{"id":34212,"date":"2022-10-22T15:31:50","date_gmt":"2022-10-22T08:31:50","guid":{"rendered":"https:\/\/www.vnras.com\/drug\/?p=34212"},"modified":"2022-10-22T15:35:25","modified_gmt":"2022-10-22T08:35:25","slug":"toan-ceton-dai-thao-duong","status":"publish","type":"post","link":"https:\/\/vnras.com\/drug\/toan-ceton-dai-thao-duong\/","title":{"rendered":"Toan ceton \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng &#8211; H\u01b0\u1edbng d\u1eabn c\u1eadp nh\u1eadt t\u1eeb Hi\u1ec7p h\u1ed9i \u0110\u00e1i th\u00e1o \u0111\u01b0\u1eddng Anh Qu\u1ed1c 2022"},"content":{"rendered":"<p style=\"text-align: right;\"><strong>Ths.Bs Ph\u1ea1m Ho\u00e0ng Thi\u00ean<\/strong><\/p>\n<p style=\"text-align: right;\"><strong>Group \u201cC\u1eadp nh\u1eadt Ki\u1ebfn th\u1ee9c Y khoa\u201d<\/strong><\/p>\n<p>&nbsp;<\/p>\n<p><b>T\u00f3m t\u1eaft<\/b><\/p>\n<p>B\u00e0i b\u00e1o n\u00e0y t\u00f3m t\u1eaft c\u00e1c h\u01b0\u1edbng d\u1eabn c\u1ee7a Hi\u1ec7p h\u1ed9i \u0110\u00e1i th\u00e1o \u0111\u01b0\u1eddng Anh cho Ch\u0103m s\u00f3c N\u1ed9i tr\u00fa v\u1ec1 qu\u1ea3n l\u00fd nhi\u1ec5m toan ceton; c\u00f3 t\u1ea1i https:\/\/abcd.care\/resource\/management-diabetic-ketoacidosis-dka-adults. T\u00e0i li\u1ec7u n\u00eau r\u00f5 r\u1eb1ng khi m\u1ed9t ng\u01b0\u1eddi t\u1eeb 16-18 tu\u1ed5i \u0111\u01b0\u1ee3c \u0111\u1ed9i ng\u0169 nhi khoa ch\u0103m s\u00f3c th\u00ec n\u00ean s\u1eed d\u1ee5ng h\u01b0\u1edbng d\u1eabn d\u00e0nh cho tr\u1ebb em v\u00e0 n\u1ebfu h\u1ecd \u0111\u01b0\u1ee3c ch\u0103m s\u00f3c b\u1edfi \u0111\u1ed9i ng\u01b0\u1eddi l\u1edbn th\u00ec n\u00ean s\u1eed d\u1ee5ng h\u01b0\u1edbng d\u1eabn n\u00e0y. H\u01b0\u1edbng d\u1eabn c\u00f3 t\u00ednh \u0111\u1ebfn b\u1eb1ng ch\u1ee9ng m\u1edbi v\u1ec1 vi\u1ec7c s\u1eed d\u1ee5ng phi\u00ean b\u1ea3n tr\u01b0\u1edbc c\u1ee7a t\u00e0i li\u1ec7u n\u00e0y, \u0111\u1eb7c bi\u1ec7t l\u00e0 t\u1ef7 l\u1ec7 h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft v\u00e0 h\u1ea1 kali m\u00e1u cao, v\u00e0 khuy\u1ebfn c\u00e1o r\u1eb1ng khi n\u1ed3ng \u0111\u1ed9 glucose gi\u1ea3m xu\u1ed1ng d\u01b0\u1edbi 14 mmol \/ L, l\u00e0m gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin t\u1eeb 0,1 xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/kg \/ h n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t. H\u01a1n n\u1eefa, m\u1ed9t ph\u1ea7n m\u1edbi \u0111\u00e3 \u0111\u01b0\u1ee3c th\u00eam v\u00e0o \u0111\u1ec3 gi\u1ea3i quy\u1ebft vi\u1ec7c s\u1eed d\u1ee5ng SGLT-2 c\u00f3 li\u00ean quan \u0111\u1ebfn vi\u1ec7c t\u0103ng nguy c\u01a1 nhi\u1ec5m ceton m\u00e1u \u0111\u1eb3ng \u0111\u01b0\u1eddng huy\u1ebft. Vi\u1ec7c qu\u1ea3n l\u00fd t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan ceton \u1edf nh\u1eefng ng\u01b0\u1eddi b\u1ecb suy th\u1eadn giai \u0111o\u1ea1n cu\u1ed1i ho\u1eb7c \u0111ang ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o c\u0169ng \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp.<\/p>\n<p><b>C\u00f3 g\u00ec m\u1edbi?<\/b><\/p>\n<ul>\n<li>Nhi\u1ec5m toan ceton v\u1eabn l\u00e0 m\u1ed9t t\u00ecnh tr\u1ea1ng c\u00f3 th\u1ec3 \u0111e d\u1ecda t\u00ednh m\u1ea1ng. Phi\u00ean b\u1ea3n tr\u01b0\u1edbc c\u1ee7a h\u01b0\u1edbng d\u1eabn n\u00e0y \u0111\u00e3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng r\u1ed9ng r\u00e3i tr\u00ean kh\u1eafp V\u01b0\u01a1ng qu\u1ed1c Anh v\u00e0 c\u00e1c n\u01a1i kh\u00e1c. Tuy nhi\u00ean, b\u1eb1ng ch\u1ee9ng v\u1ec1 s\u1ef1 ph\u1ed5 bi\u1ebfn c\u1ee7a h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft v\u00e0 h\u1ea1 kali m\u00e1u cho th\u1ea5y r\u1eb1ng c\u1ea7n ph\u1ea3i thay \u0111\u1ed5i.<\/li>\n<li>H\u01b0\u1edbng d\u1eabn n\u00e0y n\u00eau r\u00f5 r\u1eb1ng khi m\u1ed9t b\u1ec7nh nh\u00e2n t\u1eeb 16\u201318 tu\u1ed5i \u0111\u01b0\u1ee3c \u0111\u1ed9i ng\u0169 nhi khoa ch\u0103m s\u00f3c th\u00ec n\u00ean s\u1eed d\u1ee5ng h\u01b0\u1edbng d\u1eabn d\u00e0nh cho tr\u1ebb em v\u00e0 n\u1ebfu h\u1ecd \u0111\u01b0\u1ee3c ch\u0103m s\u00f3c b\u1edfi \u0111\u1ed9i ng\u01b0\u1eddi l\u1edbn th\u00ec n\u00ean s\u1eed d\u1ee5ng h\u01b0\u1edbng d\u1eabn n\u00e0y.<\/li>\n<li>H\u01b0\u1edbng d\u1eabn c\u1eadp nh\u1eadt n\u00e0y hi\u1ec7n khuy\u1ebfn ngh\u1ecb xem x\u00e9t gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin t\u1eeb 0,1 xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ gi\u1edd khi \u0111\u01b0\u1eddng huy\u1ebft gi\u1ea3m xu\u1ed1ng d\u01b0\u1edbi 14 mmol \/ L.<\/li>\n<li>C\u00e1c ph\u1ea7n m\u1edbi \u0111\u00e3 \u0111\u01b0\u1ee3c th\u00eam v\u00e0o \u0111\u1ec3 gi\u1ea3i quy\u1ebft v\u1ea5n \u0111\u1ec1 nhi\u1ec5m toan ceton trong m\u00e1u khi s\u1eed d\u1ee5ng thu\u1ed1c \u1ee9c ch\u1ebf SGLT-2, \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng t\u00fdp 2 d\u1ec5 b\u1ecb nhi\u1ec5m ceton v\u00e0 nhi\u1ec5m toan ceton \u1edf nh\u1eefng ng\u01b0\u1eddi b\u1ecb suy th\u1eadn giai \u0111o\u1ea1n cu\u1ed1i ho\u1eb7c \u0111ang l\u1ecdc m\u00e1u.<\/li>\n<\/ul>\n<h2>1. GI\u1edaI THI\u1ec6U<\/h2>\n<p>K\u1ec3 t\u1eeb khi \u0111\u01b0\u1ee3c xu\u1ea5t b\u1ea3n l\u1ea7n \u0111\u1ea7u ti\u00ean v\u00e0o n\u0103m 2010, h\u01b0\u1edbng d\u1eabn n\u00e0y v\u00e0 b\u1ea3n c\u1eadp nh\u1eadt \u0111\u01b0\u1ee3c xu\u1ea5t b\u1ea3n v\u00e0o n\u0103m 2013 \u0111\u00e3 \u0111\u01b0\u1ee3c \u00e1p d\u1ee5ng ho\u1eb7c \u0111i\u1ec1u ch\u1ec9nh r\u1ed9ng r\u00e3i tr\u00ean to\u00e0n V\u01b0\u01a1ng qu\u1ed1c Anh v\u00e0 c\u00e1c khu v\u1ef1c kh\u00e1c tr\u00ean th\u1ebf gi\u1edbi. N\u00f3 th\u01b0\u1eddng \u0111\u01b0\u1ee3c coi l\u00e0 ti\u00eau chu\u1ea9n ch\u0103m s\u00f3c. C\u00f9ng v\u1edbi h\u01b0\u1edbng d\u1eabn c\u1ee7a Hi\u1ec7p h\u1ed9i \u0110\u00e1i th\u00e1o \u0111\u01b0\u1eddng Hoa K\u1ef3 (ADA),1 \u0111\u00e2y v\u1eabn l\u00e0 m\u1ed9t trong nh\u1eefng h\u01b0\u1edbng d\u1eabn \u0111\u01b0\u1ee3c tr\u00edch d\u1eabn th\u01b0\u1eddng xuy\u00ean nh\u1ea5t v\u1ec1 qu\u1ea3n l\u00fd nhi\u1ec5m toan ceton. \u0110\u1ebfn n\u0103m 2018, phi\u00ean b\u1ea3n g\u1ed1c \u0111\u00e3 \u0111\u01b0\u1ee3c truy c\u1eadp, \u0111\u1ecdc ho\u1eb7c t\u1ea3i xu\u1ed1ng h\u01a1n 100.000 l\u1ea7n t\u1eeb c\u00e1c trang web c\u1ee7a ABCD v\u00e0 Diabetes UK. Ngo\u00e0i ra, phi\u00ean b\u1ea3n ng\u1eafn g\u1ecdn \u0111\u01b0\u1ee3c xu\u1ea5t b\u1ea3n v\u1eabn n\u1eb1m trong top 10 b\u00e0i b\u00e1o \u0111\u01b0\u1ee3c t\u1ea3i xu\u1ed1ng nhi\u1ec1u nh\u1ea5t t\u1eeb trang web Y h\u1ecdc \u0110\u00e1i th\u00e1o \u0111\u01b0\u1eddng trong nhi\u1ec1u n\u0103m. T\u00e0i li\u1ec7u n\u00e0y \u0111\u00e3 gi\u1edbi thi\u1ec7u m\u1ed9t s\u1ef1 thay \u0111\u1ed5i t\u1eeb qu\u1ea3n l\u00fd r\u1ed1i lo\u1ea1n chuy\u1ec3n h\u00f3a d\u1ef1a tr\u00ean glucose sang d\u1ef1a tr\u00ean ceton. M\u1eb7c d\u00f9 g\u00e2y tranh c\u00e3i v\u00e0o th\u1eddi \u0111i\u1ec3m \u0111\u00f3, nh\u01b0ng \u0111i\u1ec1u n\u00e0y \u0111\u00e3 d\u1eabn \u0111\u1ebfn vi\u1ec7c gi\u1ea3i quy\u1ebft nhi\u1ec5m toan ceton nhanh h\u01a1n v\u00e0 th\u1eddi gian n\u1eb1m vi\u1ec7n ng\u1eafn h\u01a1n trong c\u00e1c cu\u1ed9c ki\u1ec3m tra l\u1eb7p l\u1ea1i.<\/p>\n<p>Khi n\u00f3 \u0111\u01b0\u1ee3c vi\u1ebft l\u1ea7n \u0111\u1ea7u ti\u00ean, trong khi h\u1ea7u h\u1ebft c\u00e1c l\u1eddi khuy\u00ean \u0111\u1ec1u d\u1ef1a tr\u00ean b\u1eb1ng ch\u1ee9ng, m\u1ed9t s\u1ed1 khuy\u1ebfn ngh\u1ecb d\u1ef1a tr\u00ean s\u1ef1 \u0111\u1ed3ng thu\u1eadn. H\u1ecd d\u1ef1a tr\u00ean kinh nghi\u1ec7m chung c\u1ee7a nh\u00f3m vi\u1ebft. K\u1ec3 t\u1eeb \u0111\u00f3, \u0111\u00e3 c\u00f3 th\u00eam nhi\u1ec1u b\u1eb1ng ch\u1ee9ng cho th\u1ea5y kh\u00f4ng ch\u1ec9 nhi\u1ec1u khuy\u1ebfn ngh\u1ecb trong s\u1ed1 \u0111\u00f3 l\u00e0 ph\u00f9 h\u1ee3p m\u00e0 c\u00f2n m\u1ed9t s\u1ed1 khuy\u1ebfn ngh\u1ecb c\u00f3 th\u1ec3 c\u1ea7n \u0111\u01b0\u1ee3c s\u1eeda \u0111\u1ed5i.<\/p>\n<p>\u1ea4n b\u1ea3n m\u1edbi n\u00e0y nh\u1eb1m c\u1eadp nh\u1eadt h\u01b0\u1edbng d\u1eabn s\u1eed d\u1ee5ng b\u1eb1ng ch\u1ee9ng \u0111\u00e3 c\u00f3 s\u1eb5n. \u1ede nh\u1eefng n\u01a1i kh\u00e1c, c\u00e1c thay \u0111\u1ed5i \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111\u1ec1 xu\u1ea5t d\u1ef1a tr\u00ean s\u1ef1 \u0111\u1ed3ng thu\u1eadn c\u1ee7a c\u00e1c chuy\u00ean gia. Nh\u1eefng \u0111i\u1ec1u n\u00e0y \u0111\u01b0\u1ee3c \u0111\u00e1nh d\u1ea5u trong ph\u1ea7n c\u00e1c khu v\u1ef1c g\u00e2y tranh c\u00e3i.<\/p>\n<p>C\u00e1c phi\u00ean b\u1ea3n t\u00f3m t\u1eaft c\u1ee7a h\u01b0\u1edbng d\u1eabn \u0111\u01b0\u1ee3c th\u1ec3 hi\u1ec7n trong H\u00ecnh 1 v\u00e0 c\u1ea3 H\u00ecnh 2 trong c\u00e1c t\u00e0i li\u1ec7u b\u1ed5 sung.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-34216 size-full\" src=\"https:\/\/www.vnras.com\/drug\/wp-content\/uploads\/2022\/10\/phac-do-quan-ly-nhiem-toan-ceton.jpg\" alt=\"H\u00ccNH 1. Ph\u00e1c \u0111\u1ed3 qu\u1ea3n l\u00fd nhi\u1ec5m toan ceton\" width=\"950\" height=\"633\" title=\"\" srcset=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/10\/phac-do-quan-ly-nhiem-toan-ceton.jpg 950w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/10\/phac-do-quan-ly-nhiem-toan-ceton-600x400.jpg 600w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/10\/phac-do-quan-ly-nhiem-toan-ceton-768x512.jpg 768w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/10\/phac-do-quan-ly-nhiem-toan-ceton-350x233.jpg 350w\" sizes=\"auto, (max-width: 950px) 100vw, 950px\" \/><\/p>\n<figure id=\"attachment_34217\" aria-describedby=\"caption-attachment-34217\" style=\"width: 950px\" class=\"wp-caption alignnone\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-34217 size-full\" src=\"https:\/\/www.vnras.com\/drug\/wp-content\/uploads\/2022\/10\/kiem-soat-benh-nhiem-toan-ceton.jpg\" alt=\"H\u00ccNH 2. M\u1ed9t v\u00ed d\u1ee5 v\u1ec1 m\u1ed9t con \u0111\u01b0\u1eddng \u0111\u01a1n gi\u1ea3n h\u00f3a \u0111\u1ec3 ki\u1ec3m so\u00e1t b\u1ec7nh nhi\u1ec5m toan ceton - \u0111\u01b0\u1ee3c t\u1ea1o b\u1edfi Kind Permission of Punith Kempegowda\" width=\"950\" height=\"633\" title=\"\" srcset=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/10\/kiem-soat-benh-nhiem-toan-ceton.jpg 950w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/10\/kiem-soat-benh-nhiem-toan-ceton-600x400.jpg 600w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/10\/kiem-soat-benh-nhiem-toan-ceton-768x512.jpg 768w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2022\/10\/kiem-soat-benh-nhiem-toan-ceton-350x233.jpg 350w\" sizes=\"auto, (max-width: 950px) 100vw, 950px\" \/><figcaption id=\"caption-attachment-34217\" class=\"wp-caption-text\">H\u00ccNH 2. M\u1ed9t v\u00ed d\u1ee5 v\u1ec1 m\u1ed9t con \u0111\u01b0\u1eddng \u0111\u01a1n gi\u1ea3n h\u00f3a \u0111\u1ec3 ki\u1ec3m so\u00e1t b\u1ec7nh nhi\u1ec5m toan ceton &#8211; \u0111\u01b0\u1ee3c t\u1ea1o b\u1edfi Kind Permission of Punith Kempegowda<\/figcaption><\/figure>\n<h3>1.1 Ch\u1ea9n \u0111o\u00e1n nhi\u1ec5m toan ceton<\/h3>\n<p>T\u1ea5t c\u1ea3 nh\u1eefng \u0111i\u1ec1u n\u00e0y ph\u1ea3i hi\u1ec7n di\u1ec7n \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n:<\/p>\n<p>&#8216;D&#8217; &#8211; n\u1ed3ng \u0111\u1ed9 \u0111\u01b0\u1eddng huy\u1ebft (BG) &gt; 11,0 mmol \/ L ho\u1eb7c \u0111\u01b0\u1ee3c bi\u1ebft l\u00e0 m\u1eafc b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng.