病例报告:高渗透性高血糖状态治疗后的严重高钠血症:一种用于治疗高钠血症的实用方法

IF 0.1 Q4 ANESTHESIOLOGY Acta anaesthesiologica Belgica Pub Date : 2020-12-01 DOI:10.56126/71.4.5
O.M. Shah, A. Ziarkowski
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引用次数: 0

摘要

高渗高血糖状态(HHS)是一种内分泌紧急情况,死亡率在10%至50%之间。治疗这种情况的主要方法是大力静脉输液,密切监测血糖、血清渗透压和电解质。然而,在最初的复苏后,患者可能会出现高钠血症和血清渗透压升高,这会产生有害的后果。虽然HHS中的高钠血症可以通过输注0.45%生理盐水或5%葡萄糖来治疗,但也可以使用替代措施,如静脉(IV)低渗液输注[例如含4%葡萄糖和0.15%氯化钾的0.18%氯化钠(NaCl)],或通过鼻胃(NG)管给予游离水。我们报告了一名70岁的男子的病例,他最初因HHS住进了医疗高级护理病房(MHC),72小时后因意识水平改变和严重的高钠血症被转移到重症监护室。他的治疗包括静脉注射含4%葡萄糖和0.15%KCl的0.18%NaCl低渗液。他还通过NG管接受游离水,其速率被计算为在72小时内以0.55 meq L-1 hr-1的平均速率校正钠血症。制定了一种多管齐下的方法来管理这名患者,除了钠血症矫正外,还包括用胰岛素控制血糖,适当的静脉注射抗生素来治疗感染性足部溃疡,足够的镇痛药物,用于血栓预防的低分子肝素(LMWH),质子泵抑制剂,以及患者在格拉斯哥昏迷评分改善时继续服用抗抑郁药物。该病例报告证明了静脉注射低渗液(0.18%NaCl-4%葡萄糖-0.15%KCl)与不含NG的水一起纠正钠水平的可行性和成功性,与用0.45%盐水纠正所需的液体体积相比,液体体积更低。对于初次复苏后出现高钠血症的HHS患者,这种治疗似乎是纠正钠水平和渗透压的合理选择,因为它可以避免液体过载,并提供葡萄糖作为除钾离子外的能量底物。然而,在用低渗液纠正钠血症的同时,不应忽视其他方面的管理。
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Case Report : Severe Hypernatremia following treatment for Hyperosmolar Hyperglycaemic State : A pragmatic approach used to manage hypernatremia
The Hyperosmolar Hyperglycaemia State (HHS) is an endocrine emergency with a mortality rate between 10 and 50%. The mainstay for the treatment of this condition is vigorous IV fluid replacement with close monitoring of blood glucose, serum osmolality, and electrolytes. However, after initial resuscitation, patients can develop hypernatremia and raised serum osmolality, which have deleterious consequences. While hypernatremia in HHS can be treated with infusions of 0.45% saline or 5% dextrose, alternate measures such as intravenous (IV) hypotonic fluid infusion [e.g. 0.18% sodium chloride (NaCl) containing 4% dextrose and 0.15% potassium chloride (KCl)], or free water administration through a nasogastric (NG) tube can be used. We report the case of a 70-year-old man, who was initially admitted to a medical high care ward (MHC) with HHS, and was transferred to the ICU 72 hours later with an altered level of consciousness and severe hypernatremia. His treatment consisted in an IV hypotonic 0.18% NaCl infusion containing 4% dextrose and 0.15% KCl. He also received free water through a NG tube at a rate that was calculated to correct natremia at an average rate of 0.55 meq L-1 hr-1 over 72 hours. A multipronged approach was instituted to manage this patient, including, in addition to natremia correction, blood glucose control with insulin, appropriate IV antibiotics to treat infected foot ulcers, adequate analgesic medications, low-molecular-weight- heparin (LMWH) for thromboprophylaxis, proton- pump inhibitors, and continuation of patient’s ongoing antidepressant drugs at the time of his Glasgow Coma Score improvement. This case report demonstrates the feasibility and success of IV hypotonic fluid (0.18% NaCl - 4% dextrose - 0.15% KCl), alongside NG free water for correcting sodium levels with lower fluid volumes than would have been otherwise required if corrected with 0.45% saline. This treatment seems to be a reasonable choice for correcting sodium levels and osmolality in HHS patients who present with hypernatremia after an initial resuscitation, insofar as it avoids fluid overload and provides dextrose as an energy substrate, in addition to potassium ions. However, while correcting natremia with hypotonic fluid, other aspects of management should not be ignored.
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期刊介绍: L’Acta Anaesthesiologica Belgica est le journal de la SBAR, publié 4 fois par an. L’Acta a été publié pour la première fois en 1950. Depuis 1973 l’Acta est publié dans la langue Anglaise, ce qui a été résulté à un rayonnement plus internationaux. Depuis lors l’Acta est devenu un journal à ne pas manquer dans le domaine d’Anesthésie Belge, offrant e.a. les textes du congrès annuel, les Research Meetings, … Vous en trouvez aussi les dates des Research Meetings, du congrès annuel et des autres réunions.
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