

  • 在20–30分钟内输注初始液体大剂量

    Infusion of initial fluid bolus(es) over 20–30 min

  • 不再认为有必要在DKA治疗期间促进血清钠浓度升高

    Promoting a rise in serum sodium concentrations during DKA treatment is no longer considered necessary

  • 与标准DKA治疗相比,更加强调HHS治疗建议以及DKA和HHS(高渗性DKA)的混合表现的差异

    Increased emphasis on differences in treatment recommendation for HHS and mixed presentation of DKA and HHS (hyperosmolar DKA) compared to standard DKA treatment
2 | 执行摘要

2 | EXECUTIVE SUMMARY

诊断DKA的生化标准是:

The biochemical criteria for the diagnosis of DKA are:

  • 高血糖(血糖> 11 mmol/L [≈200 mg/dl])

    Hyperglycemia (blood glucose >11 mmol/L [≈200 mg/dl])

  • 静脉pH <7.3或血清碳酸氢盐< 18 mmol/L(C)

    Venous pH <7.3 or serum bicarbonate <18 mmol/L(C)

  • 酮血症(血β-羟丁酸≥3 mmol/L) (C)或中量或大量酮尿。

    Ketonemia (blood ß-hydroxybuyrate ≥3 mmol/L) (C) or moderate or large ketonuria.
在诊断为DKA时,并非所有儿童或看护人会提供糖尿病的典型症状(多尿、烦渴),DKA的其他症状不具有特异性。因此,对于所有表现为呼吸急促或伴有呕吐和腹痛但无腹泻的儿童,应考虑进行指血血糖检测。

Not all children or caregivers volunteer classic symptoms of diabetes (polyuria, polydipsia) at the time of diagnosis of DKA, and other symptoms of DKA are non-specific. Therefore, fingerstick blood glu-cose measurements should be considered for all children presenting with rapid breathing or with vomiting and abdominal pain without diarrhea.

以下建议基于现有证据,旨在作为DKA管理的一般指南。由于DKA表现存在相当大的个体差异(从轻度到重度危和及生命不等),一些儿童可能需要特定治疗,这需要主治医生的判断,而这些治疗可能偶尔不在此处介绍的范围内。应使用临床判断来确定针对每个儿童的最佳治疗方案,并且应根据对治疗反应的持续临床和生化监测来及时调整治疗方案。

The following recommendations are based on currently available evidence and are intended to be a general guide to DKA management. Because there is considerable individual variability in presentation of DKA (ranging from mild to severe and life threatening), some children may require specific treatment that, in the judgment of the treating physician, may occasionally be outside the range of options presented here. Clinical judgment should be used to determine optimal treat-ment for the individual child, and timely adjustments to treatment should be based on ongoing clinical and biochemical monitoring of the response to treatment.

急诊评估:应遵循儿科高级生命支持(PALS/ Pediatric Advanced Life Support)的一般指南,包括:

Emergency assessment should follow the general guidelines for Pediatric Advanced Life Support(PALS) and includes:

  • 立即检测血糖、血液或尿酮、血清电解质和血气;以及意识水平评估。(E)

    Immediate mea-surement of blood glucose, blood or urine ketones, serum electrolytes and blood gases assessment of level of consciousness. (E)

  • 建立静脉通道:两条外周静脉(IV)导管(E)。

  • Two peripheral intravenous (IV) catheters should be inserted (E)
管理实施:管理应在对DKA儿童治疗有经验的中心进行,在该中心应可经常监测生命体征、神经系统状态和实验室结果(E)。如果地理限制要求在经验较少的中心开始管理,应由在DKA具有专业知识的医生提供电话或视频会议支持(E)。

Management should be conducted in a center experienced in the treatment of DKA in children and where vital signs, neurologi-cal status, and laboratory results can be monitored frequently.(E) Where geographic constraints require that management be initi-ated in a center with less experience, there should be telephone or videoconference support from a physician with expertise in DKA (E).