<\/p>\n<p>&#8216;K&#8217; &#8211; n\u1ed3ng \u0111\u1ed9 ceton trong mao m\u1ea1ch ho\u1eb7c trong m\u00e1u &gt; 3.0 mmol \/ L ho\u1eb7c ceton ni\u1ec7u \u0111\u00e1ng k\u1ec3 (\u2265 2+ tr\u00ean que n\u01b0\u1edbc ti\u1ec3u ti\u00eau chu\u1ea9n).<\/p>\n<p>&#8216;A&#8217; &#8211; n\u1ed3ng \u0111\u1ed9 bicarbonate &lt; 15,0 mmol \/ L v\u00e0 \/ ho\u1eb7c pH t\u0129nh m\u1ea1ch &lt; 7,3.<\/p>\n<p>\u0110\u1ecbnh ngh\u0129a ADA h\u01a1i kh\u00e1c v\u00e0 n\u00f3 c\u0169ng s\u1eed d\u1ee5ng kho\u1ea3ng tr\u1ed1ng anion nh\u01b0 m\u1ed9t ph\u1ea7n c\u1ee7a ti\u00eau chu\u1ea9n ch\u1ea9n \u0111o\u00e1n \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng.1 Ph\u01b0\u01a1ng tr\u00ecnh ph\u1ed5 bi\u1ebfn nh\u1ea5t \u0111\u1ec3 t\u00ednh kho\u1ea3ng tr\u1ed1ng anion l\u00e0 ([Na + ] + [K + ]) &#8211; ([Cl &#8211; ] + [HCO 3 &#8211; ]). \u0110\u00e3 c\u00f3 m\u1ed9t cu\u1ed9c g\u1ecdi \u0111\u1ec3 c\u1eadp nh\u1eadt h\u01b0\u1edbng d\u1eabn ADA. 2<\/p>\n<h3>1.2 C\u01a1 s\u1edf l\u00fd lu\u1eadn cho th\u1ef1c h\u00e0nh hi\u1ec7n nay<\/h3>\n<h3>1.2.1 Ceton v\u00e0 nhi\u1ec5m toan<\/h3>\n<p>V\u1edbi s\u1ef1 hi\u1ec3u bi\u1ebft s\u00e2u s\u1eafc h\u01a1n v\u1ec1 sinh l\u00fd v\u00e0 h\u00f3a h\u1ecdc axit-baz\u01a1, hi\u1ec7n nay ng\u01b0\u1eddi ta \u0111\u00e3 kh\u1eb3ng \u0111\u1ecbnh r\u00f5 r\u1eb1ng \u0111o kh\u00ed m\u00e1u t\u0129nh m\u1ea1ch c\u00f9ng v\u1edbi \u0111o ceton mao m\u1ea1ch v\u00e0 \u0111o glucose l\u00e0 ch\u00eca kh\u00f3a \u0111\u1ec3 h\u01b0\u1edbng d\u1eabn x\u1eed tr\u00ed nhi\u1ec5m toan ceton.<\/p>\n<p>D\u1eef li\u1ec7u t\u1eeb m\u1ed9t cu\u1ed9c kh\u1ea3o s\u00e1t qu\u1ed1c gia \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n v\u00e0o n\u0103m 2014 t\u1ea1i V\u01b0\u01a1ng qu\u1ed1c Anh cho th\u1ea5y r\u1eb1ng 76% c\u00e1c c\u01a1 s\u1edf c\u00f3 kh\u1ea3 n\u0103ng \u0111o n\u1ed3ng \u0111\u1ed9 ceton b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng x\u00e9t nghi\u1ec7m t\u1ea1i \u0111i\u1ec3m ch\u0103m s\u00f3c. 3 B\u00e1o c\u00e1o n\u0103m 2020 c\u1ee7a NaDIA 2019 (National Inpatient Diabetes Audit) cho th\u1ea5y 71,3% ho\u1eb7c b\u1ec7nh vi\u1ec7n s\u1eed d\u1ee5ng m\u00e1y \u0111o \u0111\u01b0\u1eddng huy\u1ebft t\u1eeb xa (remote\/networked glucose meters). 4 Diabetes UK c\u0169ng khuy\u1ebfn ngh\u1ecb s\u1eed d\u1ee5ng m\u00e1y theo d\u00f5i glucose v\u00e0 ceton t\u1eeb xa trong b\u00e1o c\u00e1o n\u0103m 2018 c\u1ee7a h\u1ecd c\u00f3 t\u1ef1a \u0111\u1ec1 &#8216;L\u00e0m cho c\u00e1c b\u1ec7nh vi\u1ec7n an to\u00e0n cho ng\u01b0\u1eddi b\u1ecb b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng&#8217;. 5<\/p>\n<h3>1.2.2 Nhi\u1ec5m toan ceton \u0111\u1eb3ng \u0111\u01b0\u1eddng huy\u1ebft (euglycaemic ketoacidosis)<\/h3>\n<p>\u0110\u00e2y l\u00e0 s\u1ef1 ph\u00e1t tri\u1ec3n c\u1ee7a nhi\u1ec5m toan chuy\u1ec3n h\u00f3a t\u0103ng kho\u1ea3ng tr\u1ed1ng anion, ceton huy\u1ebft (&gt; 3.0 mmol \/ L) ho\u1eb7c ceton ni\u1ec7u \u0111\u00e1ng k\u1ec3 (t\u1eeb 2+ tr\u1edf l\u00ean tr\u00ean que n\u01b0\u1edbc ti\u1ec3u ti\u00eau chu\u1ea9n) \u1edf nh\u1eefng ng\u01b0\u1eddi \u0111\u01b0\u1ee3c bi\u1ebft l\u00e0 m\u1eafc b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng nh\u01b0ng glucose v\u1eabn b\u00ecnh th\u01b0\u1eddng ho\u1eb7c kh\u00f4ng t\u0103ng \u0111\u1eb7c bi\u1ec7t. C\u1ea3i thi\u1ec7n gi\u00e1o d\u1ee5c cho nh\u1eefng ng\u01b0\u1eddi b\u1ecb b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng v\u1edbi t\u0103ng theo d\u00f5i \u0111\u01b0\u1eddng huy\u1ebft v\u00e0 ceton mao m\u1ea1ch t\u1ea1i nh\u00e0 \u0111\u00e3 d\u1eabn \u0111\u1ebfn \u0111i\u1ec1u tr\u1ecb m\u1ed9t ph\u1ea7n nhi\u1ec5m toan ceton tr\u01b0\u1edbc khi nh\u1eadp vi\u1ec7n v\u1edbi m\u1ee9c BG th\u1ea5p<\/p>\n<p>h\u01a1n khi v\u00e0o vi\u1ec7n. T\u00ecnh tr\u1ea1ng n\u00e0y \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb gi\u1ed1ng h\u1ec7t nh\u01b0 nhi\u1ec5m toan ceton t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft.<\/p>\n<ol>\n<li>B\u1eaft \u0111\u1ea7u ngay l\u1eadp t\u1ee9c glucose 10% \u1edf 125 ml \/ h v\u00ec glucose &lt;14 mmol \/ L<\/li>\n<li>B\u1eaft \u0111\u1ea7u v\u1edbi t\u1ed1c \u0111\u1ed9 insulin 0,1 \u0111\u01a1n v\u1ecb \/ kg \/ h<\/li>\n<li>N\u1ebfu glucose gi\u1ea3m m\u1eb7c d\u00f9 d\u00f9ng glucose 10%, h\u00e3y gi\u1ea3m xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ h \u0111\u1ec3 tr\u00e1nh h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft<\/li>\n<\/ol>\n<p>V\u1edbi vi\u1ec7c s\u1eed d\u1ee5ng r\u1ed9ng r\u00e3i nh\u00f3m thu\u1ed1c \u1ee9c ch\u1ebf SGLT (sodium-glucose cotransporter) (v\u00ed d\u1ee5: dapagliflozin, canagliflozin, empagliflozin, ertugliflozin, sotagliflozin) \u1edf nh\u1eefng ng\u01b0\u1eddi m\u1eafc b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng tu\u00fdp 2 v\u00e0 ng\u00e0y c\u00e0ng t\u0103ng \u1edf nh\u1eefng ng\u01b0\u1eddi m\u1eafc b\u1ec7nh t\u00edp 1, \u0111\u00e3 l\u00e0m n\u1ed5i b\u1eadt t\u1ea7m quan tr\u1ecdng c\u1ee7a s\u1eed d\u1ee5ng pH v\u00e0 ceton (thay v\u00ec ch\u0103m s\u00f3c &#8216;l\u1ea5y glucose l\u00e0m trung t\u00e2m&#8217; c\u0169 h\u01a1n) \u0111\u1ec3 h\u01b0\u1edbng d\u1eabn ch\u1ea9n \u0111o\u00e1n v\u00e0 x\u1eed tr\u00ed. \u0110i\u1ec1u n\u00e0y l\u00e0 do nguy c\u01a1 ph\u00e1t tri\u1ec3n nhi\u1ec5m toan ceton \u0111\u1eb3ng \u0111\u01b0\u1eddng huy\u1ebft v\u1edbi c\u00e1c t\u00e1c nh\u00e2n n\u00e0y. T\u1ef7 l\u1ec7 nhi\u1ec5m toan ceton \u0111\u1eb3ng \u0111\u01b0\u1eddng huy\u1ebft tr\u01b0\u1edbc khi s\u1eed d\u1ee5ng r\u1ed9ng r\u00e3i c\u00e1c ch\u1ea5t \u1ee9c ch\u1ebf SGLT cho th\u1ea5y r\u1eb1ng n\u00f3 kh\u00f4ng ph\u1ea3i l\u00e0 hi\u1ebfm. Tuy nhi\u00ean, t\u1ef7 l\u1ec7 nhi\u1ec5m toan ceton li\u00ean quan \u0111\u1ebfn SGLT trong &#8216;th\u1ebf gi\u1edbi th\u1ef1c&#8217;, t\u1ee9c l\u00e0 b\u00ean ngo\u00e0i d\u00e2n s\u1ed1 th\u1eed nghi\u1ec7m v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c bi\u1ebft \u0111\u1ebfn, nh\u01b0ng c\u00f3 th\u1ec3 cao h\u01a1n d\u1eef li\u1ec7u th\u1eed nghi\u1ec7m \u0111\u1ec1 xu\u1ea5t. \u0110i\u1ec1u n\u00e0y l\u00e0 do s\u1ef1 l\u1ef1a ch\u1ecdn c\u1ea9n th\u1eadn, gi\u00e1o d\u1ee5c v\u00e0 theo d\u00f5i nh\u1eefng ng\u01b0\u1eddi tham gia th\u1eed nghi\u1ec7m c\u0169ng nh\u01b0 c\u00e1c \u0111\u1ecbnh ngh\u0129a kh\u00e1c nhau v\u1ec1 nhi\u1ec5m toan ceton \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong c\u00e1c th\u1eed nghi\u1ec7m. N\u1ebfu t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan ceton x\u1ea3y ra khi s\u1eed d\u1ee5ng thu\u1ed1c \u1ee9c ch\u1ebf SGLT, n\u00ean ng\u1eebng s\u1eed d\u1ee5ng ch\u00fang. C\u00e1c c\u01a1 quan qu\u1ea3n l\u00fd c\u1ea7n \u0111\u01b0\u1ee3c bi\u1ebft v\u1ec1 ph\u1ea3n \u1ee9ng c\u00f3 h\u1ea1i c\u1ee7a thu\u1ed1c. \u1ede V\u01b0\u01a1ng qu\u1ed1c Anh, \u0111i\u1ec1u n\u00e0y l\u00e0 th\u00f4ng qua h\u1ec7 th\u1ed1ng \u201cYellow card\u201d. Li\u1ec7u c\u00f3 n\u00ean b\u1eaft \u0111\u1ea7u l\u1ea1i thu\u1ed1c khi b\u1ec7nh nh\u00e2n \u0111\u00e3 h\u1ed3i ph\u1ee5c hay kh\u00f4ng c\u1ea7n \u0111\u01b0\u1ee3c th\u1ea3o lu\u1eadn v\u1edbi \u0111\u1ed9i ng\u0169 \u0111i\u1ec1u tr\u1ecb \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng.<\/p>\n<h3>1.2.3 B\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng t\u00edp 2 d\u1ec5 nhi\u1ec5m ceton<\/h3>\n<p>Nhi\u1ec5m toan ceton kh\u00f4ng ch\u1ec9 x\u1ea3y ra \u1edf nh\u1eefng ng\u01b0\u1eddi m\u1eafc \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng tu\u00fdp, nh\u1eefng ng\u01b0\u1eddi m\u1eafc \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng t\u00edp 2 c\u0169ng c\u00f3 th\u1ec3 ph\u00e1t tri\u1ec3n nhi\u1ec5m toan ceton \u2014 c\u00f2n g\u1ecdi l\u00e0 &#8216; \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng t\u00edp 2 d\u1ec5 b\u1ecb nhi\u1ec5m ceton&#8217;. 10 \u0110i\u1ec1u n\u00e0y th\u01b0\u1eddng x\u1ea3y ra nh\u1ea5t \u1edf nh\u1eefng ng\u01b0\u1eddi g\u1ed1c Phi-Carib\u00ea ho\u1eb7c g\u1ed1c T\u00e2y Ban Nha. Vi\u1ec7c \u0111i\u1ec1u tr\u1ecb t\u00ecnh tr\u1ea1ng n\u00e0y c\u0169ng gi\u1ed1ng nh\u01b0 \u0111\u1ed1i v\u1edbi nh\u1eefng ng\u01b0\u1eddi b\u1ecb nhi\u1ec5m toan ceton, nh\u01b0ng h\u1ecd th\u01b0\u1eddng gi\u1ea3m insulin nhanh ch\u00f3ng sau khi t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan ceton v\u00e0 t\u00ecnh tr\u1ea1ng th\u00fac \u0111\u1ea9y ti\u1ec1m \u1ea9n \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft.<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h3>1.2.4 Ch\u1ea9n \u0111o\u00e1n ph\u00e2n bi\u1ec7t<\/h3>\n<p>\u0110i\u1ec1u quan tr\u1ecdng l\u00e0 ph\u1ea3i lo\u1ea1i tr\u1eeb c\u00e1c nguy\u00ean nh\u00e2n kh\u00e1c c\u1ee7a nhi\u1ec5m toan ceton, ch\u1eb3ng h\u1ea1n nh\u01b0 nhi\u1ec5m toan ceton do r\u01b0\u1ee3u v\u00e0 nhi\u1ec5m ceton do \u0111\u00f3i (starvation ketosis).