林文森 周劍文 楊純宜 陳素榆 沈 ... - tsim.org.tw

1 1 .. 1 .. ( hyperglycemic hyperosmolar state HHS ) . HHS . 2002 1 2004 4 HHS 75 76 HHS . 47 29 24 93 . HHS ( ) . ( ) ( ) ( Glasgow coma scale GCS) 3. 8 11 . Glasgow HHS .. ( Hyperglycemic hyperosmolar state ). (Precipitating factor ). ( Glasgow coma scale ). Clinical Analysis of Hyperglycemic Hyperosmolar State Wen-Sen Lin, Chien-Wen Chou, Chwen-Yi Yang, Su-Yu Chen, Sjen-Jung Shen1, and Hon-Mei Cheng . ( hyperglycemic hyperosmolar state, HHS ) . ( diabetic ketoacidosis, DKA ) .. 10 50% 1-6 ( HHS ) . (hyperglycemic hyperosmolar nonketotic coma, HHNK ) . 1-3 ( American Diabetes Association, ADA ) 2001 . 7-8 . 1980 90 9-11 . ADA 2002 1 2004 4 HHS . HHS .. 2002 1 2004 4 . ( ICD ) 392 76 . HHS ( ) 600 mg/ dL ( ) ( . 2Na + glucose/ 18 ) 320 mOsm/ kg H2O ( ) . ( nitroprusside reaction ) . 15 mEq/ L . ( bedridden ). ( precipitating factor ).

2 ( Glasgow coma scale, GCS ) .. ( Fisher's exact test ) Mann-Whitney . ( multiple logistic regression ) HHS p .. 2002 1 2004 4 28 ( ICD. ) 392 75 76 HHS . 88% 320 mOsm/ kg H2O . HHS 75 HHS 46 . 1 2 29 1 HHS 24 . 93 . HHS 24 ( ) . 37 ( ) 8 ( ) . 7 ( ) 73 ( ) . 1 2 . 41 HHS 32 . 78% . HHS 49 ( ) . 12 ( ) 8 ( ) . ( ) . HHS Glasgow 18 . GCS 15 ( ) 35 ( ) GCS 9 14 . 23 ( ) GCS 3 8 HHS 1. 82 5 . HHS 35 ( ) . 41 ( ) . 76 HHS 11 10 . 1 . ( ) GCS ( ) .. GCS HHS . ( odds ratio ) 95% p . Glasgow 1 42% . GCS GCS 15 9 14 . 3 8 HHS . ( ) .. 1-2 .. HHS .. 1-6 . HHS . ( HHS ) . ( HHNK ) 10%. 1-3 . 2001 7-8 ( ) . 600 mg/ dL ( ) 320 mOsm/ kg H2O ( ) . 15 mEq/ L . ( mEq/ L ) ( . mg/ dl ) 18 . HHS . ( tonicity ) . 4-5 . (freezing-point depression ) 12 1 mOsm/ kg .. HHS . DKA HHS . DKA HHS. 30 33% 13-15 .. 9-11 HHS HHS . 70 79 40 HHS.

3 HHS . DKA . 15 . HHNK 42% 11 HHS . 78% .. 3,15 HHS HHS ( predisposing factor ) . HHS . 1-3, 9-11 .. 3,15 HHS . HHS . 1-6 . HHS . HHS HHS 20 . DKA ( 17% ) 9-11 HHS . HHS . DKA ( ) . HHS . 1-6, 9-11 HHS . ( Glasgow ) HHS . Glasgow GCS 3 8 .. HHS . HHS . 9 . HHS. HHS .. AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001; 24: 131-53. JL, Aris-Jilwan N, Belanger R, et al. Diagnosis and treatment of diabetic ketoacidosis and hyperglycemic hyperosmolar state. CMAJ 2003; 168: 859-66. ED, Stahl E, Kreisberg RA. The hyperosmolar hyperglycemic syndrome. Diabetes Rev 1994; 2: 115-26. D. Nonketotic hypertonicity in diabetes mellitus. Med Clin North Am 1995; 79: 39-52. SN, Sanson TH. Treatment of hyperglycemic hyperosmolar non-ketotic syndrome. Drugs 1989; 38: 462-72.

4 MF, Zisman A, Kettyle WM. Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Endocrinol Metab Clin North Am 2000; 29: 683-705. Diabetes Association. Hyperglycemic crises in diabetes. Diabetes Care 2001; 24: 1988-96. Diabetes Association. Hyperglycemic crises in diabetes. Diabetes Care 2004; 27. (suppl 1): S94-102. JD, Huang MJ, Huang BY, Wang PW, Huang HS. Analysis of diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic coma. J Formos Med Assoc 1985; 84: 707-14. FY, Tsai ST, Wang GG, Ho LT, Ching KN. Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic coma: A reappraisal after seven years. Chin Med J (Taipei) 1989; 44: 121-8. CH, Lee JK, Lam HC, Lu CC. Prognostic factors of hyperglycemic hyperosmolar nonketotic state. Chang Gung Med J 2001; 24: 345-51. LA. Measurement of colligative properties.

