Disorders of carbohydrate metabolism in critical conditions
Background. Carbohydrate metabolism disorders (CMD) include ketoacidosis and ketoacidotic hyperglycemic coma, non-diabetic ketoacidosis, hyperosmolar coma, hypoglycemic syndrome and hypoglycemic coma, lactic acid coma. The main factors in the development of CMD are newly diagnosed diabetes mellitus (DM) or inadequate therapy of previously diagnosed DM, infectious processes, acute diseases (myocardial infarction, strokes, pancreatitis, renal failure, severe burns, thyrotoxicosis), use of certain drugs (calcium channel blockers, osmotic and thiazide diuretics, propranolol, chemotherapeutic drugs), alcohol or cocaine abuse.
Objective. To describe the course and management of patients with CMD.
Materials and methods. Review of the available literature on this issue.
Results and discussion. CMD in critical conditions leads to the development of hyperglycemia, hyperketonemia, metabolic acidosis, dehydration, hyperosmolarity, electrolyte imbalance, arising against the background of the underlying disease, being masked by it and worsening the patient’s condition. When diagnosing ketoacidosis, one should focus primarily on the clinical condition of the patient, because the test for ketonuria does not reflect the actual level of ketone bodies in the urine. CMD therapy should include rehydration (infusion therapy – IT), insulin therapy, partial correction of severe metabolic acidosis, use of antiketogenic drugs, compensation of electrolyte disorders and elimination of the CMD causes. Isotonic NaCl solution or Ringer solution must be used for IT. Elderly patients and patients with heart failure should be treated with caution, with a possible dose reduction of 50 %. In case of hyperglycemia, insulin therapy (intravenous bolus 0.15 IU/kg, then infusion 0.1 IU/kg/h) is prescribed to ensure a reduction in glucose concentration by 2-3 mmol/L per hour. To correct metabolic acidosis, hydrocarbonate solutions are prescribed under the control of acid-base status (ABS). If it is not possible to determine ABS, in the presence of clinical signs of ketoacidosis, it is possible to prescribe Soda-Bufer (“Yuria-Pharm”) up to 300 ml. Xylitol (Xylate, “Yuria-Pharm”) is the main antiketogenic solution. It reduces the amount of free fatty acids, which oxidize to acetyl-CoA, acts as an insulin-independent energy source, increases the intensity of glycolysis and glycogen production, stimulates insulin secretion. If the patient has a fasting blood glucose level >13.9 mmol/L, nausea, vomiting, dizziness, drowsiness, dry skin and dry mouth, Kussmaul’s breathing, frequent urination, or a patient with diabetes is scheduled for surgery, it is advisable to prescribe xylitol-containing solution. Xylate should be prescribed for various CMD (hyperglycemia, dehydration, hypokalemia, ketoacidosis). Another area of CMD treatment is the normalization of potassium levels, which should be started in the conditions of normokalemia, because CMD are characterized by an initial increase and subsequent decrease in potassium content. The latter should be maintained at 4-5 mmol/h with tight monitoring every 2 hours firstly and then every 4 hours.
Conclusions. 1. Many patients in the intensive care unit develop CMD. 2. CMD in critical conditions involve the development of hyperglycemia, hyperketonemia, metabolic acidosis, dehydration, hyperosmolarity, and electrolyte imbalance. 3. CMD therapy should include rehydration, insulin therapy, partial correction of severe metabolic acidosis, use of antiketogenic drugs, compensation of electrolyte disorders and elimination of the CMD causes. 4. Isotonic NaCl solution, Ringer solution, insulin therapy, hydrocarbonate solutions, xylitol, potassium preparations are used in CMD therapy.
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