<\/p>\n<p>Trong nhi\u1ec5m toan ceton do r\u01b0\u1ee3u, n\u1ed3ng \u0111\u1ed9 glucose b\u00ecnh th\u01b0\u1eddng l\u00e0 \u0111i\u1ec3m kh\u00e1c bi\u1ec7t c\u01a1 b\u1ea3n v\u1edbi nhi\u1ec5m toan ceton &#8211; tuy nhi\u00ean, c\u1ea7n khai th\u00e1c b\u1ec7nh s\u1eed c\u1ea9n th\u1eadn \u0111\u1ec3 ph\u00e2n bi\u1ec7t v\u1edbi nhi\u1ec5m toan ceton \u0111\u1eb3ng \u0111\u01b0\u1eddng huy\u1ebft. Nhi\u1ec5m toan ceton m\u00e0 kh\u00f4ng k\u00e8m t\u0103ng glucose \u1edf m\u1ed9t ng\u01b0\u1eddi nghi\u1ec7n r\u01b0\u1ee3u h\u1ea7u nh\u01b0 \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n l\u00e0 nhi\u1ec5m toan ceton do r\u01b0\u1ee3u. N\u1ebfu nghi ng\u1edd nhi\u1ec5m toan ceton do r\u01b0\u1ee3u, th\u00ec n\u00ean \u0111o \u03b2-hydroxybutyrat mao m\u1ea1ch ch\u1ee9 kh\u00f4ng ph\u1ea3i \u0111o ceton trong n\u01b0\u1edbc ti\u1ec3u v\u00ec qu\u00e1 tr\u00ecnh s\u1ea3n xu\u1ea5t acetoacetate c\u00f3 th\u1ec3 b\u1ecb k\u00ecm h\u00e3m trong nhi\u1ec5m toan ceton do r\u01b0\u1ee3u. Ngo\u00e0i ra, acetoacetate \u0111\u01b0\u1ee3c \u0111o b\u1eb1ng que th\u0103m n\u01b0\u1edbc ti\u1ec3u.<\/p>\n<p>Nhi\u1ec5m ceton do \u0111\u00f3i x\u1ea3y ra do thi\u1ebfu l\u01b0\u1ee3ng carbohydrate v\u00e0 th\u01b0\u1eddng ph\u00e1t tri\u1ec3n trong v\u00e0i ng\u00e0y. Vi\u1ec7c h\u1ea5p th\u1ee5 \u00edt carbohydrate s\u1ebd d\u1eabn \u0111\u1ebfn ti\u1ebft insulin th\u1ea5p, ti\u1ebfp theo l\u00e0 ph\u00e2n gi\u1ea3i lipid v\u00e0 nhi\u1ec5m ceton. N\u1ed3ng \u0111\u1ed9 ceton c\u00f3 th\u1ec3 t\u0103ng l\u00ean tr\u00ean 6 mmol \/ L. 12 Tuy nhi\u00ean, do t\u00ecnh tr\u1ea1ng n\u00e0y ph\u00e1t sinh trong m\u1ed9t th\u1eddi gian d\u00e0i, th\u1eadn s\u1ebd b\u00f9 tr\u1eeb toan c\u00f3 ngh\u0129a l\u00e0 (mi\u1ec5n l\u00e0 c\u00e1c ch\u1ea5t dinh d\u01b0\u1ee1ng kh\u00e1c \u0111\u01b0\u1ee3c \u0103n v\u00e0o) r\u1ed1i lo\u1ea1n axit-baz\u01a1 v\u00e0 \u0111i\u1ec7n gi\u1ea3i th\u01b0\u1eddng \u1edf m\u1ee9c t\u1ed1i thi\u1ec3u.<\/p>\n<h3>1.2.5 Ki\u1ec3m tra t\u1ea1i \u0111i\u1ec3m ch\u0103m s\u00f3c \u2013 point of care testing &#8211; POCT (&#8216;theo d\u00f5i t\u1ea1i gi\u01b0\u1eddng&#8217;)<\/h3>\n<p>C\u00e1c h\u01b0\u1edbng d\u1eabn n\u00e0y khuy\u1ebfn ngh\u1ecb r\u1eb1ng vi\u1ec7c qu\u1ea3n l\u00fd d\u1ef1a tr\u00ean x\u00e9t nghi\u1ec7m POCT c\u1ee7a nh\u1eefng ng\u01b0\u1eddi nh\u1eadp vi\u1ec7n v\u00ec nhi\u1ec5m toan ceton. BG th\u01b0\u1eddng \u0111\u01b0\u1ee3c ki\u1ec3m tra b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng POCT, nh\u01b0ng m\u00e1y \u0111o ceton c\u1ea7m tay hi\u1ec7n nay c\u0169ng cho ph\u00e9p ki\u1ec3m tra 3-beta-hydroxybutyrate, ceton m\u00e1u qua POCT. \u0110o ceton m\u00e1u \u0111\u1ea1i di\u1ec7n cho ph\u01b0\u01a1ng ph\u00e1p t\u1ed1t nh\u1ea5t trong vi\u1ec7c theo d\u00f5i \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb. \u0110\u00e3 c\u00f3 m\u1ed9t s\u1ed1 lo ng\u1ea1i v\u1ec1 \u0111\u1ed9 ch\u00ednh x\u00e1c c\u1ee7a ch\u00fang, nhi\u00ean, cho \u0111\u1ebfn nay, kh\u00f4ng c\u00f3 t\u00e1c h\u1ea1i n\u00e0o \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o t\u1eeb vi\u1ec7c s\u1eed d\u1ee5ng ch\u00fang v\u00e0 d\u1eef li\u1ec7u t\u1eeb c\u00e1c m\u00e1y \u0111o n\u00e0y ch\u1ec9 l\u00e0 m\u1ed9t trong nh\u1eefng ph\u00e9p \u0111o gi\u00fap \u0111\u1ecbnh h\u01b0\u1edbng li\u1ec7u ph\u00e1p \u0111i\u1ec1u tr\u1ecb v\u00e0 ch\u1ea9n \u0111o\u00e1n s\u1ef1 kh\u1ecfi b\u1ec7nh.<\/p>\n<p>Vi\u1ec7c ti\u1ebfp c\u1eadn v\u1edbi kh\u00ed m\u00e1u v\u00e0 \u0111i\u1ec7n gi\u1ea3i hi\u1ec7n nay t\u01b0\u01a1ng \u0111\u1ed1i d\u1ec5 d\u00e0ng v\u00e0 c\u00f3 s\u1eb5n trong v\u00f2ng v\u00e0i ph\u00fat sau khi l\u1ea5y m\u00e1u. Kh\u00ed m\u00e1u t\u0129nh m\u1ea1ch c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng m\u1ed9t c\u00e1ch an to\u00e0n. 16 &#8211; 18 Do \u0111\u00f3, glucose, ceton v\u00e0 ch\u1ea5t \u0111i\u1ec7n gi\u1ea3i, bao g\u1ed3m bicarbonate v\u00e0 pH t\u0129nh m\u1ea1ch, n\u00ean \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 t\u1ea1i ho\u1eb7c g\u1ea7n gi\u01b0\u1eddng b\u1ec7nh b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng x\u00e9t nghi\u1ec7m POCT.<\/p>\n<p>D\u1eef li\u1ec7u cung c\u1ea5p c\u00e1c khuy\u1ebfn ngh\u1ecb n\u00e0y n\u00eau ra c\u00e1c v\u1ea5n \u0111\u1ec1 quan tr\u1ecdng :<\/p>\n<ul>\n<li>Nh\u00e2n vi\u00ean ph\u1ea3i \u0111\u01b0\u1ee3c \u0111\u00e0o t\u1ea1o v\u1ec1 c\u00e1ch s\u1eed d\u1ee5ng m\u00e1y \u0111o BG v\u00e0 ketone POCT ph\u00f9 h\u1ee3p v\u1edbi ch\u00ednh s\u00e1ch x\u00e9t nghi\u1ec7m t\u1ea1i \u0111\u1ecba ph\u01b0\u01a1ng v\u00e0 ch\u1ee9ng minh n\u0103ng l\u1ef1c li\u00ean t\u1ee5c trong vi\u1ec7c s\u1eed d\u1ee5ng ch\u00fang.<\/li>\n<li>M\u00e1y \u0111o ph\u1ea3i \u0111\u01b0\u1ee3c \u0111\u1ea3m b\u1ea3o ch\u1ea5t l\u01b0\u1ee3ng nghi\u00eam ng\u1eb7t<\/li>\n<li>Ph\u00e9p \u0111o trong ph\u00f2ng th\u00ed nghi\u1ec7m s\u1ebd \u0111\u01b0\u1ee3c y\u00eau c\u1ea7u trong m\u1ed9t s\u1ed1 tr\u01b0\u1eddng h\u1ee3p nh\u1ea5t \u0111\u1ecbnh, ch\u1eb3ng h\u1ea1n nh\u01b0 khi m\u00e1y \u0111o BG ho\u1eb7c ceton &#8216;n\u1eb1m ngo\u00e0i gi\u1edbi h\u1ea1n&#8217;<\/li>\n<li>Nh\u00e2n vi\u00ean c\u1ea7n \u0111\u01b0\u1ee3c bi\u1ebft v\u1ec1 c\u00e1c nhi\u1ec5u \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn m\u00e1y \u0111o BG v\u00e0 c\u00e1c t\u00e1c \u0111\u1ed9ng tr\u01b0\u1edbc khi ph\u00e2n t\u00edch nh\u01b0 t\u1eafc v\u00e0 s\u1ed1c ngo\u1ea1i vi.<\/li>\n<\/ul>\n<p>H\u01a1n n\u1eefa, \u0111\u00e0o t\u1ea1o ban \u0111\u1ea7u v\u1edbi c\u00e1c c\u1eadp nh\u1eadt th\u01b0\u1eddng xuy\u00ean v\u00e0 \/ ho\u1eb7c \u0111\u00e1nh gi\u00e1 l\u1ea1i n\u00ean \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n cho t\u1ea5t c\u1ea3 c\u00e1c nh\u00e2n vi\u00ean ch\u0103m s\u00f3c s\u1ee9c kh\u1ecfe s\u1eed d\u1ee5ng thi\u1ebft b\u1ecb POCT v\u00e0 \u0111\u01b0\u1ee3c qu\u1ea3n l\u00fd theo h\u01b0\u1edbng d\u1eabn c\u1ee7a ph\u00f2ng x\u00e9t nghi\u1ec7m \u0111\u1ecba ph\u01b0\u01a1ng. Ngo\u00e0i ra, m\u00e1y \u0111o POCT ph\u1ea3i \u0111\u01b0\u1ee3c ki\u1ec3m tra th\u01b0\u1eddng xuy\u00ean b\u1eb1ng t\u00e0i li\u1ec7u ki\u1ec3m so\u00e1t ch\u1ea5t l\u01b0\u1ee3ng n\u1ed9i b\u1ed9 v\u00e0 ph\u1ea3i th\u1ef1c hi\u1ec7n \u0111\u0103ng k\u00fd ch\u01b0\u01a1ng tr\u00ecnh \u0111\u00e1nh gi\u00e1 ch\u1ea5t l\u01b0\u1ee3ng b\u00ean ngo\u00e0i \u0111\u1ec3 \u0111\u1ea3m b\u1ea3o ch\u1ee9c n\u0103ng ch\u00ednh x\u00e1c c\u1ee7a m\u00e1y \u0111o.<\/p>\n<p>C\u00f4ng nh\u1eadn r\u1eb1ng h\u1ea7u h\u1ebft t\u1ea5t c\u1ea3 c\u00e1c \u0111\u01a1n v\u1ecb hi\u1ec7n nay \u0111\u1ec1u c\u00f3 th\u1ec3 s\u1eed d\u1ee5ng m\u00e1y \u0111o ceton. Tuy nhi\u00ean, h\u01b0\u1edbng d\u1eabn c\u0169ng \u0111\u01b0\u1ee3c \u0111\u01b0a ra v\u1ec1 vi\u1ec7c theo d\u00f5i \u0111i\u1ec1u tr\u1ecb b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng t\u1ed1c \u0111\u1ed9 t\u0103ng bicarbonate v\u00e0 gi\u1ea3m BG nh\u01b0 c\u00e1c bi\u1ec7n ph\u00e1p thay th\u1ebf.<\/p>\n<h2>2. S\u1ef0 THAM GIA C\u1ee6A C\u00c1C NH\u00d3M CHUY\u00caN<\/h2>\n<p>GIA V\u1ec0 B\u1ec6NH \u0110\u00c1I TH\u00c1O \u0110\u01af\u1edcNG<\/p>\n<p>Nh\u00f3m chuy\u00ean gia v\u1ec1 b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng ph\u1ea3i lu\u00f4n tham gia v\u00e0o vi\u1ec7c ch\u0103m s\u00f3c nh\u1eefng b\u1ec7nh nh\u00e2n<\/p>\n<p>nh\u1eadp vi\u1ec7n v\u1edbi t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan ceton. S\u1ef1 tham gia c\u1ee7a h\u1ecd gi\u00fap r\u00fat ng\u1eafn th\u1eddi gian n\u1eb1m vi\u1ec7n v\u00e0<\/p>\n<p>c\u1ea3i thi\u1ec7n \u0111\u1ed9 an to\u00e0n 19 , 20 . \u0110i\u1ec1u n\u00e0y th\u1ef1c hi\u1ec7n c\u00e0ng s\u1edbm c\u00e0ng t\u1ed1t trong giai \u0111o\u1ea1n c\u1ea5p t\u00ednh nh\u01b0ng s\u1ebd<\/p>\n<p>ph\u1ee5 thu\u1ed9c v\u00e0o ho\u00e0n c\u1ea3nh \u0111\u1ecba ph\u01b0\u01a1ng. Ph\u00f9 h\u1ee3p v\u1edbi BPT (Best Practice Tariff) cho nhi\u1ec5m toan ceton,<\/p>\n<p>c\u00e1c b\u00e1c s\u0129 chuy\u00ean khoa c\u0169ng ph\u1ea3i tham gia v\u00e0o vi\u1ec7c \u0111\u00e1nh gi\u00e1 nguy\u00ean nh\u00e2n g\u00e2y nhi\u1ec5m toan ceton,<\/p>\n<p>qu\u1ea3n l\u00fd, xu\u1ea5t vi\u1ec7n v\u00e0 theo d\u00f5i 21 , 22. \u0110i\u1ec1u n\u00e0y c\u1ea7n bao g\u1ed3m vi\u1ec7c \u0111\u00e1nh gi\u00e1 s\u1ef1 hi\u1ec3u bi\u1ebft v\u1ec1 t\u00ecnh tr\u1ea1ng<\/p>\n<p>c\u1ee7a ng\u01b0\u1eddi b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng c\u1ed9ng v\u1edbi th\u00e1i \u0111\u1ed9 v\u00e0 ni\u1ec1m tin c\u1ee7a h\u1ecd c\u0169ng nh\u01b0 \u0111\u1ea3m b\u1ea3o cung c\u1ea5p<\/p>\n<p>gi\u00e1o d\u1ee5c c\u00f3 c\u1ea5u tr\u00fac. S\u1ef1 tham gia c\u1ee7a chuy\u00ean gia l\u00e0 c\u1ea7n thi\u1ebft \u0111\u1ec3 \u0111\u1ea3m b\u1ea3o \u0111\u00e1nh gi\u00e1 th\u01b0\u1eddng xuy\u00ean<\/p>\n<p>v\u00e0 c\u1ea3i ti\u1ebfn ch\u1ea5t l\u01b0\u1ee3ng li\u00ean t\u1ee5c trong vi\u1ec7c th\u1ef1c hi\u1ec7n c\u00e1c h\u01b0\u1edbng d\u1eabn v\u1ec1 nhi\u1ec5m toan ceton. Vi\u1ec7c ti\u1ebfp<\/p>\n<p>nh\u1eadn, \u0111i\u1ec1u tr\u1ecb v\u00e0 xu\u1ea5t vi\u1ec7n nh\u1eefng ng\u01b0\u1eddi b\u1ecb nhi\u1ec5m toan ceton m\u00e0 kh\u00f4ng c\u00f3 s\u1ef1 tham gia c\u1ee7a nh\u00f3m<\/p>\n<p>chuy\u00ean gia v\u1ec1 b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng c\u00f3 th\u1ec3 \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn vi\u1ec7c ch\u0103m s\u00f3c b\u1ec7nh nh\u00e2n an to\u00e0n. Vi\u1ec7c<\/p>\n<p>ki\u1ec3m tra v\u00e0 gi\u00e1m s\u00e1t th\u01b0\u1eddng xuy\u00ean k\u1ebft qu\u1ea3 nhi\u1ec5m toan ceton v\u00e0 k\u1ebft qu\u1ea3 ho\u1ea1t \u0111\u1ed9ng c\u1ee7a c\u00e1c nh\u00f3m<\/p>\n<p>chuy\u00ean gia v\u00e0 kh\u00f4ng chuy\u00ean khoa c\u00f3 th\u1ec3 kh\u00f4ng \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n th\u01b0\u1eddng xuy\u00ean. 3<\/p>\n<p>2.1 C\u00e1c v\u1ea5n \u0111\u1ec1 chung v\u1ec1 qu\u1ea3n l\u00fd<\/p>\n<p>2.1.1 Qu\u1ea3n l\u00fd d\u1ecbch v\u00e0 nh\u1eefng thi\u1ebfu h\u1ee5t<\/p>\n<p>C\u00f3 s\u1ef1 th\u1ed1ng nh\u1ea5t chung r\u1eb1ng can thi\u1ec7p \u0111i\u1ec1u tr\u1ecb ban \u0111\u1ea7u quan tr\u1ecdng nh\u1ea5t trong nhi\u1ec5m toan ceton l\u00e0<\/p>\n<p>b\u00f9 d\u1ecbch th\u00edch h\u1ee3p, sau \u0111\u00f3 l\u00e0 d\u00f9ng insulin.