仔细监测:有必要对治疗的临床和生化反应进行仔细监测,以便在临床或实验室数据表明需要时及时调整治疗(E)。

Meticulous monitoring of the clinical and biochemical response to treatment is necessary so that timely adjustments in treatment can be made when indicated by clinical or laboratory data (E).

治疗目标:是纠正脱水、纠正酸中毒和逆转酮症,逐渐纠正高渗性和血糖浓度至接近正常,监测急性并发症,识别和治疗任何诱发事件。

Goals of therapy are to correct dehydration, correct acidosis and reverse ketosis, gradually restore hyperosmolality and blood glucose concentration to near normal, monitor for acute complications, and identify and treat any precipitating event.

补液:应在开始胰岛素治疗前开始补液。在20–30min内使用一剂或多剂0.9%盐水扩张容量,以恢复外周循环(E)。计算液体给药(0.45%-0.9%盐水)的后续速率,包括提供维持所需液体,旨在24-48小时期间替代估计液体不足(A)。

Fluid replacement should begin before starting insulin therapy. Expand volume using one or more boluses of 0.9% saline infused over 20–30 min to restore peripheral circulation (E). Calculate the subse-quent rate of fluid administration (0.45% to 0.9% saline), including the provision of maintenance fluid requirements, aiming to replace the estimated fluid deficit over 24 to 48 h (A).

胰岛素治疗:从0.05–0.1 U/kg/h(pH > 7.15时可考虑0.05 U/kg/h)起始,至少在补液治疗后1 h开始 (B)。

Insulin therapy: begin with 0.05–0.1 U/kg/h (0.05 U/kg/h can be considered with pH > 7.15) at least 1 h AFTER starting fluid replace-ment therapy (B).

钾:如果患儿有高钾血症(钾> 5.5 mmol/L),推迟钾替代治疗,直至记录到尿排出量。开始使用不含钾的液体进行静脉输液治疗,并每小时检测一次钾含量。当钾< 5.5 mmol/L时开始输注钾。在罕见的低钾血症儿童(钾< 3.0 mmol/L)中,推迟胰岛素治疗并给予一次钾快速输注(不超过0.5 mEq/Kg/h),同时进行心脏监测。其他情况,从40 mmol钾/L (E)开始。

Potassium: If the child has hyperkalemia (potassium >5.5 mmol/L), defer potassium replacement therapy until urine out-put is documented. Begin intravenous fluid treatment with non-potassium containing fluids and measure potassium hourly. Begin potassium infusion when potassium <5.5 mmol/L. In the rare child with hypokalemia (potassium <3.0 mmol/L), defer insulin treatment and give a bolus of potassium (not to exceed 0.5 mEq/Kg/h), along with cardiac monitoring. Otherwise, begin with 40 mmol potas-sium/L (E).

碳酸氢盐:除治疗危及生命的高钾血症或严重酸中毒(静脉pH < 6.9)并有证据表明心脏收缩力受损外,其他情况不建议服用碳酸氢盐(C)。

Bicarbonate administration is not recommended except for treat-ment of life-threatening hyperkalemia or for severe acidosis (venous pH < 6.9) with evidence of compromised cardiac contractility (C).

脑损伤的警戒信号和症状包括:开始治疗后出现头痛或呕吐,或头痛进行性恶化或严重,心率减慢与睡眠无关,或血管内容量改善,神经系统状态改变(烦躁、嗜睡、意识模糊、失禁),特定神经系统体征(如颅神经麻痹),血氧饱和度降低(C)。高血压常见于DKA患儿,在没有其他发现的情况下,不应将其视为脑损伤的警告信号。

Warning signs and symptoms of cerebral injury include: Onset of headache or vomiting after beginning treatment or progressively worsening or severe headache, slowing of heart rate not related to sleep or improved intravascular volume, change in neurological status (irritability, lethargy, confusion, incontinence), specific neurological signs (e.g., cranial nerve palsies), decreased oxygen saturation.(C) Hypertension occurs commonly in children with DKA and should not be considered a warning sign for cerebral injury, in the absence of other findings.