5 In: Kaplan LA, Pesce AJ, eds. Clinical chemistry: therapy, analysis and correlation. 3rd ed. St. Louis: Mosby; 1996; 270-6. TJ, Tetu-Mouradjian LM, Goldman DL, Ellis SE, O'Sullivan PS. Hyperosmolarity and acidosis in diabetes mellitus: a three year experience in Rhode Island. J Gen Intern Med 1991; 6: 495-502. RJ, Lee LY, McNeil KJ, Tsalamandris C, Jerums G. Influence of age on the presentation and outcome of acidotic and hyperosmolar diabetic emergencies. Intern Med J 2002;. 32: 379-85. ED, Kreisberg RA. Diabetic ketoacidosis and the hyperglycemic hyperosmolar syndrome. In: LeRoith D, Taylor SI, Olefsky JM, eds. Diabetes Mellitus: A Fundamental and Clinical text. 2nd ed. Philadelphia: Lippincott Williams 2000; 336-47.. N = 76. ( ) + ( / ) 47/ 29.. 24 ( ). 7 ( ). 37 ( ). 8 ( ).. 0. 73 ( ). 1 ( ). 2 ( ). N = 41 ( ).

6 32 ( ). 3 ( ). 2 ( ). 2 ( ). 2 ( ).. 49 ( ). 25 ( ). 16 ( ). 3 ( ). 5 ( ). 8 ( ). 12 ( ). 4 ( ). 2 ( ). 1 ( ). Glasgow + + 11 ( ).. HHS (N = 76). (mg/ dl) + (mOsm/ kg) + (N = 74). (mOsm/ kg) + N = 35 ( ). + (N = 71). (mmol/ L) + (N = 71). (mEq/ L) + (mEq/ L) + (mg/ dl) + (mg/ dl) + . (N = 11) (N = 65) p . ( ) + + 5 (45%) 24 (37%) 3 (27%) 21 (32%) 8 (73%) 33 (51%) 10 (91%) 39 (60%) Glasgow + + < (mg/ dl) + + (mOsm/ kg) + (N = 9) + (mOsm/ kg) + + 9 (82%) 32 (49%) + (N = 10) + (N = 61) (mmol/ L) + (N = 10) + (N = 61) (mEq/ L) + + (mEq/ L) + + (mg/ dl) + + (mg/ dl) + + (Glasgow ) .. p . Glasgow 15 9 - 14 3-8.. N = 18 N = 35 N = 23. 0 1 ( ) 10 ( ) < ( ) 1 ( ) 21 ( ) 19 ( ) < 6 ( ) 23 ( ) 20 ( ) (mg/ dl) 1140 + 322 949 + 327 946 + 343 (mOsm/ kg) + + + (mOsm/ kg) + + + (mEq/ L) + + + (mg/ dl) + + + + + + . (mmol/ L) + + +.

7 9 10 11 . 1981-82 1986-87 1992-98 2002-04. 32 50 119 76. ( ) 62 ( ) 50% 44% 44% 20% (mg/dl) > 600 > 600 > 600.. (mOsm/ kg) > 340 > 350 > 350 - . (mOsm/ kg) - - - > 320 . (mg/ dl) < 15 . - > > > . (mEq/ L) - > 15 - > 15. = 2 [Na + K] + Glu/18 + = 2Na + Glu/18.. Clinical Analysis of Hyperglycemic Hyperosmolar State Wen-Sen Lin, Chien-Wen Chou, Chwen-Yi Yang, Su-Yu Chen, Sjen-Jung Shen1, and Hon-Mei Cheng Division of Endocrinology and Metabolism, Department of Internal Medicine, Chi-Mei Medical Center 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Liuying Chi-Mei Hospital Hyperglycemic hyperosmolar state (HHS) is one of the most serious acute complications of diabetes and its mortality rate had been higher. We retrospectively analyzed the clinical profiles of patients who were admitted to Chi-Mei Medical Center from January 2002 to April 2004 due to HHS according to the current diagnostic criteria.

8 Seventy-five patients with 76. episodes (47 males and 29 females) were included in our study. The age of the patients ranged from 24 to 93 years (mean years). Twenty-four episodes ( ) occurred with no diabetic history. Bedridden was the common predisposing factor ( ). The leading precipitating factor was infection ( ), followed by undiagnosed diabetes ( ) and poor compliance of medication ( ). Twenty-three episodes ( ) whose initial Glasgow coma scale 3-8 had more severe consciousness disturbance. Thirty-five episodes ( ) consisted of variable degrees of ketonemia without significant acidosis. Eleven patients died during the 76 episodes, giving a fatality rate of Multiple logistic regression analysis showed that low Glasgow coma scale was the only independent predictor of mortality of HHS. ( J Intern Med Taiwan 2004; 15: 223-229).