<\/p>\n<p>M\u1ee5c \u0111\u00edch ch\u00ednh c\u1ee7a vi\u1ec7c b\u00f9 d\u1ecbch nh\u01b0 sau:<\/p>\n<ul>\n<li>Ph\u1ee5c h\u1ed3i th\u1ec3 t\u00edch tu\u1ea7n ho\u00e0n<\/li>\n<li>Thanh th\u1ea3i ceton<\/li>\n<li>\u0110i\u1ec1u ch\u1ec9nh s\u1ef1 m\u1ea5t c\u00e2n b\u1eb1ng \u0111i\u1ec7n gi\u1ea3i<\/li>\n<\/ul>\n<p>S\u1ef1 thi\u1ebfu h\u1ee5t d\u1ecbch v\u00e0 \u0111i\u1ec7n gi\u1ea3i \u0111i\u1ec3n h\u00ecnh \u0111\u01b0\u1ee3c th\u1ec3 hi\u1ec7n trong B\u1ea3ng 1 . V\u00ed d\u1ee5, m\u1ed9t ng\u01b0\u1eddi l\u1edbn n\u1eb7ng<\/p>\n<p>70 kg b\u1ecb nhi\u1ec5m toan ceton c\u00f3 th\u1ec3 b\u1ecb th\u00e2m h\u1ee5t t\u1edbi 7 L. N\u00ean \u0111\u01b0\u1ee3c b\u00f9 b\u1eb1ng d\u1ecbch tinh th\u1ec3. \u1ede nh\u1eefng<\/p>\n<p>ng\u01b0\u1eddi b\u1ecb suy th\u1eadn ho\u1eb7c suy tim, c\u0169ng nh\u01b0 ng\u01b0\u1eddi gi\u00e0 v\u00e0 thanh thi\u1ebfu ni\u00ean, t\u1ed1c \u0111\u1ed9 v\u00e0 th\u1ec3 t\u00edch b\u00f9 d\u1ecbch<\/p>\n<p>c\u00f3 th\u1ec3 c\u1ea7n \u0111\u01b0\u1ee3c \u0111i\u1ec1u ch\u1ec9nh. M\u1ee5c \u0111\u00edch c\u1ee7a v\u00e0i l\u00edt d\u1ecbch \u0111\u1ea7u ti\u00ean l\u00e0 \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh b\u1ea5t k\u1ef3 t\u00ecnh tr\u1ea1ng h\u1ea1<\/p>\n<p>huy\u1ebft \u00e1p n\u00e0o, b\u1ed5 sung s\u1ef1 thi\u1ebfu h\u1ee5t trong l\u00f2ng m\u1ea1ch v\u00e0 ch\u1ed1ng l\u1ea1i t\u00e1c \u0111\u1ed9ng c\u1ee7a b\u00e0i ni\u1ec7u th\u1ea9m th\u1ea5u<\/p>\n<p>v\u1edbi vi\u1ec7c \u0111i\u1ec1u ch\u1ec9nh r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i.<\/p>\n<p>B\u1ea2NG 1. C\u00e1c thi\u1ebfu h\u1ee5t \u0111i\u1ec3n h\u00ecnh trong nhi\u1ec5m toan ceton \u1edf ng\u01b0\u1eddi l\u1edbn<\/p>\n<table style=\"border-collapse: collapse; width: 100%; height: 105px;\">\n<tbody>\n<tr style=\"height: 21px;\">\n<td style=\"width: 50%; height: 21px;\">N\u01b0\u1edbc<\/td>\n<td style=\"width: 50%; height: 21px;\">100 ml \/ kg<\/td>\n<\/tr>\n<tr style=\"height: 21px;\">\n<td style=\"width: 50%; height: 21px;\">Natri<\/td>\n<td style=\"width: 50%; height: 21px;\">7\u201310 mmol \/ kg<\/td>\n<\/tr>\n<tr style=\"height: 21px;\">\n<td style=\"width: 50%; height: 21px;\">Clorua<\/td>\n<td style=\"width: 50%; height: 21px;\">3\u20135 mmol \/ kg<\/td>\n<\/tr>\n<tr style=\"height: 21px;\">\n<td style=\"width: 50%; height: 21px;\">Kali<\/td>\n<td style=\"width: 50%; height: 21px;\">3\u20135 mmol \/ kg<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Lo\u1ea1i d\u1ecbch b\u00f9 ban \u0111\u1ea7u \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn l\u00e0 natri clorid 0,9%. Nh\u01b0ng m\u1ed9t khi BG gi\u1ea3m xu\u1ed1ng d\u01b0\u1edbi 14,0\u00a0mmol \/ L, d\u1ecbch truy\u1ec1n dextrose 10% n\u00ean \u0111\u01b0\u1ee3c th\u00eam v\u00e0o \u0111\u1ec3 ho\u1ea1t \u0111\u1ed9ng nh\u01b0 ch\u1ea5t n\u1ec1n cho insulin, \u0111\u1ec3\u00a0ng\u0103n ng\u1eeba h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft. T\u1ea1i sao nh\u1eefng lo\u1ea1i d\u1ecbch n\u00e0y \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng s\u1ebd \u0111\u01b0\u1ee3c th\u1ea3o lu\u1eadn chi ti\u1ebft\u00a0trong <em>C\u00e1c khu v\u1ef1c g\u00e2y tranh c\u00e3i<\/em> .<\/p>\n<h3>2.1.2 Li\u1ec7u ph\u00e1p insulin<\/h3>\n<p>N\u00ean truy\u1ec1n insulin t\u0129nh m\u1ea1ch t\u1ed1c \u0111\u1ed9 c\u1ed1 \u0111\u1ecbnh (FRIII: fix rate intravenous insulin infusion) t\u00ednh tr\u00ean 0,1 \u0111\u01a1n v\u1ecb \/ kg (xem B\u1ea3ng 2 ). C\u00f3 th\u1ec3 c\u1ea7n ph\u1ea3i \u01b0\u1edbc t\u00ednh tr\u1ecdng l\u01b0\u1ee3ng c\u1ee7a c\u00e1 nh\u00e2n. Insulin c\u00f3 m\u1ed9t s\u1ed1 t\u00e1c d\u1ee5ng, nh\u01b0ng nh\u1eefng t\u00e1c d\u1ee5ng sau \u0111\u00e2y l\u00e0 quan tr\u1ecdng nh\u1ea5t khi \u0111i\u1ec1u tr\u1ecb nhi\u1ec5m toan ceton:<\/p>\n<ul>\n<li>\u1ee8c ch\u1ebf s\u1ef1 t\u1ea1o ceton<\/li>\n<li>Gi\u1ea3m BG<\/li>\n<li>\u0110i\u1ec1u ch\u1ec9nh r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i<\/li>\n<\/ul>\n<p>B\u1ea2NG 2. T\u00ednh li\u1ec1u insulin theo c\u00e2n n\u1eb7ng<\/p>\n<table>\n<tbody>\n<tr>\n<td>Tr\u1ecdng l\u01b0\u1ee3ng t\u00ednh b\u1eb1ng kg<\/td>\n<td>Li\u1ec1u insulin m\u1ed7i gi\u1edd (\u0111\u01a1n v\u1ecb) \u1edf 0,1 \u0111\u01a1n v\u1ecb \/ kg \/ h n\u1ebfu glucose \u226514 mmol \/ L<\/td>\n<\/tr>\n<tr>\n<td>40\u201349<\/td>\n<td>4<\/td>\n<\/tr>\n<tr>\n<td>50\u201359<\/td>\n<td>5<\/td>\n<\/tr>\n<tr>\n<td>60-69<\/td>\n<td>6<\/td>\n<\/tr>\n<tr>\n<td>70-79<\/td>\n<td>7<\/td>\n<\/tr>\n<tr>\n<td>80-89<\/td>\n<td>8<\/td>\n<\/tr>\n<tr>\n<td>90-99<\/td>\n<td>9<\/td>\n<\/tr>\n<tr>\n<td>100-109<\/td>\n<td>10<\/td>\n<\/tr>\n<tr>\n<td>110-119<\/td>\n<td>11<\/td>\n<\/tr>\n<tr>\n<td>120-130<\/td>\n<td>12<\/td>\n<\/tr>\n<tr>\n<td>130-139<\/td>\n<td>13<\/td>\n<\/tr>\n<tr>\n<td>140-150<\/td>\n<td>14<\/td>\n<\/tr>\n<tr>\n<td>&gt;150<\/td>\n<td>15 (b\u1ea5t k\u1ef3 li\u1ec1u n\u00e0o cao h\u01a1n m\u1ee9c n\u00e0y ph\u1ea3i theo l\u1eddi khuy\u00ean c\u1ee7a Nh\u00f3m chuy\u00ean gia v\u1ec1 b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<table>\n<tbody>\n<tr>\n<td>Tr\u1ecdng l\u01b0\u1ee3ng t\u00ednh b\u1eb1ng kg<\/td>\n<td>Li\u1ec1u insulin m\u1ed7i gi\u1edd (\u0111\u01a1n v\u1ecb) 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ h\u00a0n\u1ebfu glucose &lt;14 mmol \/ L<\/td>\n<\/tr>\n<tr>\n<td>40\u201349<\/td>\n<td>2<\/td>\n<\/tr>\n<tr>\n<td>50\u201359<\/td>\n<td>2.5<\/td>\n<\/tr>\n<tr>\n<td>60-69<\/td>\n<td>3<\/td>\n<\/tr>\n<tr>\n<td>70-79<\/td>\n<td>3.5<\/td>\n<\/tr>\n<tr>\n<td>80-89<\/td>\n<td>4<\/td>\n<\/tr>\n<tr>\n<td>90-99<\/td>\n<td>4.5<\/td>\n<\/tr>\n<tr>\n<td>100-109<\/td>\n<td>5<\/td>\n<\/tr>\n<tr>\n<td>110-119<\/td>\n<td>5.5<\/td>\n<\/tr>\n<tr>\n<td>120-130<\/td>\n<td>6<\/td>\n<\/tr>\n<tr>\n<td>130-139<\/td>\n<td>6.5<\/td>\n<\/tr>\n<tr>\n<td>140-150<\/td>\n<td>7<\/td>\n<\/tr>\n<tr>\n<td>&gt;150<\/td>\n<td>7.5<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>D\u1ecbch truy\u1ec1n insulin \u0111\u01b0\u1ee3c t\u1ea1o th\u00e0nh t\u1eeb 50 \u0111\u01a1n v\u1ecb insulin h\u00f2a tan trong 49,5 ml dung d\u1ecbch natri clorid 0,9% (t\u1ee9c l\u00e0 1 \u0111\u01a1n v\u1ecb \/ ml). B\u1ea3ng 2 h\u1ed7 tr\u1ee3 t\u00ednh to\u00e1n li\u1ec1u l\u01b0\u1ee3ng insulin theo c\u00e2n n\u1eb7ng:<\/p>\n<p>Khi glucose gi\u1ea3m xu\u1ed1ng &lt;14 mmol \/ L th\u00ec ngo\u00e0i vi\u1ec7c b\u1ed5 sung th\u00eam d\u1ecbch truy\u1ec1n dextrose 10%, h\u00e3y c\u00e2n nh\u1eafc gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin t\u0129nh m\u1ea1ch xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ h \u0111\u1ec3 tr\u00e1nh nguy c\u01a1 ph\u00e1t tri\u1ec3n h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft v\u00e0 h\u1ea1 kali m\u00e1u.<\/p>\n<h3>2.1.3 M\u1ee5c ti\u00eau \u0111i\u1ec1u tr\u1ecb chuy\u1ec3n h\u00f3a<\/h3>\n<p>C\u00e1c m\u1ee5c ti\u00eau \u0111\u01b0\u1ee3c \u0111\u1ec1 xu\u1ea5t l\u00e0<\/p>\n<ul>\n<li>Gi\u1ea3m n\u1ed3ng \u0111\u1ed9 ceton trong m\u00e1u 0,5 mmol \/ L \/ h<\/li>\n<li>T\u0103ng bicarbonate t\u0129nh m\u1ea1ch th\u00eam 3,0 mmol \/ L \/ h<\/li>\n<li>Gi\u1ea3m BG mao m\u1ea1ch 3.0 mmol \/ L \/ h<\/li>\n<li>Duy tr\u00ec kali t\u1eeb 4,0 \u0111\u1ebfn 5,5 mmol \/ L<\/li>\n<\/ul>\n<p>N\u1ebfu c\u00e1c m\u1ee5c ti\u00eau n\u00e0y kh\u00f4ng \u0111\u1ea1t \u0111\u01b0\u1ee3c, th\u00ec t\u1ed1c \u0111\u1ed9 FRIII n\u00ean \u0111\u01b0\u1ee3c t\u0103ng l\u00ean (xem Qu\u1ea3n l\u00fd DKA Ph\u1ea7n B, H\u00e0nh \u0111\u1ed9ng 2).<\/p>\n<h3>2.1.4 Ti\u1ebfp t\u1ee5c insulin n\u1ec1n v\u00e0 t\u0129nh m\u1ea1ch v\u00e0 n\u1ed3ng \u0111\u1ed9 glucose t\u0129nh m\u1ea1ch<\/h3>\n<p>\u0110\u1ec3 \u0111\u1ea3m b\u1ea3o r\u1eb1ng ceton \u0111\u01b0\u1ee3c \u0111\u00e0o th\u1ea3i, FRIII n\u00ean \u0111\u01b0\u1ee3c ti\u1ebfp t\u1ee5c c\u0169ng nh\u01b0 truy\u1ec1n dung d\u1ecbch natri clorid 0,9% \u0111\u1ec3 duy tr\u00ec b\u00f9 d\u1ecbch. Nh\u01b0ng m\u1ed9t khi BG gi\u1ea3m xu\u1ed1ng d\u01b0\u1edbi 14,0 mmol \/ L, n\u00ean th\u00eam d\u1ecbch truy\u1ec1n dextrose 10% \u0111\u1ec3 ho\u1ea1t \u0111\u1ed9ng nh\u01b0 ch\u1ea5t n\u1ec1n cho insulin, \u0111\u1ec3 ng\u0103n ng\u1eeba h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft. Th\u01b0\u1eddng c\u1ea7n truy\u1ec1n \u0111\u1ed3ng th\u1eddi dung d\u1ecbch natri clorid 0,9% v\u00e0 dextrose 10% (Ph\u1ea7n B, H\u00e0nh \u0111\u1ed9ng 2). Kh\u00f4ng n\u00ean ng\u1eebng insulin v\u00e0 dextrose t\u0129nh m\u1ea1ch cho \u0111\u1ebfn khi BN \u0103n u\u1ed1ng b\u00ecnh th\u01b0\u1eddng.<\/p>\n<p>\u0110\u1ed1i v\u1edbi nh\u1eefng ng\u01b0\u1eddi \u0111\u00e3 s\u1eed d\u1ee5ng insulin n\u1ec1n t\u00e1c d\u1ee5ng d\u00e0i, n\u00f3 n\u00ean \u0111\u01b0\u1ee3c ti\u1ebfp t\u1ee5c s\u1eed d\u1ee5ng v\u1edbi li\u1ec1u l\u01b0\u1ee3ng th\u00f4ng th\u01b0\u1eddng c\u1ee7a h\u1ecd. \u1ede nh\u1eefng ng\u01b0\u1eddi m\u1edbi \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n, n\u00ean b\u1eaft \u0111\u1ea7u s\u1eed d\u1ee5ng insulin n\u1ec1n t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i, v\u1edbi li\u1ec1u 0,25 \u0111\u01a1n v\u1ecb \/ Kg ti\u00eam d\u01b0\u1edbi da m\u1ed9t l\u1ea7n m\u1ed7i ng\u00e0y.