对于有多种脑损伤危险因素的儿童:包括血清尿素氮浓度升高(> 20 mg/dl)、严重酸中毒(pH < 7.1)、严重低二氧化碳血症(pCO2 < 21 mmHg)、年龄< 5岁等,应床旁使用甘露醇或高渗盐水,并计算剂量(E)。如果神经功能状态急性恶化,应立即给予甘露醇或高渗盐水高渗治疗(C)。

In children with multiple risk factors for cerebral injury (elevated serum urea nitrogen concentration (>20 mg/dl), severe acidosis (pH < 7.1), severe hypocapnia (pCO2 < 21 mmHg), age < 5 years), have mannitol or hypertonic saline at the bedside and the dose calcu-lated. (E) If neurologic status deteriorates acutely, hyperosmolar ther-apy with mannitol or hypertonic saline should be given immediately (C).

预防:在未识别和治疗病因之前,DKA的管理就未完成。

Prevention: Management of DKA is not complete until an attempt has been made to identify and treat the cause.

  • 在已知糖尿病无既往疾病的儿童中,DKA几乎总是未能适当地进行胰岛素注射或中断胰岛素输送的结果,最常见的原因是胰岛素泵输入装置功能障碍。

    DKA without a preceding illness in a child with known diabetes is almost always the result of failure to appropriately administer insulin injections or inter-ruption of insulin delivery, most often as a result of insulin pump infu-sion set dysfunction. In new onset diabetes

  • 在新发糖尿病中,DKA常常是诊断延迟的结果(E)。

    DKA is frequently the consequence of a delay in diagnosis (E).
高血糖高渗状态(HHS)的标准包括以下所有内容:

The criteria for Hyperglycemic Hyperosmolar State (HHS) include all the following:

  • 血浆葡萄糖浓度> 33.3 mmol/L (600 mg/dl)

    Plasma glucose concentration > 33.3 mmol/L (600 mg/dl)

  • 静脉pH > 7.25动脉pH > 7.30

    Venous pH > 7.25; arterial pH > 7.30

  • 血清碳酸氢盐> 15 mmol/L

    Serum bicarbonate >15 mmol/L

  • 较轻的酮尿症,无至轻度酮血症

    Small ketonuria, absent to mild ketonemia

  • 有效血清渗透压> 320 mOsm/kg

    Effective serum osmolality >320 mOsm/kg

在HHS,初始液体治疗的目标是血管内和血管外扩容,恢复正常肾灌注,并促进校正后的血清钠浓度和血清渗透压逐渐下降。HHS和DKA在治疗策略上的差异包括给药液体量、胰岛素给药时间以及监测校正后血清钠浓度下降。

In HHS, the goals of initial fluid therapy are to expand the intra-and extravascular volume, restore normal renal perfusion, and pro-mote a gradual decline in corrected serum sodium concentration and serum osmolality. Differences in treatment strategy between HHS and DKA include the volume of fluid administered, the timing of insulin administration, and monitoring of the decline in corrected serum sodium concentration.

在HHS,一旦单独应用液体时血浆葡萄糖浓度降低至每小时低于3 mmol/L (50 mg/dl)时,起始胰岛素给药,以0.025-0.05 U/kg/h的剂量进行(C)。无论是作为恢复循环的初始液体快速输注还是作为持续的胰岛素替代,液体速率都应显著高于DKA。

In HHS, begin insulin administration at a dose of 0.025 to 0.05 U/kg/h once plasma glucose is decreasing less than 3 mmol/L (50 mg/dl) per hour with fluid alone (C). Rates of fluid administration, both as initial fluid boluses to restore circulation and as ongoing defi-cit replacement, are substantially higher than for DKA.

 

本文荟萃自,只做学术交流学习使用,不做为临床指导,本文观点不代表数字重症立场。

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