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3. CURS 3-DZ

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  • 7/25/2019 3. CURS 3-DZ

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    COMPLICATIILE DZ

    ACUTE

    CRONICE

    CETOACIDOZA DZ

    STATUSUL NONCETONIC, HOSM

    DZ 1

    DZ 2

    - deficit relativa!"#l$t de I- de%letie v#le&ica

    -"tat$" &e'tal alterat

    - H( cet#acid#)a

    - $r*e'te &edicale c#'"eci'te "evere

    d*+ "i &a"$ri tera%e$tice %r#&%te

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    COMPLICATIILE CRONICE ALE DZI+ ASCULARE

    - MICROASCULARE - retinopatia DZ

    - neuropatia DZ

    - nefropatia DZ

    - MACROASCULARE - CAD - boala vasculara periferica

    - boli cerebrovasculare

    II+ NONASCULARE- Gastropareza

    - TDS

    - modificari cutanate

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    C-r#'ic C#&%licati#'" #f Dia!ete" Mellit$"

    MicrovascularEye disease

    etinopat!y "nonproliferative#proliferative$Macular edemaCataractsGlaucoma

    %europat!y

    Sensory and motor "mono- and polyneuropat!y$Autonomic%ep!ropat!yMacrovascularCoronary artery disease

    &erip!eral vascular diseaseCerebrovascular disease't!er

    Gastrointestinal "(astroparesis) diarr!ea$Genitourinary "uropat!y#se*ual dysfunction$

    Dermatolo(ic

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    MECANISMUL .IZIOPATOLO(IC AL COMEI

    CETOACIDOTICE

    Circ$&"ta'te de a%aritie - fact#ri %reci%ita'ti - (luca(on "relativ # absolut$

    - deficit de insulina / - catecolamine

    - (lucocorticoizi "cortisol$

    - !G+

    - intreruperea administrarii de , "la insulinecesitanti$

    - stres - fizic "infectii) interventii c!irur(icale$ desi ,-terapia

    - psi!ic) emotional se mentine

    - ca urmare a deficitului de ,

    conc !ormonilor de contrare(lare

    - catecolaminele "E %E$ stimuleaza secretia de

    (luca(on

    bloc!eaza eliberarea , si transportul transmembranar

    de G indus de ,

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    MECANISMUL .IZIOPATOLO(IC AL COMEI

    CETOACIDOTICE

    , # Gluca(on

    HIPER(LICEMIE

    ACTIAREA CETO(ENEZEI

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    MECANISMUL HIPER(LICEMIEI DIN COMA

    CETOACIDOTICA

    - %r#d$ctiei e%atice de (

    *lic#*e'#li)a

    *l$c#'e#*e'e)a

    -

    $tili)arii %eriferice a (

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    MECANISMUL HIPER(LICEMIEI DIN COMA

    CETOACIDOTICA

    (lic#*e'#li)ei- *l$ca*#' deficit de I

    - catec#la&i'e

    Utili)arii %eriferice a (

    - deficit$l de I

    'ivelel#r de (LUT 0

    - %rel$area ( i' te"+ && "i adi%#"

    -

    &eta!#li"&$l i'tracel$lar al (

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    MECANISMUL HIPER(LICEMIEI DIN COMA

    CETOACIDOTICA

    -

    I (l$ca*#'

    / 'ivel$l e%atic de .-2,-P

    - Hi%er*lice&ie

    -I activitatea PEP car!#i-3i'a)ei

    - (l$ca*#' activitatea %ir$vat-3i'a)ei

    .-2,-P

    *lic#li)a, viaactivarii P.-3i'a)ei

    *l$c#'e#*e'e)ei,via

    i'i!arii .-1,-!iP

    M#dificarea $tili)arii e%atice a

    %ir$vat$l$i 4

    "i'te)a de *l$c#)a

    *lic#li)ei

    HIPER(LICEMIE

    (LUCOZURIE

    DIUREZA OSMOTICA

    DEPLETIE OLEMICA

    DESHIDRATARE

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    MECANISMUL CETO(ENEZEI DIN COMA

    CETOACIDOTICA

    - DISPONI5ILIZAREA SU5STRATULUI

    CETO(ENEZEI

    ..A, AA

    - ACTIAREA CETO(ENEZEI 6e%atice7

    Deficit$l de I

    catec#la&i'e, (H

    activarea LPL ..A

    Ece"$l de *l$c#*#'activarea "i"te&$l$i CPT

    6car'iti'-%al&it#il-tra'"fera)el#r7

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    SISTEMUL

    CARNITIN-

    PALMITOIL-

    TRANSFERAZELOR

    (CPT)

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    MECANISMUL CETO(ENEZEI DIN COMA