<\/p>\n<h3>2.2 C\u00e1c \u0111\u1ed1i t\u01b0\u1ee3ng \u0111\u1eb7c bi\u1ec7t<\/h3>\n<p>C\u00e1c \u0111\u1ed1i t\u01b0\u1ee3ng sau \u0111\u00e2y c\u1ea7n \u00fd ki\u1ebfn chuy\u00ean gia c\u00e0ng s\u1edbm c\u00e0ng t\u1ed1t v\u00e0 c\u1ea7n \u0111\u1eb7c bi\u1ec7t ch\u00fa \u00fd \u0111\u1ebfn s\u1ef1 c\u00e2n b\u1eb1ng d\u1ecbch c\u1ee7a h\u1ecd:<\/p>\n<ul>\n<li>Ng\u01b0\u1eddi gi\u00e0<\/li>\n<li>C\u00f3 thai<\/li>\n<li>Thanh ni\u00ean 18\u201325 tu\u1ed5i (xem ph\u1ea7n ph\u00f9 n\u00e3o)<\/li>\n<li>Suy tim ho\u1eb7c th\u1eadn<\/li>\n<li>C\u00e1c b\u1ec7nh \u0111\u1ed3ng m\u1eafc nghi\u00eam tr\u1ecdng kh\u00e1c<\/li>\n<\/ul>\n<h3>2.3 C\u00e1c c\u00e2n nh\u1eafc kh\u00e1c<\/h3>\n<p>Ph\u00f9 h\u1ee3p v\u1edbi m\u1ed9t s\u1ed1 kh\u00eda c\u1ea1nh c\u1ee7a BPT, nh\u1eefng ng\u01b0\u1eddi m\u1eafc b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng nh\u1eadp vi\u1ec7n v\u1edbi nhi\u1ec5m toan ceton n\u00ean \u0111\u01b0\u1ee3c gi\u1edbi thi\u1ec7u \u0111\u1ebfn nh\u00f3m chuy\u00ean gia \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng trong v\u00f2ng m\u1ed9t ng\u00e0y. C\u1ea7n t\u1eadn d\u1ee5ng m\u1ecdi c\u01a1 h\u1ed9i \u0111\u1ec3 gi\u00e1o d\u1ee5c BN. \u0110\u1eb7c bi\u1ec7t, h\u1ecd n\u00ean \u0111\u01b0\u1ee3c t\u01b0 v\u1ea5n v\u1ec1 c\u00e1c nguy\u00ean nh\u00e2n g\u00e2y b\u1ec7nh v\u00e0 c\u00e1c tri\u1ec7u ch\u1ee9ng c\u1ea3nh b\u00e1o s\u1edbm. Nh\u1eefng \u0111i\u1ec1u c\u1ea7n xem x\u00e9t l\u00e0:<\/p>\n<ul>\n<li>X\u00e1c \u0111\u1ecbnh (c\u00e1c) y\u1ebfu t\u1ed1 th\u00fac \u0111\u1ea9y, v\u00ed d\u1ee5, b\u1ec7nh t\u1eebng \u0111\u1ee3t ho\u1eb7c b\u1ecf qua vi\u1ec7c ti\u00eam insulin<\/li>\n<li>Xem x\u00e9t ki\u1ec3m so\u00e1t \u0111\u01b0\u1eddng huy\u1ebft th\u00f4ng th\u01b0\u1eddng c\u1ee7a h\u1ecd<\/li>\n<li>Xem x\u00e9t k\u1ef9 thu\u1eadt ti\u00eam \/ gi\u00e1m s\u00e1t BG \/ thi\u1ebft b\u1ecb \/ v\u1ecb tr\u00ed ti\u00eam<\/li>\n<li>\u0110\u1ed1i v\u1edbi nh\u1eefng ng\u01b0\u1eddi s\u1eed d\u1ee5ng m\u00e1y b\u01a1m insulin, h\u00e3y xem x\u00e9t vi\u1ec7c s\u1eed d\u1ee5ng thi\u1ebft b\u1ecb c\u1ee7a h\u1ecd v\u00e0 cung c\u1ea5p ch\u01b0\u01a1ng tr\u00ecnh \u0111\u00e0o t\u1ea1o th\u00eam v\u1ec1 vi\u1ec7c s\u1eed d\u1ee5ng c\u00f4ng ngh\u1ec7 \u0111\u00f3, n\u1ebfu c\u1ea7n<\/li>\n<li>Ph\u00f2ng ng\u1eeba t\u00e1i ph\u00e1t, v\u00ed d\u1ee5, cung c\u1ea5p c\u00e1c quy t\u1eafc vi\u1ebft v\u1ec1 ng\u00e0y \u1ed1m<\/li>\n<li>Hi\u1ec7u qu\u1ea3 c\u1ee7a insulin, v\u00ed d\u1ee5, insulin c\u1ee7a ch\u00ednh h\u1ecd c\u00f3 th\u1ec3 h\u1ebft h\u1ea1n ho\u1eb7c b\u1ecb bi\u1ebfn t\u00ednh. \u0110i\u1ec1u n\u00e0y n\u00ean \u0111\u01b0\u1ee3c ki\u1ec3m tra tr\u01b0\u1edbc khi s\u1eed d\u1ee5ng l\u1ea1i<\/li>\n<li>\u0110\u00e1nh gi\u00e1 nhu c\u1ea7u v\u00e0 khi c\u1ea7n thi\u1ebft, cung c\u1ea5p m\u00e1y \u0111o ceton c\u1ea7m tay \u0111\u1ec3 s\u1eed d\u1ee5ng t\u1ea1i nh\u00e0 &#8211; \u0111\u00e2y ph\u1ea3i l\u00e0 v\u1ecb tr\u00ed m\u1eb7c \u0111\u1ecbnh<\/li>\n<li>Cung c\u1ea5p s\u1ed1 li\u00ean l\u1ea1c v\u1ec1 c\u00e1ch li\u00ean h\u1ec7 v\u1edbi nh\u00f3m chuy\u00ean gia \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng ngo\u00e0i gi\u1edd<\/li>\n<li>Gi\u00e1o d\u1ee5c c\u1ee7a c\u00e1c chuy\u00ean gia ch\u0103m s\u00f3c s\u1ee9c kh\u1ecfe v\u1ec1 c\u00e1ch qu\u1ea3n l\u00fd ceton m\u00e1u<\/li>\n<li>Cung c\u1ea5p m\u1ed9t k\u1ebf ho\u1ea1ch ch\u0103m s\u00f3c b\u1eb1ng v\u0103n b\u1ea3n \u2014 cho ph\u00e9p BN c\u00f3 vai tr\u00f2 t\u00edch c\u1ef1c trong vi\u1ec7c qu\u1ea3n l\u00fd b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng c\u1ee7a h\u1ecd, v\u1edbi m\u1ed9t b\u1ea3n sao c\u1ee7a k\u1ebf ho\u1ea1ch n\u00e0y s\u1ebd \u0111\u01b0\u1ee3c g\u1eedi cho b\u00e1c s\u0129 gia \u0111\u00ecnh c\u1ee7a h\u1ecd<\/li>\n<li>\u0110\u1ed1i v\u1edbi nh\u1eefng ng\u01b0\u1eddi nh\u1eadp vi\u1ec7n t\u00e1i ph\u00e1t, th\u01b0\u1eddng c\u00f3 y\u1ebfu t\u1ed1 t\u00e2m l\u00fd (v\u00ed d\u1ee5: r\u1ed1i lo\u1ea1n \u0103n u\u1ed1ng, c\u00e1c r\u1ed1i lo\u1ea1n s\u1ee9c kh\u1ecfe t\u00e2m th\u1ea7n ch\u01b0a \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n kh\u00e1c), c\u00f3 kh\u1ea3 n\u0103ng \u0111\u01b0\u1ee3c h\u01b0\u1edfng l\u1ee3i t\u1eeb s\u1ef1 tham gia c\u1ee7a nh\u00f3m s\u1ee9c kh\u1ecfe t\u00e2m th\u1ea7n ch\u00ednh th\u1ee9c.<\/li>\n<\/ul>\n<h3>2.4 Nhi\u1ec5m toan ceton t\u00e1i ph\u00e1t<\/h3>\n<p>Nh\u1eefng ng\u01b0\u1eddi b\u1ecb nhi\u1ec5m toan ceton t\u00e1i ph\u00e1t nhi\u1ec1u l\u1ea7n (t\u1ee9c l\u00e0 h\u01a1n m\u1ed9t \u0111\u1ee3t m\u1ed7i n\u0103m) chi\u1ebfm m\u1ed9t t\u1ef7 l\u1ec7 \u0111\u00e1ng k\u1ec3 trong s\u1ed1 t\u1ea5t c\u1ea3 c\u00e1c tr\u01b0\u1eddng h\u1ee3p nhi\u1ec5m toan ceton nh\u1eadp vi\u1ec7n &#8211; \u1edf V\u01b0\u01a1ng qu\u1ed1c Anh, chi\u1ebfm 66% nh\u1eefng ng\u01b0\u1eddi m\u1eafc b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng tu\u00fdp 1 v\u00e0 35% nh\u1eefng ng\u01b0\u1eddi m\u1eafc b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng t\u00edp 2 . 23 Nhi\u1ec1u ng\u01b0\u1eddi trong s\u1ed1 nh\u1eefng ng\u01b0\u1eddi n\u00e0y c\u00f3 s\u1ef1 ch\u0103m s\u00f3c r\u1eddi r\u1ea1c, nh\u1eefng c\u00e2n nh\u1eafc v\u1ec1 x\u00e3 h\u1ed9i, h\u00e0nh vi ho\u1eb7c t\u00e2m l\u00fd c\u1ea7n \u0111\u01b0\u1ee3c t\u00ednh \u0111\u1ebfn. 24 , 25 C\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 kh\u00e1c c\u1ee7a c\u00e1c \u0111\u1ee3t t\u00e1i ph\u00e1t bao g\u1ed3m<\/p>\n<p>gi\u1edbi t\u00ednh n\u1eef, tu\u1ed5i v\u1ecb th\u00e0nh ni\u00ean, t\u00ecnh tr\u1ea1ng kinh t\u1ebf x\u00e3 h\u1ed9i th\u1ea5p v\u00e0 nh\u1eadp vi\u1ec7n nhi\u1ec5m toan ceton tr\u01b0\u1edbc \u0111\u00f3. C\u00e1c \u0111\u1ee3t nhi\u1ec5m toan ceton t\u00e1i ph\u00e1t c\u00f3 li\u00ean quan \u0111\u1ebfn t\u0103ng nguy c\u01a1 suy gi\u1ea3m nh\u1eadn th\u1ee9c l\u00e2u d\u00e0i v\u00e0 t\u1eed vong s\u1edbm. C\u00e1c chi\u1ebfn l\u01b0\u1ee3c \u0111\u1ec3 gi\u00fap \u0111\u1ee1 c\u00e1c c\u00e1 nh\u00e2n c\u00f3 th\u1ec3 bao g\u1ed3m li\u00ean l\u1ea1c qua \u0111i\u1ec7n tho\u1ea1i th\u01b0\u1eddng xuy\u00ean, gi\u1edbi thi\u1ec7u ch\u00ednh th\u1ee9c \u0111\u1ebfn t\u00e2m l\u00fd h\u1ecdc, qu\u1ea3n l\u00fd insulin c\u00f3 gi\u00e1m s\u00e1t \u2014 v\u00ed d\u1ee5, s\u1eed d\u1ee5ng c\u00e1c ch\u1ea5t t\u01b0\u01a1ng t\u1ef1 insulin t\u00e1c d\u1ee5ng si\u00eau d\u00e0i.<\/p>\n<h3>2.5 C\u00e1c l\u0129nh v\u1ef1c g\u00e2y tranh c\u00e3i<\/h3>\n<p>M\u1eb7c d\u00f9 \u0111\u00e1nh gi\u00e1 l\u00e2m s\u00e0ng v\u00e0 m\u1ee5c ti\u00eau \u0111i\u1ec1u tr\u1ecb trong x\u1eed tr\u00ed nhi\u1ec5m toan ceton kh\u00f4ng c\u00f2n b\u00e0n c\u00e3i, nh\u01b0ng v\u1eabn c\u00f2n b\u1ea5t \u0111\u1ed3ng v\u1ec1 ph\u00e1c \u0111\u1ed3 \u0111i\u1ec1u tr\u1ecb t\u1ed1i \u01b0u. Trong tr\u01b0\u1eddng h\u1ee3p c\u01a1 s\u1edf b\u1eb1ng ch\u1ee9ng kh\u00f4ng m\u1ea1nh, c\u00e1c khuy\u1ebfn ngh\u1ecb d\u1ef1a tr\u00ean s\u1ef1 \u0111\u1ed3ng thu\u1eadn v\u00e0 kinh nghi\u1ec7m. M\u1ed9t s\u1ed1 \u0111i\u1ec3m g\u00e2y tranh c\u00e3i h\u01a1n b\u00e2y gi\u1edd s\u1ebd \u0111\u01b0\u1ee3c xem x\u00e9t v\u00e0 \u0111\u01b0a ra c\u00e1c khuy\u1ebfn ngh\u1ecb th\u1ef1c h\u00e0nh t\u1ed1t. C\u00e1c khuy\u1ebfn ngh\u1ecb \u0111\u01b0\u1ee3c \u0111\u01b0a ra \u0111\u1ea7u ti\u00ean sau \u0111\u00f3 l\u00e0 c\u01a1 s\u1edf l\u00fd lu\u1eadn. S\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa c\u00e1c h\u01b0\u1edbng d\u1eabn c\u1ee7a Hoa K\u1ef3 v\u00e0 V\u01b0\u01a1ng qu\u1ed1c Anh \u0111\u01b0\u1ee3c th\u1ea3o lu\u1eadn \u1edf nh\u1eefng n\u01a1i kh\u00e1c.<\/p>\n<p>C\u00f3 m\u1ed9t s\u1ed1 v\u1ea5n \u0111\u1ec1 \u0111\u01b0\u1ee3c coi l\u00e0 &#8216;g\u00e2y tranh c\u00e3i&#8217; trong c\u00e1c phi\u00ean b\u1ea3n tr\u01b0\u1edbc c\u1ee7a t\u00e0i li\u1ec7u n\u00e0y, nay \u0111\u00e3 tr\u1edf th\u00e0nh th\u00f4ng l\u1ec7 ti\u00eau chu\u1ea9n. Ch\u00fang \u0111\u00e3 b\u1ecb x\u00f3a kh\u1ecfi ph\u1ea7n n\u00e0y. Nh\u1eefng \u0111i\u1ec1u n\u00e0y nh\u01b0 sau:<\/p>\n<ol>\n<li>\u0110o \u0111\u1ed9 pH v\u00e0 bicarbonate trong t\u0129nh m\u1ea1ch h\u01a1n l\u00e0 \u0111\u1ed9ng m\u1ea1ch<\/li>\n<li>M\u00e1y \u0111o ketone trong m\u00e1u n\u00ean \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng cho POCT<\/li>\n<li>Dung d\u1ecbch natri clorua 0,9% l\u00e0 ch\u1ea5t l\u1ecfng \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o l\u1ef1a ch\u1ecdn t\u1ea1i ph\u00f2ng y t\u1ebf t\u1ed5ng qu\u00e1t (\u0111\u01b0\u1ee3c khuy\u1ebfn ngh\u1ecb v\u00ec n\u00f3 \u0111\u01b0\u1ee3c b\u00e1n tr\u00ean th\u1ecb tr\u01b0\u1eddng v\u1edbi kali clorid pha s\u1eb5n, v\u00e0 do \u0111\u00f3, tu\u00e2n theo khuy\u1ebfn ngh\u1ecb c\u1ee7a NPSA)<\/li>\n<li>Insulin ng\u01b0\u1eddi \/ analogue t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i ti\u00eam d\u01b0\u1edbi da n\u00ean \u0111\u01b0\u1ee3c ti\u1ebfp t\u1ee5c<\/li>\n<li>Insulin n\u00ean \u0111\u01b0\u1ee3c d\u00f9ng d\u01b0\u1edbi d\u1ea1ng FRIII \u0111\u01b0\u1ee3c t\u00ednh theo tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3<\/li>\n<li>Kh\u00f4ng s\u1eed d\u1ee5ng li\u1ec1u insulin m\u1ed3i (bolus)<\/li>\n<\/ol>\n<h3>2.6 C\u00e1c khuy\u1ebfn ngh\u1ecb<\/h3>\n<ol>\n<li>C\u00e2n nh\u1eafc gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ h khi glucose gi\u1ea3m xu\u1ed1ng &lt;14 mmol \/ L<\/li>\n<li>Dung d\u1ecbch tinh th\u1ec3 ch\u1ee9 kh\u00f4ng ph\u1ea3i dung d\u1ecbch keo \u0111\u01b0\u1ee3c khuy\u1ebfn kh\u00edch \u0111\u1ec3 h\u1ed3i s\u1ee9c d\u1ecbch<\/li>\n<li>Dung d\u1ecbch natri clorua 0,9% l\u00e0 lo\u1ea1i d\u1ecbch h\u1ed3i s\u1ee9c \u0111\u01b0\u1ee3c ch\u1ecdn<\/li>\n<li>Th\u1eadn tr\u1ecdng b\u00f9 d\u1ecbch \u1edf ng\u01b0\u1eddi tr\u1ebb<\/li>\n<li>S\u1eed d\u1ee5ng bicarbonate kh\u00f4ng \u0111\u01b0\u1ee3c khuy\u1ebfn kh\u00edch th\u01b0\u1eddng quy<\/li>\n<li>Phosphat kh\u00f4ng n\u00ean \u0111\u01b0\u1ee3c b\u1ed5 sung th\u01b0\u1eddng quy<\/li>\n<li>T\u1ed1c \u0111\u1ed9 h\u1ea1 glucose \u00edt nh\u1ea5t ph\u1ea3i l\u00e0 3,0 mmol \/ L \/ h<\/li>\n<li>C\u00e2n nh\u1eafc gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ h khi glucose gi\u1ea3m xu\u1ed1ng &lt;14,0 mmol \/ L<\/li>\n<\/ol>\n<p>M\u1ed9t cu\u1ed9c kh\u1ea3o s\u00e1t qu\u1ed1c gia v\u1ec1 qu\u1ea3n l\u00fd nhi\u1ec5m toan ceton theo phi\u00ean b\u1ea3n tr\u01b0\u1edbc c\u1ee7a h\u01b0\u1edbng d\u1eabn n\u00e0y cho th\u1ea5y t\u1ef7 l\u1ec7 h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft (&lt; 4,0 mmol \/ L) v\u00e0 h\u1ea1 kali m\u00e1u (&lt; 4,0 mmol \/ L) l\u1ea7n l\u01b0\u1ee3t l\u00e0 27,6% v\u00e0 67%. M\u1eb7c d\u00f9 c\u00f3 th\u1ec3 nh\u1eefng \u0111i\u1ec1u n\u00e0y x\u1ea3y ra do 10% dextrose kh\u00f4ng \u0111\u01b0\u1ee3c b\u1ed5 sung k\u1ecbp th\u1eddi, ho\u1eb7c d\u1ecbch ch\u1ee9a kali kh\u00f4ng \u0111\u01b0\u1ee3c cung c\u1ea5p \u0111\u00fang c\u00e1ch, nh\u01b0ng nguy\u00ean nh\u00e2n ch\u00ednh d\u1eabn \u0111\u1ebfn c\u1ea3 hai b\u1ea5t th\u01b0\u1eddng sinh h\u00f3a n\u00e0y l\u00e0 do s\u1eed d\u1ee5ng insulin. Do \u0111\u00f3, khi glucose gi\u1ea3m xu\u1ed1ng d\u01b0\u1edbi 14 mmol \/ L, c\u1ea7n xem x\u00e9t gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin t\u0129nh m\u1ea1ch xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ gi\u1edd. \u0110\u00e2y \u0111\u00e3 l\u00e0 m\u1ed9t l\u1ef1a ch\u1ecdn trong h\u01b0\u1edbng d\u1eabn d\u00e0nh cho ng\u01b0\u1eddi l\u1edbn \u1edf nh\u1eefng n\u01a1i kh\u00e1c, 24 v\u00e0 m\u1ed9t s\u1ed1 nghi\u00ean c\u1ee9u nhi khoa \u0111\u00e3 g\u1ee3i \u00fd r\u1eb1ng t\u1ed1c \u0111\u1ed9 ph\u00e2n gi\u1ea3i nhi\u1ec5m toan ceton kh\u00f4ng l\u00e2u h\u01a1n so v\u1edbi 0,1 \u0111\u01a1n v\u1ecb \/ kg \/ h. 29 &#8211; 31 Do \u0111\u00f3, n\u00f3 c\u0169ng \u0111\u01b0\u1ee3c \u0111\u01b0a v\u00e0o h\u01b0\u1edbng d\u1eabn nhi khoa c\u1ee7a V\u01b0\u01a1ng qu\u1ed1c Anh.