※ 引述《guesttry (塵歸塵土歸土)》之銘言：
[恕刪]
: What is the fluid will be dripped next?
: 1. HS 125ml/hr D5W125ml/hr insulin 2u/hr
: 2. D5W 250ml/hr insulin 2u/hr
: 3. D5W (500ml+Jusomin (7%) 60ml) 250ml/hr insulin 2u/hr
: 4. D10W(500ml+Jusomin(7%) 60ml) 250ml/hr insulin 5u/hr
: 5. others?
: ------------------------------
: 我選4
: 1. 滿笨的.只想到Na不要降太快. 沒考慮到acidosis根本沒能控制
: 2. 只會管血糖,其他一概不管
: 3. fluid Na值約等於 NS. 有管到Na降很快的事實. 也管到病人越來越酸了
: 可是沒有管到為什麼越來越酸
: 4. 我覺得是標準作法
: 有沒有人覺得現在應該run更好的配方呢?

參考: The Washington Manual of Endocrinology Subspecialty Consult

1. Bicarbonate should not be routinely administered to patients in DKA unless
the serum pH is < 7.0 or the patient had life-threatening hyperkalemia

2. Do not decrease or discontinue the insulin infusion when glucose levels
approach the normal range.

3. Patient recovering from DKA may develop a transient non-anion gap
hyperchloremic metabolic acidosis that occurs due to urinary loss of
"potential bicarbonate" in the form of ketoanions and their replacement by
chloride ions from IV fluids. This non-anion-gap acidosis is transient and
has not been shown to be clinically significant except in renal failure.

治療DKA，要monitor"酸"，理論上，應該要看AG的變化....
題目少了Cl-, 因此，無從得知是怎麼酸法。
(舉例，若一開始直接打鹼，雖然pH會往正常跑，但只是把酸鹼狀態變成了
"mixed AG acidosis and metabolic alkalosis")

治療"酸"，大多都是治underlying，很少是直接補鹼的(paradoxical intracellular
acidosis)。

看起來，我會選擇half saline + KCl + RI + D5W....

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※ 編輯: Copper 來自: 140.112.5.84 (11/03 19:33)

> -------------------------------------------------------------------------- <

作者: yoli (靈魂穿上囚衣) 站內: medstudent
標題: Re: [心得] DKA with severe dehydration
時間: Mon Nov 6 18:43:42 2006

※ 引述《guesttry (塵歸塵土歸土)》之銘言：
: 25F type 1 DM 10 yr, poor control.55Kg 167cm
: Admitted to ER due to severe abdominal pain.
: No insulin use for 10 days was told.
: Blood gas revealed pH 7.2, PaO2:97 under room air. HCO3 was 10 BE:-15
: Blood ketone was 94mg/dL.One tough glucose was 348mg/dL. Na was 167,K was 3.9
: HR: 126/min NSR. Appearance: dehydrated
: Admitted to ICU
: Insulin pump with 100units/100ml half saline was infused at rates of 5ml/hr
: after 10units bolus
: one touch was checked per 2 hours. Na/K/ABG per 4 hours
: ------------------------------
: 2 hours later one touch was 160 and D5W was added at rate 250ml/hr for
: dehydration and severe hypernatremia
: At 4 hours: One touch was 124, Na: 149, K 3.5. Blood gas: 7.14. PaO2:80
: HCO3:12.
: Nasal canula 2L/min was given.
: What is the fluid will be dripped next?
: 1. HS 125ml/hr D5W125ml/hr insulin 2u/hr
: 2. D5W 250ml/hr insulin 2u/hr
: 3. D5W (500ml+Jusomin (7%) 60ml) 250ml/hr insulin 2u/hr
: 4. D10W(500ml+Jusomin(7%) 60ml) 250ml/hr insulin 5u/hr
: 5. others?
: ------------------------------
: 我選4
: 1. 滿笨的.只想到Na不要降太快. 沒考慮到acidosis根本沒能控制
: 2. 只會管血糖,其他一概不管
: 3. fluid Na值約等於 NS. 有管到Na降很快的事實. 也管到病人越來越酸了
: 可是沒有管到為什麼越來越酸
: 4. 我覺得是標準作法
: 有沒有人覺得現在應該run更好的配方呢?

DKA處理的principle，我是根據2004 ADA的guideline來處理的
請上pubmed找 "Hyperglycemic crises"相關的文章應該可以找到

簡單講幾個原則
1. Insulin要給到ABG已經不酸了，也就是ketoacidosis已經correct
如果glucose已經回到正常範圍，請用兩條以上的IV line
一條可調整insulin，一條keep sugar，或者給病人feeding

2.Sodium要特別注意，記得要先算出Corrected Na
病人來的時候可能測得的Na在normal range，但是correct後反而是hypernatremia
Na高的時候請用HNS

3.Potassium的補充應該不用講了吧
4.Bicarbonate的給予只有在severe acidosis: PH<7.0在給

針對你的問題，我的答案是A


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