    CETOACIDOTICA

    Ece"$l de *l$ca*#' activea)a "i"t+ CPT %e 2 cai4

    17 c#'ti'$t$l$i e%atic de &al#'il-C#A

    via i'trer$%erii "ecve'tei &eta!#lice 4

    (--P

    %ir$vat

    citrat

    acetil-C#A

    &al#'il-C#A

    Mal#'il-C#A 6%ri&$l i'ter&ediar %e cale "i'te)ei ( di' ..A7

    i'i!it#r c#&%etitiv al CPT I

    27 c#'ti'$t$l e%atic de car'iti'a

    #rie'tarea reactiei "%re f#r&area acil-car'iti'a 6efect de&a"a7

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    CORPII CETONICI

    - acet#'a6v#latil7

    - acet#-acetat4 N 6%la"&a7 8 199 lL SI 6 8 1&*dL 7

    - -OH-!$tirat4 N 6%la"&a7 8 :99 lL SI 6 8 :

    &*dL 7..A: N 6%la"&a7 8 1;9 &*L SI 6 8 1; &*dL 7

    O"lalitate %la"&atica 4

    N < 2;=-2>= &l?* a%a "erica < 2;=-2>= &O"&?* a%a

    (l$ca*#'e&ie !a)ala

    N 6%la"&a7 < 19 - 199 '*L SI 6 =9 - 199 %*&L 7

    I'"$li'e&ie !a)ala

    N 6%la"&a7 < 0: - 1; %lL SI

    6 - 2

    U&L 7

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    La!#rat#r@ ,al$e" i' Dia!etic ?et#acid#"i" 6D?A7 a'd N#'3et#tic H@%er#"lar State" 6N?HS7 6Re%re"e'tative Ra'*e" at Pre"e'tati#'7

    D?A N?HS

    Glucose)ammol#. "m(#d.$ /01-222 "233-033$ 222-000 "033-/433$

    Sodium) me5#. /46-/26 /26-/76

    &otassium)ame5#. %ormal to b %ormal

    Ma(nesium a %ormal b %ormal

    C!loridea %ormal %ormal

    &!osp!ate

    a %ormal

    Creatinine) mol#. "m(#d.$ Sli(!tly Moderately 'smolality) m'sm#m. 233-243 223-283

    &lasma 9etonesa ++++ +#

    Serum bicarbonate)ame5#. 12Arterial &C'4) mm+( 43-23 %ormal

    Anion (apa:%a "Cl ++C'2$;) me5#. %ormal to sli(!tly

    a.ar(e c!an(es occur durin( treatment of D

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    Ma'ife"tati#'" #f Dia!etic ?et#acid#"i"

    Symptoms%ausea#vomitin(T!irst#polyuria

    Abdominal pain

    Altered mental functionS!ortness of breat!

    &!ysical findin(sTac!ycardiaDry mucous membranes#reduced s9in tur(or

    De!ydration # !ypotensionTac!ypnea # T,#(astroenteritis#sepsis$,nfarction "cerebral) coronary) mesenteric) perip!eral$Dru(s "cocaine$

    %'TE? >T,) urinary tract infection-

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    MECANISMUL .IZIOPATOLO(IC

    AL STATUS-ULUI 6COMEI7 NONCETONICE,

    HIPEROSMOLARE

    .act#ri %reci%ita'ti

    - deficit$l de I 6&ai %$ti' i&%#rta't fata de D?A7

    /

    - a%#rt i'adecvat de fl$ide - idratare i'adecvata

    -Dia!etic var"t'ic "i'*$r

    - "tr#3e i'fectie "evera "tre" %"iic

    - i'a%t de a "e idrata c#re"%$')at#r

    - %r#ced$ri 4 - ediali)adiali)a %erit#'eala

    - ra'ire %e t$! c$ "#l+ c$ f#r&$le H%r#t+

    - %erf$)ii c$ "#l+ c$ c#'t+

    HC 6&a'it#l7 $ree

    - &edica&e'te 4 - fe'it#i'

    - i&$'#"$%re"ive 6*l$c#c#rtic#i)i7

    - di$retice

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    MECANISMUL STATUS-$l$i HIPEROSMOLAR

    - la pacientii cu DZ / "insulinonecesitanti$) la care , administrata ?

    suficienta pentru prevenirea

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    MECANISMUL STATUS-$l$i HIPEROSMOLAR

    DE CE NU ?A

    C#'ce'tratia I i' ve'a %#rta la DZ 2 f+d+ DZ 1

    %reve'irea activarii de%li'e a "i"t+ CPT

    Re)i"te'ta la *l$ca*#'

    &e'ti'erea $'#r 'ivele e%atice de Mal#'il-C#A

    cicl$l C#ri 4

    - te"$t$rile %eriferice 4 ( circ$la'ta lactat rel$are circ$it

    "%re ficat 6%t+ *l$c#'e#*e'e)a7

    Lactat$l < %rec$r"#r de Mal#'il-C#A

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    A!revieri

    -DKA = Diabetic Ketoacidosis cetoacidoza diabetica

    -NKHS = Non-ketonic Hyperosmolar States = statusul non-

    cetonic, hiperosmolar-+osm !iperosmolar


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