<\/p>\n<h2>2. D\u1ecbch keo so v\u1edbi d\u1ecbch tinh th\u1ec3?<\/h2>\n<p>M\u1ed9t t\u1ed5ng quan c\u1ee7a Cochrane n\u0103m 2007 c\u0169ng kh\u00f4ng \u1ee7ng h\u1ed9 vi\u1ec7c s\u1eed d\u1ee5ng d\u1ecbch keo thay v\u00ec d\u1ecbch tinh th\u1ec3. 33 M\u1ed9t t\u00e0i li\u1ec7u \u0111\u1ed3ng thu\u1eadn kh\u00e1c n\u0103m 2013 \u0111\u1ec1 xu\u1ea5t r\u1eb1ng n\u00ean tr\u00e1nh d\u00f9ng d\u1ecbch keo khi c\u00f3 th\u1ec3, v\u00ec c\u00f3 th\u1ec3 c\u00f3 nguy c\u01a1 t\u0103ng t\u1ef7 l\u1ec7 t\u1eed vong v\u00e0 b\u1ec7nh t\u1eadt li\u00ean quan \u0111\u1ebfn vi\u1ec7c s\u1eed d\u1ee5ng ch\u00fang. V\u00ec v\u1eady, ch\u00fang t\u00f4i khuy\u1ebfn ngh\u1ecb s\u1eed d\u1ee5ng d\u1ecbch th\u1ec3 tinh th\u1ec3 l\u00e0m lo\u1ea1i d\u1ecbch ban \u0111\u1ea7u \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn.<\/p>\n<h2>3. Dung d\u1ecbch natri clorid 0,9% hay dung d\u1ecbch tinh th\u1ec3 c\u00e2n b\u1eb1ng \u0111\u1ec3 h\u1ed3i s\u1ee9c?<\/h2>\n<p>\u0110\u00e3 c\u00f3 nhi\u1ec1u tranh lu\u1eadn v\u1ec1 gi\u00e1 tr\u1ecb t\u01b0\u01a1ng \u0111\u1ed1i c\u1ee7a hai gi\u1ea3i ph\u00e1p n\u00e0y. Hai th\u1eed nghi\u1ec7m ng\u1eabu nhi\u00ean \u0111\u00e3 so s\u00e1nh dung d\u1ecbch natri clorid 0,9% v\u1edbi dung d\u1ecbch Hartmann. C\u1ea3 hai \u0111\u1ec1u kh\u00f4ng cho th\u1ea5y s\u1ef1 v\u01b0\u1ee3t tr\u1ed9i c\u1ee7a lo\u1ea1i d\u1ecbch n\u00e0y so v\u1edbi lo\u1ea1i d\u1ecbch kia v\u1ec1 k\u1ebft qu\u1ea3 l\u00e2m s\u00e0ng. G\u1ea7n \u0111\u00e2y h\u01a1n, m\u1ed9t ph\u00e2n t\u00edch sau ph\u00e2n nh\u00f3m th\u1ee9 c\u1ea5p c\u1ee7a hai th\u1eed nghi\u1ec7m \u0111\u01b0\u1ee3c ti\u1ebfn h\u00e0nh trong ph\u00f2ng c\u1ea5p c\u1ee9u cho th\u1ea5y r\u1eb1ng d\u1ecbch tinh th\u1ec3 c\u00e2n b\u1eb1ng c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn ph\u00e2n gi\u1ea3i nhi\u1ec5m toan ceton nhanh h\u01a1n so v\u1edbi natri clorid 0,9%. \u0110i\u1ec1u n\u00e0y h\u1ea1n ch\u1ebf vi\u1ec7c s\u1eed d\u1ee5ng tinh th\u1ec3 \u1edf nh\u1eefng m\u00f4i tr\u01b0\u1eddng c\u00f3 kh\u1ea3 n\u0103ng ti\u1ebfp c\u1eadn t\u0129nh m\u1ea1ch trung t\u00e2m v\u00e0 n\u1ed3ng \u0111\u1ed9 kali cao h\u01a1n c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c cung c\u1ea5p. K\u1ebft qu\u1ea3 c\u1ee7a m\u1ed9t \u0111\u00e1nh gi\u00e1 c\u00f3 h\u1ec7 th\u1ed1ng v\u1ec1 vi\u1ec7c l\u1ef1a ch\u1ecdn lo\u1ea1i d\u1ecbch th\u1ec3 tinh th\u1ec3 trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft c\u1ea5p c\u1ee9u \u0111ang \u0111\u01b0\u1ee3c ch\u1edd \u0111\u1ee3i. Cho \u0111\u1ebfn l\u00fac \u0111\u00f3, ch\u00fang t\u00f4i ti\u1ebfp t\u1ee5c khuy\u1ebfn ngh\u1ecb r\u1eb1ng natri clorid 0,9% v\u1edbi kali clorid pha s\u1eb5n l\u00e0 dung d\u1ecbch m\u1eb7c \u0111\u1ecbnh \u0111\u1ec3 h\u1ed3i s\u1ee9c d\u1ecbch v\u00ec n\u00f3 tu\u00e2n th\u1ee7 c\u00e1c khuy\u1ebfn ngh\u1ecb c\u1ee7a NPSA. H\u01a1n n\u1eefa, c\u00e1c chuy\u00ean gia v\u00e0 b\u00e1c s\u0129 \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng c\u00f3 nhi\u1ec1u kinh nghi\u1ec7m trong vi\u1ec7c s\u1eed d\u1ee5ng an to\u00e0n lo\u1ea1i d\u1ecbch n\u00e0y. Ch\u00fang t\u00f4i c\u0169ng nh\u1eadn th\u1ea5y r\u1eb1ng nhi\u1ec1u \u0111\u01a1n v\u1ecb ICU s\u1ebd th\u00edch s\u1eed d\u1ee5ng c\u00e1c tinh th\u1ec3 c\u00e2n b\u1eb1ng nh\u01b0 dung d\u1ecbch Hartmann. \u0110i\u1ec1u n\u00e0y c\u00f3 th\u1ec3 ch\u1ea5p nh\u1eadn \u0111\u01b0\u1ee3c v\u1edbi \u0111i\u1ec1u ki\u1ec7n c\u00e1c ch\u00ednh s\u00e1ch \u0111\u1ecba ph\u01b0\u01a1ng \u0111\u01b0\u1ee3c tu\u00e2n th\u1ee7 \u0111\u1ec3 s\u1eed d\u1ee5ng an to\u00e0n kali clorua b\u1ed5 sung (B\u1ea3ng 3 ).<\/p>\n<p>B\u1ea2NG 3. \u01afu nh\u01b0\u1ee3c \u0111i\u1ec3m c\u1ee7a dung d\u1ecbch ti\u00eam truy\u1ec1n<\/p>\n<table>\n<tbody>\n<tr>\n<td>Dung d\u1ecbch truy\u1ec1n<\/td>\n<td>Thu\u1eadn l\u1ee3i<\/td>\n<td>Nh\u01b0\u1ee3c \u0111i\u1ec3m<\/td>\n<\/tr>\n<tr>\n<td>0,9% natri clorua<\/td>\n<td>\n<ul>\n<li>Nhi\u1ec1u th\u1eadp k\u1ef7 kinh nghi\u1ec7m l\u00e2m s\u00e0ng<\/li>\n<li>S\u1eb5n c\u00f3 trong c\u00e1c khoa l\u00e2m s\u00e0ng<\/li>\n<li>C\u00f3 b\u00e1n s\u1eb5n tr\u00ean th\u1ecb tr\u01b0\u1eddng lo\u1ea1i \u0111\u00e3 tr\u1ed9n s\u1eb5n v\u1edbi kali \u1edf n\u1ed3ng \u0111\u1ed9 c\u1ea7n thi\u1ebft\u00a020 mmol \/ L (0,15%) ho\u1eb7c 40 mmol \/ L\u00a0(0,3%)<\/li>\n<li>H\u1ed7 tr\u1ee3 th\u1ef1c h\u00e0nh an to\u00e0n v\u1edbi kali ti\u00eam (tu\u00e2n th\u1ee7 NPSA (c\u1ea3nh b\u00e1o NPSA 2002))<\/li>\n<\/ul>\n<\/td>\n<td>\n<ul>\n<li>Nhi\u1ec5m toan chuy\u1ec3n h\u00f3a t\u0103ng clo m\u00e1u, c\u00f3 th\u1ec3 g\u00e2y co ti\u1ec3u \u0111\u1ed9ng m\u1ea1ch th\u1eadn d\u1eabn \u0111\u1ebfn thi\u1ec3u ni\u1ec7u v\u00e0 l\u00e0m ch\u1eadm qu\u00e1\u00a0tr\u00ecnh ph\u00e2n gi\u1ea3i toan<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 21px;\">\n<td>Dung d\u1ecbch\u00a0Hartmanns<\/td>\n<td>\n<ul>\n<li>Tinh th\u1ec3 c\u00e2n b\u1eb1ng \u00edt g\u00e2y nhi\u1ec5m toan chuy\u1ec3n h\u00f3a t\u0103ng clo m\u00e1u<\/li>\n<\/ul>\n<\/td>\n<td>\n<ul>\n<li>Kh\u00f4ng \u0111\u1ee7 kali n\u1ebfu s\u1eed d\u1ee5ng m\u1ed9t m\u00ecnh<\/li>\n<li>Kh\u00f4ng c\u00f3 s\u1eb5n tr\u00ean th\u1ecb tr\u01b0\u1eddng lo\u1ea1i tr\u1ed9n s\u1eb5n kali \u0111\u1ea7y \u0111\u1ee7. B\u1ed5 sung kali trong c\u00e1c khoa l\u00e2m s\u00e0ng t\u1ed5ng qu\u00e1t l\u00e0 kh\u00f4ng an to\u00e0n. (C\u1ea3nh b\u00e1o NPSA 2002)<\/li>\n<li>Kh\u00f4ng quen thu\u1ed9c v\u00e0 kh\u00f4ng th\u01b0\u1eddng xuy\u00ean \u0111\u01b0\u1ee3c l\u01b0u gi\u1eef t\u1ea1i c\u00e1c khoa ph\u00f2ng<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2>4. T\u1ed1c \u0111\u1ed9 b\u00f9 d\u1ecbch?<\/h2>\n<p>Trong nhi\u1ec1u n\u0103m, ng\u01b0\u1eddi ta lo ng\u1ea1i r\u1eb1ng vi\u1ec7c b\u00f9 d\u1ecbch nhanh ch\u00f3ng c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn ph\u00f9 n\u00e3o \u1edf tr\u1ebb em v\u00e0 thanh ni\u00ean. Cho \u0111\u1ebfn n\u0103m 2018, kh\u00f4ng c\u00f3 th\u1eed nghi\u1ec7m \u0111\u1ed1i ch\u1ee9ng ng\u1eabu nhi\u00ean n\u00e0o t\u1ed3n t\u1ea1i \u0111\u1ec3 h\u01b0\u1edbng d\u1eabn vi\u1ec7c ra quy\u1ebft \u0111\u1ecbnh trong l\u0129nh v\u1ef1c n\u00e0y. Tuy nhi\u00ean, m\u1ed9t th\u1eed nghi\u1ec7m l\u1edbn, ng\u1eabu nhi\u00ean c\u00f3 \u0111\u1ed1i ch\u1ee9ng g\u1ed3m 1389 \u0111\u1ee3t nhi\u1ec5m toan ceton \u0111\u00e3 ch\u1ecdn ng\u1eabu nhi\u00ean tr\u1ebb em t\u1eeb 0 \u0111\u1ebfn 18 tu\u1ed5i d\u00f9ng dung d\u1ecbch natri clorid 0,45% ho\u1eb7c 0,9% b\u00f9 nhanh hay ch\u1eadm (t\u1ee9c l\u00e0 th\u1eed nghi\u1ec7m giai th\u1eeba 2 x 2). Ch\u1eafc ch\u1eafn r\u1eb1ng c\u00e1c t\u00e1c gi\u1ea3 n\u00e0y kh\u00f4ng t\u00ecm th\u1ea5y s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 k\u1ebft c\u1ee5c th\u1ea7n kinh \u1edf tr\u1ebb em b\u1ecb nhi\u1ec5m toan ceton \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng c\u00e1ch \u0111i\u1ec1u ch\u1ec9nh th\u1ec3 t\u00edch nhanh v\u00e0 ch\u1eadm h\u01a1n ho\u1eb7c s\u1eed d\u1ee5ng natri clorid 0,9% so v\u1edbi 0,45%. Ng\u01b0\u1eddi ta c\u1ea3m th\u1ea5y r\u1eb1ng s\u1ef1 ph\u00e1t tri\u1ec3n c\u1ee7a ph\u00f9 n\u00e3o l\u00e0 \u0111a y\u1ebfu t\u1ed1, nh\u01b0ng th\u01b0\u1eddng mang t\u00ednh ch\u1ea5t ri\u00eang (idiosyncratic).<\/p>\n<h2>5. Bicarbonat t\u0129nh m\u1ea1ch?<\/h2>\n<p>\u0110i\u1ec1u tr\u1ecb b\u1eb1ng insulin v\u00e0 b\u00f9 d\u1ecbch \u0111\u1ea7y \u0111\u1ee7 s\u1ebd gi\u1ea3i quy\u1ebft t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan trong DKA, v\u00e0 vi\u1ec7c s\u1eed d\u1ee5ng bicarbonate kh\u00f4ng \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh. Nhi\u1ec5m toan c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t ph\u1ea3n \u1ee9ng th\u00edch \u1ee9ng v\u00ec n\u00f3 c\u1ea3i thi\u1ec7n vi\u1ec7c cung c\u1ea5p oxy \u0111\u1ebfn c\u00e1c m\u00f4 b\u1eb1ng c\u00e1ch g\u00e2y ra s\u1ef1 d\u1ecbch chuy\u1ec3n sang ph\u1ea3i c\u1ee7a \u0111\u01b0\u1eddng cong ph\u00e2n ly oxy. Qu\u00e1 nhi\u1ec1u bicarbonate c\u00f3 th\u1ec3 l\u00e0m t\u0103ng \u00e1p su\u1ea5t ri\u00eang ph\u1ea7n CO2 trong d\u1ecbch n\u00e3o t\u1ee7y (CSF) v\u00e0 c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn t\u0103ng nhi\u1ec5m toan d\u1ecbch n\u00e3o t\u1ee7y m\u1ed9t c\u00e1ch ngh\u1ecbch l\u00fd. Ngo\u00e0i ra, vi\u1ec7c s\u1eed d\u1ee5ng bicarbonate trong nhi\u1ec5m toan ceton c\u00f3 th\u1ec3 l\u00e0m ch\u1eadm s\u1ef1 gi\u1ea3m t\u1ec9 lactate:pyruvate v\u00e0 ceton trong m\u00e1u so v\u1edbi truy\u1ec1n t\u0129nh m\u1ea1ch natri clorid 0,9%. 