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7/25/2019 3. CURS 3-DZ
1/19
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$tice %r#&%te
7/25/2019 3. CURS 3-DZ
2/19
COMPLICATIILE CRONICE ALE DZI+ ASCULARE
- MICROASCULARE - retinopatia DZ
- neuropatia DZ
- nefropatia DZ
- MACROASCULARE - CAD - boala vasculara periferica
- boli cerebrovasculare
II+ NONASCULARE- Gastropareza
- TDS
- modificari cutanate
7/25/2019 3. CURS 3-DZ
3/19
C-r#'ic C#&%licati#'" #f Dia!ete" Mellit$"
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
7/25/2019 3. CURS 3-DZ
4/19
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 ,
7/25/2019 3. CURS 3-DZ
5/19
MECANISMUL .IZIOPATOLO(IC AL COMEI
CETOACIDOTICE
, # Gluca(on
HIPER(LICEMIE
ACTIAREA CETO(ENEZEI
7/25/2019 3. CURS 3-DZ
6/19
MECANISMUL HIPER(LICEMIEI DIN COMA
CETOACIDOTICA
- %r#d$ctiei e%atice de (
*lic#*e'#li)a
*l$c#'e#*e'e)a
-
$tili)arii %eriferice a (
7/25/2019 3. CURS 3-DZ
7/19
MECANISMUL HIPER(LICEMIEI DIN COMA
CETOACIDOTICA
(lic#*e'#li)ei- *l$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 (
7/25/2019 3. CURS 3-DZ
8/19
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$c#)a
*lic#li)ei
HIPER(LICEMIE
(LUCOZURIE
DIUREZA OSMOTICA
DEPLETIE OLEMICA
DESHIDRATARE
7/25/2019 3. CURS 3-DZ
9/19
MECANISMUL CETO(ENEZEI DIN COMA
CETOACIDOTICA
- DISPONI5ILIZAREA SU5STRATULUI
CETO(ENEZEI
..A, AA
- ACTIAREA CETO(ENEZEI 6e%atice7
Deficit$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
7/25/2019 3. CURS 3-DZ
10/19
SISTEMUL
CARNITIN-
PALMITOIL-
TRANSFERAZELOR
(CPT)
7/25/2019 3. CURS 3-DZ
11/19
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
7/25/2019 3. CURS 3-DZ
12/19
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'"$li'e&ie !a)ala
N 6%la"&a7 < 0: - 1; %lL SI
6 - 2
U&L 7
7/25/2019 3. CURS 3-DZ
13/19
7/25/2019 3. CURS 3-DZ
14/19
La!#rat#r@ ,al$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$;) me5#. %ormal to sli(!tly
a.ar(e c!an(es occur durin( treatment of D
7/25/2019 3. CURS 3-DZ
15/19
Ma'ife"tati#'" #f Dia!etic ?et#acid#"i"
Symptoms%ausea#vomitin(T!irst#polyuria
Abdominal pain
Altered mental functionS!ortness of breat!
&!ysical findin(sTac!ycardiaDry mucous membranes#reduced s9in tur(or
De!ydration # !ypotensionTac!ypnea # T,#(astroenteritis#sepsis$,nfarction "cerebral) coronary) mesenteric) perip!eral$Dru(s "cocaine$
%'TE? >T,) urinary tract infection-
7/25/2019 3. CURS 3-DZ
16/19
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$retice
7/25/2019 3. CURS 3-DZ
17/19
MECANISMUL STATUS-$l$i HIPEROSMOLAR
- la pacientii cu DZ / "insulinonecesitanti$) la care , administrata ?
suficienta pentru prevenirea
7/25/2019 3. CURS 3-DZ
18/19
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
7/25/2019 3. CURS 3-DZ
19/19
A!revieri
-DKA = Diabetic Ketoacidosis cetoacidoza diabetica
-NKHS = Non-ketonic Hyperosmolar States = statusul non-
cetonic, hiperosmolar-+osm !iperosmolar