43 \u0110\u1ed9i ICU \u0111\u00f4i khi c\u00f3 th\u1ec3 s\u1eed d\u1ee5ng bicarbonate t\u0129nh m\u1ea1ch n\u1ebfu \u0111\u1ed9 pH v\u1eabn th\u1ea5p v\u00e0 inotrope \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh.<\/p>\n<h2>6. S\u1eed d\u1ee5ng phosphat t\u0129nh m\u1ea1ch?<\/h2>\n<p>N\u1ed3ng \u0111\u1ed9 photphat th\u01b0\u1eddng \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n theo ti\u00eau chu\u1ea9n khi &#8216;h\u1ed3 s\u01a1 x\u01b0\u01a1ng&#8217; (bone profile) \u0111\u01b0\u1ee3c y\u00eau c\u1ea7u. M\u1eb7c d\u00f9 n\u1ed3ng \u0111\u1ed9 ban \u0111\u1ea7u trong huy\u1ebft thanh c\u00f3 v\u1ebb b\u00ecnh th\u01b0\u1eddng, nh\u01b0ng s\u1ef1 suy gi\u1ea3m n\u1ed9i b\u00e0o \u0111\u00e1ng k\u1ec3 c\u00f3 ngh\u0129a l\u00e0 s\u1ef1 thi\u1ebfu h\u1ee5t phosphate to\u00e0n c\u01a1 th\u1ec3 trong nhi\u1ec5m toan ceton l\u00e0 \u0111\u00e1ng k\u1ec3, trung b\u00ecnh l\u00e0 1 mmol \/ kg th\u1ec3 tr\u1ecdng. Thi\u1ebfu phosphat tr\u1ea7m tr\u1ecdng c\u00f3 th\u1ec3 l\u00e0m tr\u1ea7m tr\u1ecdng th\u00eam t\u00ecnh tr\u1ea1ng suy h\u00f4 h\u1ea5p, l\u00e0m r\u1ed1i lo\u1ea1n nh\u1ecbp tim v\u00e0 g\u00e2y ti\u00eau c\u01a1 v\u00e2n. N\u1ebfu c\u00f3 b\u1ea5t k\u1ef3 d\u1ea5u hi\u1ec7u n\u00e0o trong s\u1ed1 n\u00e0y th\u00ec vi\u1ec7c \u0111o l\u01b0\u1eddng v\u00e0 b\u1ed5 sung photphat n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t theo h\u01b0\u1edbng d\u1eabn c\u1ee7a \u0111\u1ecba ph\u01b0\u01a1ng. Tuy nhi\u00ean, n\u00f3i chung, kh\u00f4ng c\u00f3 b\u1eb1ng ch\u1ee9ng v\u1ec1 l\u1ee3i \u00edch c\u1ee7a vi\u1ec7c b\u1ed5 sung phosphate th\u01b0\u1eddng quy. Do \u0111\u00f3, ch\u00fang t\u00f4i kh\u00f4ng khuy\u1ebfn ngh\u1ecb b\u1ed5 sung phosphate th\u01b0\u1eddng quy.<\/p>\n<h2>7. T\u1ed1c \u0111\u1ed9 h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft n\u00ean l\u00e0 bao nhi\u00eau?<\/h2>\n<p>D\u1eef li\u1ec7u t\u1eeb c\u00e1c nghi\u00ean c\u1ee9u \u0111\u01b0\u1ee3c c\u00f4ng b\u1ed1 v\u00e0o nh\u1eefng n\u0103m 1970 48 , 49 cho th\u1ea5y r\u1eb1ng vi\u1ec7c s\u1eed d\u1ee5ng truy\u1ec1n insulin li\u1ec1u th\u1ea5p (t\u1ee9c l\u00e0 0,1 \u0111\u01a1n v\u1ecb \/ kg \/ gi\u1edd) d\u1eabn \u0111\u1ebfn m\u1ee9c \u0111\u01b0\u1eddng huy\u1ebft gi\u1ea3m xu\u1ed1ng \u1edf c\u00f9ng t\u1ed1c \u0111\u1ed9 so v\u1edbi insulin li\u1ec1u cao trong nhi\u1ec1u th\u1eadp k\u1ef7 tr\u01b0\u1edbc, v\u1edbi m\u1ee9c \u0111\u01b0\u1eddng huy\u1ebft gi\u1ea3m kho\u1ea3ng 50% &#8211; 60% trong 4 gi\u1edd \u0111\u1ea7u ti\u00ean. Nguy c\u01a1 l\u00fd thuy\u1ebft v\u1ec1 s\u1ef1 thay \u0111\u1ed5i th\u1ea9m th\u1ea5u l\u1edbn do s\u1ef1 thay \u0111\u1ed5i nhanh ch\u00f3ng c\u1ee7a glucose huy\u1ebft t\u01b0\u01a1ng l\u00e0 r\u1ea5t hi\u1ebfm trong nhi\u1ec5m toan ceton, v\u00e0 do \u0111\u00f3 \u0111\u1ed9 an to\u00e0n c\u1ee7a vi\u1ec7c s\u1eed d\u1ee5ng 0,1 \u0111\u01a1n v\u1ecb \/ kg \/ h cao h\u01a1n b\u1ea5t k\u1ef3 nguy c\u01a1 n\u00e0o.<\/p>\n<h3>2.7 C\u00e1c bi\u1ebfn ch\u1ee9ng c\u1ee7a nhi\u1ec5m toan ceton v\u00e0 c\u00e1ch \u0111i\u1ec1u tr\u1ecb<\/h3>\n<h4>2.7.1. H\u1ea1 kali m\u00e1u v\u00e0 t\u0103ng kali m\u00e1u<\/h4>\n<p>Do m\u1ea5t n\u01b0\u1edbc, thi\u1ebfu insulin v\u00e0 nhi\u1ec5m toan chuy\u1ec3n h\u00f3a, t\u0103ng kali huy\u1ebft n\u00ean \u0111\u01b0\u1ee3c t\u00ecm ki\u1ebfm khi ch\u1ea9n \u0111o\u00e1n ban \u0111\u1ea7u nhi\u1ec5m toan ceton. Trong m\u1ed9t cu\u1ed9c kh\u1ea3o s\u00e1t qu\u1ed1c gia c\u1ee7a V\u01b0\u01a1ng qu\u1ed1c Anh 283 ng\u01b0\u1eddi \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb v\u1edbi \u1ea5n b\u1ea3n n\u0103m 2013 c\u1ee7a h\u01b0\u1edbng d\u1eabn n\u00e0y, l\u01b0\u1ee3ng kali nh\u1eadp vi\u1ec7n trung b\u00ecnh (\u00b1 SD) l\u00e0 4,8 (\u00b1 1,0) mmol \/ L. H\u1ea1 kali m\u00e1u v\u00e0 t\u0103ng kali m\u00e1u l\u00e0 nh\u1eefng t\u00ecnh tr\u1ea1ng c\u00f3 th\u1ec3 \u0111e d\u1ecda t\u00ednh m\u1ea1ng trong qu\u00e1 tr\u00ecnh \u0111i\u1ec1u tr\u1ecb nhi\u1ec5m toan ceton. Do nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p tr\u01b0\u1edbc th\u1eadn li\u00ean quan \u0111\u1ebfn m\u1ea5t n\u01b0\u1edbc nghi\u00eam tr\u1ecdng, khuy\u1ebfn c\u00e1o kh\u00f4ng k\u00ea \u0111\u01a1n kali khi h\u1ed3i s\u1ee9c d\u1ecbch ban \u0111\u1ea7u ho\u1eb7c n\u1ebfu n\u1ed3ng \u0111\u1ed9 kali huy\u1ebft thanh v\u1eabn tr\u00ean 5,5 mmol \/ L. N\u1ed3ng \u0111\u1ed9 kali huy\u1ebft thanh b\u00ecnh th\u01b0\u1eddng ho\u1eb7c th\u1eadm ch\u00ed t\u0103ng cao c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c nh\u00ecn th\u1ea5y do s\u1ef1 chuy\u1ec3n d\u1ecbch ngo\u1ea1i b\u00e0o c\u1ee7a kali trong t\u00ecnh tr\u1ea1ng toan, v\u00e0 \u0111i\u1ec1u n\u00e0y ph\u1ea3n \u00e1nh r\u1ea5t k\u00e9m t\u1ed5ng l\u01b0\u1ee3ng kali d\u1ef1 tr\u1eef. Tuy nhi\u00ean, kali h\u1ea7u nh\u01b0 s\u1ebd lu\u00f4n gi\u1ea3m khi nhi\u1ec5m toan ceton \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng insulin v\u00e0 kh\u1ea3o s\u00e1t \u1edf Anh cho th\u1ea5y 67,1% b\u1ecb h\u1ea1 kali m\u00e1u (&lt;4,0 mmol \/ L) sau 24 gi\u1edd sau khi nh\u1eadp vi\u1ec7n.<\/p>\n<p>Do \u0111\u00f3, ng\u01b0\u1eddi ta khuy\u1ebfn c\u00e1o r\u1eb1ng dung d\u1ecbch natri clorid 0,9% v\u1edbi kali 40 mmol \/ L (pha s\u1eb5n) \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh mi\u1ec5n l\u00e0 n\u1ed3ng \u0111\u1ed9 kali huy\u1ebft thanh d\u01b0\u1edbi 5,5 mmol \/ L v\u00e0 ng\u01b0\u1eddi b\u1ec7nh \u0111ang \u0111i ti\u1ec3u. N\u1ebfu n\u1ed3ng \u0111\u1ed9 kali huy\u1ebft thanh gi\u1ea3m xu\u1ed1ng d\u01b0\u1edbi 3,5 mmol \/ L, ch\u1ebf \u0111\u1ed9 \u0111i\u1ec1u tr\u1ecb kali c\u1ea7n \u0111\u01b0\u1ee3c xem x\u00e9t l\u1ea1i. Khi c\u00e2n b\u1eb1ng d\u1ecbch cho ph\u00e9p, c\u00f3 th\u1ec3 t\u0103ng t\u1ed1c \u0111\u1ed9 truy\u1ec1n dung d\u1ecbch natri clorid 0,9% v\u1edbi kali 40 mmol \/L. N\u1ebfu kh\u00f4ng, s\u1ebd c\u1ea7n truy\u1ec1n kali \u0111\u1eadm \u0111\u1eb7c h\u01a1n v\u00e0 \u0111\u1ec3 \u0111\u1ea3m b\u1ea3o th\u1ef1c h\u00e0nh an to\u00e0n, t\u1ea5t c\u1ea3 c\u00e1c kh\u00eda c\u1ea1nh c\u1ee7a vi\u1ec7c s\u1eed d\u1ee5ng n\u00f3 ph\u1ea3i tu\u00e2n theo h\u01b0\u1edbng d\u1eabn c\u1ee7a \u0111\u1ecba ph\u01b0\u01a1ng v\u00e0 qu\u1ed1c gia. Ngo\u00e0i vi\u1ec7c b\u00f9 kh\u00f4ng \u0111\u1ea7y \u0111\u1ee7, nguy\u00ean nh\u00e2n ch\u00ednh d\u1eabn \u0111\u1ebfn h\u1ea1 kali m\u00e1u l\u00e0 vi\u1ec7c s\u1eed d\u1ee5ng insulin. Do \u0111\u00f3, khi glucose gi\u1ea3m xu\u1ed1ng d\u01b0\u1edbi 14 mmol \/ L, c\u1ea7n xem x\u00e9t gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin t\u0129nh m\u1ea1ch xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ h.<\/p>\n<p>C\u1ea7n \u0111\u1ea3m b\u1ea3o r\u1eb1ng c\u00f3 c\u00e1c protocol ri\u00eang, cho ph\u00e9p s\u1eed d\u1ee5ng c\u00e1c dung d\u1ecbch kali \u0111\u1eadm \u0111\u1eb7c m\u1ed9t c\u00e1ch an to\u00e0n. \u0110i\u1ec1u n\u00e0y c\u00f3 th\u1ec3 y\u00eau c\u1ea7u chuy\u1ec3n sang m\u00f4i tr\u01b0\u1eddng ch\u0103m s\u00f3c C\u1ea5p 2 ho\u1eb7c C\u1ea5p 3.<\/p>\n<h4>2.7.2. H\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft<\/h4>\n<p>BG c\u00f3 th\u1ec3 gi\u1ea3m r\u1ea5t nhanh khi t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan ceton \u0111\u01b0\u1ee3c \u0111i\u1ec1u ch\u1ec9nh v\u00e0 m\u1ed9t sai l\u1ea7m ph\u1ed5 bi\u1ebfn l\u00e0 \u0111\u1ec3 cho BG gi\u1ea3m xu\u1ed1ng m\u1ee9c h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft. Trong cu\u1ed9c kh\u1ea3o s\u00e1t qu\u1ed1c gia c\u1ee7a V\u01b0\u01a1ng qu\u1ed1c Anh tr\u00ean 283 ng\u01b0\u1eddi \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb v\u1edbi \u1ea5n b\u1ea3n n\u0103m 2013 c\u1ee7a h\u01b0\u1edbng d\u1eabn n\u00e0y, \u0111\u01b0\u1eddng huy\u1ebft \u0111\u00e3 gi\u1ea3m xu\u1ed1ng &lt; 4,0 mmol \/ L \u1edf 27,6% s\u1ed1 ng\u01b0\u1eddi. H\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft nghi\u00eam tr\u1ecdng (t\u1ee9c l\u00e0 c\u1ea7n s\u1ef1 tr\u1ee3 gi\u00fap c\u1ee7a b\u00ean th\u1ee9 ba) c\u0169ng li\u00ean quan \u0111\u1ebfn vi\u1ec7c t\u0103ng th\u1eddi gian n\u1eb1m vi\u1ec7n, r\u1ed1i lo\u1ea1n nh\u1ecbp tim, t\u1ed5n th\u01b0\u01a1ng n\u00e3o c\u1ea5p t\u00ednh v\u00e0 t\u1eed vong. Nguy\u00ean nh\u00e2n ch\u00ednh d\u1eabn \u0111\u1ebfn h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft l\u00e0 s\u1eed d\u1ee5ng insulin. V\u00ec v\u1eady, ngo\u00e0i vi\u1ec7c b\u1eaft \u0111\u1ea7u d\u00f9ng dextrose 10% c\u00f9ng v\u1edbi dung d\u1ecbch natri clorid 0,9%, khi glucose gi\u1ea3m xu\u1ed1ng d\u01b0\u1edbi 14 mmol \/ L, c\u1ea7n xem x\u00e9t gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin t\u0129nh m\u1ea1ch xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ h.<\/p>\n<h4>2.7.3. Ph\u00f9 n\u00e3o<\/h4>\n<p>C\u00e1c tri\u1ec7u ch\u1ee9ng g\u00e2y ra ph\u00f9 n\u00e3o t\u01b0\u01a1ng \u0111\u1ed1i kh\u00f4ng ph\u1ed5 bi\u1ebfn \u1edf ng\u01b0\u1eddi l\u1edbn, m\u1eb7c d\u00f9 c\u00f3 th\u1ec3 x\u1ea3y ra \u1edf nh\u1eefng ng\u01b0\u1eddi th\u1ec3 ch\u1ea5t g\u1ea7y ho\u1eb7c \u1edf nh\u1eefng ng\u01b0\u1eddi tr\u1ebb tu\u1ed5i. Ph\u00f9 n\u00e3o kh\u00f4ng tri\u1ec7u ch\u1ee9ng c\u00f3 th\u1ec3 l\u00e0 hi\u1ec7n t\u01b0\u1ee3ng ph\u1ed5 bi\u1ebfn v\u00e0 c\u00f3 th\u1ec3 t\u1ed3n t\u1ea1i tr\u01b0\u1edbc khi b\u1eaft \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb. 24 , 53 Nguy\u00ean nh\u00e2n ch\u00ednh x\u00e1c c\u1ee7a hi\u1ec7n t\u01b0\u1ee3ng n\u00e0y v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c bi\u1ebft. Ch\u1eafc ch\u1eafn r\u1eb1ng m\u1ed9t th\u1eed nghi\u1ec7m ng\u1eabu nhi\u00ean l\u1edbn c\u00f3 \u0111\u1ed1i ch\u1ee9ng gi\u1eefa dung d\u1ecbch natri clorid 0,9% so v\u1edbi dung d\u1ecbch natri clorid 0,45%, m\u1ed7i l\u1ea7n \u0111\u01b0\u1ee3c cho nhanh ho\u1eb7c ch\u1eadm, cho th\u1ea5y kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 t\u1ef7 l\u1ec7 ph\u00e1t tri\u1ec3n t\u1ed5n th\u01b0\u01a1ng th\u1ea7n kinh. 40 Do \u0111\u00f3, n\u00f3 c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t ph\u1ea3n \u1ee9ng \u0111\u1eb7c tr\u01b0ng \u0111\u1ed1i v\u1edbi t\u1ed5n th\u01b0\u01a1ng chuy\u1ec3n h\u00f3a v\u00e0 \u0111i\u1ec1u tr\u1ecb ti\u1ebfp theo. Tuy nhi\u00ean, b\u1ea5t k\u1ef3 s\u1ef1 suy gi\u1ea3m n\u00e0o trong thang \u0111i\u1ec3m H\u00f4n m\u00ea Glasgow \u0111\u1ec1u c\u1ea7n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb v\u00e0 ch\u1ee5p h\u00ecnh \u1ea3nh kh\u1ea9n c\u1ea5p. N\u1ebfu nghi ng\u1edd c\u00f3 ph\u00f9 n\u00e3o, n\u00ean b\u1eaft \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb kh\u1ea9n c\u1ea5p b\u1eb1ng mannitol ho\u1eb7c n\u01b0\u1edbc mu\u1ed1i \u01b0u tr\u01b0\u01a1ng \u0111\u1ec3 g\u00e2y chuy\u1ec3n d\u1ecbch d\u1ecbch th\u1ea9m th\u1ea5u v\u00e0 kh\u00f4ng \u0111\u01b0\u1ee3c tr\u00ec ho\u00e3n trong khi ch\u1edd ch\u1ee5p h\u00ecnh \u1ea3nh.<\/p>\n<h4>2.7.4. C\u00e1c bi\u1ebfn ch\u1ee9ng kh\u00e1c<\/h4>\n<p>M\u1ed9t s\u1ed1 bi\u1ebfn ch\u1ee9ng kh\u00e1c c\u00f3 th\u1ec3 x\u1ea3y ra v\u1edbi m\u1ed9t s\u1ed1 bi\u1ebfn ch\u1ee9ng t\u01b0\u01a1ng \u0111\u1ed1i ph\u1ed5 bi\u1ebfn, th\u01b0\u1eddng nh\u1eb9 v\u00e0 d\u1ec5 \u0111i\u1ec1u tr\u1ecb. Tuy nhi\u00ean, m\u1ed9t s\u1ed1 bi\u1ebfn ch\u1ee9ng kh\u00e1c c\u00f3 th\u1ec3 nghi\u00eam tr\u1ecdng h\u01a1n. Ch\u00fang bao g\u1ed3m s\u1ef1 ph\u00e1t tri\u1ec3n c\u1ee7a b\u1ec7nh huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch, \u0111\u1eb7c bi\u1ec7t n\u1ebfu s\u1eed d\u1ee5ng catheter t\u0129nh m\u1ea1ch trung t\u00e2m. T\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p tho\u00e1ng qua c\u00f3 th\u1ec3 x\u1ea3y ra \u1edf 50% ng\u01b0\u1eddi l\u1edbn. C\u00e1c bi\u1ebfn ch\u1ee9ng hi\u1ebfm g\u1eb7p kh\u00e1c bao g\u1ed3m ph\u00f9 ph\u1ed5i; t\u0103ng men t\u1ee5y, c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 vi\u00eam t\u1ee5y c\u1ea5p; b\u1ec7nh c\u01a1 tim; ti\u00eau c\u01a1 v\u00e2n; v\u00e0 xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a.<\/p>\n<h3>2.8 X\u1eed tr\u00ed nhi\u1ec5m toan ceton \u1edf ng\u01b0\u1eddi suy th\u1eadn giai \u0111o\u1ea1n cu\u1ed1i ho\u1eb7c \u0111ang l\u1ecdc m\u00e1u<\/h3>\n<p>May m\u1eafn thay, \u0111\u00e2y l\u00e0 m\u1ed9t s\u1ef1 xu\u1ea5t hi\u1ec7n t\u01b0\u01a1ng \u0111\u1ed1i hi\u1ebfm. C\u00f3 r\u1ea5t \u00edt d\u1eef li\u1ec7u v\u1ec1 vi\u1ec7c qu\u1ea3n l\u00fd nhi\u1ec5m toan ceton trong tr\u01b0\u1eddng h\u1ee3p n\u00e0y. 54 &#8211; 57 S\u1ef1 thi\u1ebfu thanh th\u1ea3i insulin \u1edf th\u1eadn c\u00f3 ngh\u0129a l\u00e0 nhi\u1ec5m toan ceton \u00edt x\u1ea3y ra h\u01a1n nhi\u1ec1u. N\u00f3 c\u0169ng c\u00f3 th\u1ec3 kh\u00f3 x\u00e1c \u0111\u1ecbnh v\u00ec nhi\u1ec5m toan chuy\u1ec3n h\u00f3a m\u00e3n t\u00ednh li\u00ean quan \u0111\u1ebfn b\u1ec7nh th\u1eadn m\u00e3n t\u00ednh ti\u1ebfn tri\u1ec3n (giai \u0111o\u1ea1n 4 v\u00e0 5). D\u1eef li\u1ec7u g\u1ea7n \u0111\u00e2y cho th\u1ea5y r\u1eb1ng nh\u1eefng ng\u01b0\u1eddi c\u00f3 bi\u1ec3u hi\u1ec7n nhi\u1ec5m toan ceton v\u1edbi b\u1ec7nh th\u1eadn giai \u0111o\u1ea1n cu\u1ed1i c\u00f3 n\u1ed3ng \u0111\u1ed9 \u00df-hydroxybutyrate th\u1ea5p h\u01a1n, m\u1ee9c glucose v\u00e0 kho\u1ea3ng tr\u1ed1ng anion cao h\u01a1n so v\u1edbi nh\u1eefng ng\u01b0\u1eddi c\u00f3 ch\u1ee9c n\u0103ng th\u1eadn \u0111\u01b0\u1ee3c b\u1ea3o t\u1ed3n. Bicarbonate v\u00e0 pH kh\u00f4ng kh\u00e1c nhau c\u00f3 \u00fd ngh\u0129a. 58 Khi nhi\u1ec5m toan ceton x\u1ea3y ra trong b\u1ec7nh th\u1eadn giai \u0111o\u1ea1n cu\u1ed1i, c\u1ea7n ph\u1ea3i xem x\u00e9t m\u1ed9t s\u1ed1 v\u1ea5n \u0111\u1ec1.<\/p>\n<h4>2.8.1 B\u00f9 d\u1ecbch<\/h4>\n<p>Kh\u00f4ng c\u00f3 kh\u1ea3 n\u0103ng ph\u00e1t tri\u1ec3n b\u00e0i ni\u1ec7u th\u1ea9m th\u1ea5u c\u00f3 ngh\u0129a l\u00e0 t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft li\u00ean quan \u0111\u1ebfn l\u1ecdc m\u00e1u v\u00e0 nhi\u1ec5m ceton c\u00f3 th\u1ec3 x\u1ea3y ra m\u00e0 kh\u00f4ng b\u1ecb m\u1ea5t n\u01b0\u1edbc nhi\u1ec1u. B\u1ed1i c\u1ea3nh h\u1ed7n h\u1ee3p c\u1ee7a nhi\u1ec5m toan ceton v\u00e0 t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft t\u0103ng \u00e1p l\u1ef1c th\u1ea9m th\u1ea5u c\u0169ng c\u00f3 th\u1ec3 x\u1ea3y ra do tr\u01b0\u01a1ng l\u1ef1c huy\u1ebft thanh cao. Ngo\u00e0i ra, th\u1ec3 t\u00edch n\u1ed9i m\u1ea1ch tu\u1ea7n ho\u00e0n c\u00f3 th\u1ec3 t\u0103ng l\u00ean c\u00f9ng v\u1edbi th\u1ec3 t\u00edch n\u1ed9i b\u00e0o \u0111\u01b0\u1ee3c ph\u00e2n gi\u1ea3i khi glucose v\u00e0 nhi\u1ec5m toan ceton \u0111\u01b0\u1ee3c b\u00ecnh th\u01b0\u1eddng h\u00f3a. Do \u0111\u00f3, c\u00f3 th\u1ec3 kh\u00f4ng c\u1ea7n b\u00f9 d\u1ecbch \u1edf nh\u1eefng ng\u01b0\u1eddi suy th\u1eadn giai \u0111o\u1ea1n cu\u1ed1i ho\u1eb7c nh\u1eefng ng\u01b0\u1eddi \u0111ang l\u1ecdc m\u00e1u. Tuy nhi\u00ean, \u0111\u1ed1i v\u1edbi nh\u1eefng ng\u01b0\u1eddi \u0111\u01b0\u1ee3c coi l\u00e0 gi\u1ea3m th\u1ec3 t\u00edch m\u00e1u, c\u00f3 th\u1ec3 d\u00f9ng 250 ml (0,9% natri clorid ho\u1eb7c 10% dextrose) v\u1edbi c\u00e1c \u0111\u00e1nh gi\u00e1 l\u00e2m s\u00e0ng th\u01b0\u1eddng xuy\u00ean.<\/p>\n<h4>2.8.2 \u0110i\u1ec1u tr\u1ecb b\u1eb1ng insulin<\/h4>\n<p>\u0110\u1ed1i v\u1edbi nh\u1eefng ng\u01b0\u1eddi b\u1ecb suy th\u1eadn giai \u0111o\u1ea1n cu\u1ed1i ho\u1eb7c nh\u1eefng ng\u01b0\u1eddi \u0111ang l\u1ecdc m\u00e1u, thay th\u1ebf insulin l\u00e0 ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb ch\u00ednh. \u0110i\u1ec1u n\u00e0y n\u00ean \u0111\u01b0\u1ee3c cung c\u1ea5p d\u01b0\u1edbi d\u1ea1ng FRIII v\u1edbi t\u1ed1c \u0111\u1ed9 ban \u0111\u1ea7u l\u00e0 0,1 \u0111\u01a1n v\u1ecb \/ kg \/ h, nh\u01b0ng c\u00f3 th\u1ec3 c\u1ea7n t\u0103ng l\u00ean n\u1ebfu kh\u00f4ng \u0111\u1ea1t \u0111\u01b0\u1ee3c t\u1ed1c \u0111\u1ed9 gi\u1ea3m glucose theo y\u00eau c\u1ea7u. Tuy nhi\u00ean, vi\u1ec7c th\u1eadn kh\u00f4ng \u0111\u00e0o th\u1ea3i insulin s\u1ebd l\u00e0m t\u0103ng nguy c\u01a1 h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft. Tuy nhi\u00ean, t\u1ed1c \u0111\u1ed9 gi\u1ea3m glucose c\u0169ng gi\u1ed1ng nh\u01b0 \u1edf nh\u1eefng ng\u01b0\u1eddi c\u00f3 ch\u1ee9c n\u0103ng th\u1eadn \u0111\u01b0\u1ee3c b\u1ea3o t\u1ed3n &#8211; ngh\u0129a l\u00e0 3,0 mmol \/ L \/ h. N\u1ebfu t\u1ed1c \u0111\u1ed9 gi\u1ea3m nhanh h\u01a1n, ho\u1eb7c glucose gi\u1ea3m xu\u1ed1ng &lt; 14,0 mmol \/ L th\u00ec c\u1ea7n xem x\u00e9t gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin t\u0129nh m\u1ea1ch xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ h.<\/p>\n<h4>2.8.3 Kali<\/h4>\n<p>Th\u01b0\u1eddng kh\u00f4ng c\u1ea7n b\u1ed5 sung kali v\u00ec thi\u1ebfu b\u00e0i ni\u1ec7u th\u1ea9m th\u1ea5u c\u00f3 ngh\u0129a l\u00e0 m\u1ea5t kali \u00edt h\u01a1n \u0111\u00e1ng k\u1ec3 so v\u1edbi nh\u1eefng ng\u01b0\u1eddi c\u00f3 ch\u1ee9c n\u0103ng th\u1eadn \u0111\u01b0\u1ee3c b\u1ea3o t\u1ed3n. Tuy nhi\u00ean, t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn t\u0103ng kali huy\u1ebft \u0111\u00e1ng k\u1ec3, v\u00e0 \u0111i\u1ec1u n\u00e0y th\u01b0\u1eddng x\u1ea3y ra h\u01a1n \u1edf nh\u1eefng ng\u01b0\u1eddi b\u1ecb suy th\u1eadn. Trong tr\u01b0\u1eddng h\u1ee3p n\u00e0y, theo d\u00f5i monitoring tim li\u00ean t\u1ee5c l\u00e0 \u0111i\u1ec1u c\u1ea7n thi\u1ebft, v\u00e0 \u0111\u1ed9i ch\u0103m s\u00f3c quan tr\u1ecdng ho\u1eb7c chuy\u00ean khoa th\u1eadn n\u00ean tham gia \u0111\u1ec3 xem x\u00e9t vi\u1ec7c ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o \/ l\u1ecdc m\u00e1u kh\u1ea9n c\u1ea5p.<\/p>\n<h2>3. C\u00c1CH CH\u0102M S\u00d3C TOAN CETON<\/h2>\n<p>Nhi\u1ec5m toan ceton l\u00e0 m\u1ed9t c\u1ea5p c\u1ee9u n\u1ed9i khoa v\u1edbi t\u1ef7 l\u1ec7 t\u00e0n t\u1eadt v\u00e0 t\u1eed vong \u0111\u00e1ng k\u1ec3. N\u00f3 c\u1ea7n \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n k\u1ecbp th\u1eddi v\u00e0 qu\u1ea3n l\u00fd chuy\u00ean s\u00e2u. Nh\u00f3m chuy\u00ean gia v\u1ec1 b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng ph\u1ea3i lu\u00f4n tham gia c\u00e0ng s\u1edbm c\u00e0ng t\u1ed1t v\u00e0 l\u00fd t\u01b0\u1edfng nh\u1ea5t l\u00e0 trong v\u00f2ng 24 gi\u1edd v\u00ec \u0111i\u1ec1u n\u00e0y \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 c\u00f3 li\u00ean quan \u0111\u1ebfn tr\u1ea3i nghi\u1ec7m t\u1ed1t h\u01a1n cho BN v\u00e0 gi\u1ea3m th\u1eddi gian l\u01b0u tr\u00fa. Trong tr\u01b0\u1eddng h\u1ee3p thanh thi\u1ebfu ni\u00ean t\u1eeb 16\u201318 tu\u1ed5i \u0111\u01b0\u1ee3c qu\u1ea3n l\u00fd b\u1edfi c\u00e1c \u0111\u1ed9i y t\u1ebf ng\u01b0\u1eddi l\u1edbn do s\u1ef1 s\u1eafp x\u1ebfp c\u1ee7a \u0111\u1ecba ph\u01b0\u01a1ng, th\u00ec vi\u1ec7c qu\u1ea3n l\u00fd h\u1ecd b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng c\u00e1c h\u01b0\u1edbng d\u1eabn d\u00e0nh cho ng\u01b0\u1eddi l\u1edbn t\u1ea1i \u0111\u1ecba ph\u01b0\u01a1ng m\u00e0 c\u00e1c nh\u00f3m \u0111\u00e3 quen thu\u1ed9c \u0111\u01b0\u1ee3c coi l\u00e0 ph\u00f9 h\u1ee3p h\u01a1n l\u00e0 s\u1eed d\u1ee5ng c\u00e1c h\u01b0\u1edbng d\u1eabn d\u00e0nh cho tr\u1ebb em c\u00f3 th\u1ec3 kh\u00f4ng quen thu\u1ed9c.<\/p>\n<p>Khi c\u00e1c b\u1ec7nh nh\u00e2n trong \u0111\u1ed9 tu\u1ed5i 16-18 \u0111\u01b0\u1ee3c qu\u1ea3n l\u00fd b\u1edfi c\u00e1c \u0111\u1ed9i nhi khoa, c\u1ea7n tu\u00e2n th\u1ee7 c\u00e1c h\u01b0\u1edbng d\u1eabn v\u1ec1 nhi khoa.<\/p>\n<h3>3.1 \u0110\u00e1nh gi\u00e1 m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng<\/h3>\n<p>S\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a m\u1ed9t ho\u1eb7c nhi\u1ec1u \u0111i\u1ec1u sau \u0111\u00e2y c\u00f3 th\u1ec3 cho th\u1ea5y nhi\u1ec5m toan ceton nghi\u00eam tr\u1ecdng:<\/p>\n<ul>\n<li>Ceton m\u00e1u tr\u00ean 6,0 mmol \/ L<\/li>\n<li>M\u1ee9c bicarbonate d\u01b0\u1edbi 5,0 mmol \/ L<\/li>\n<li>\u0110\u1ed9 pH t\u0129nh m\u1ea1ch \/ \u0111\u1ed9ng m\u1ea1ch d\u01b0\u1edbi 7,0<\/li>\n<li>H\u1ea1 kali m\u00e1u khi nh\u1eadp vi\u1ec7n (d\u01b0\u1edbi 3,5 mmol \/ L)<\/li>\n<li>GCS th\u1ea5p h\u01a1n 12 ho\u1eb7c AVPU b\u1ea5t th\u01b0\u1eddng<\/li>\n<li>\u0110\u1ed9 b\u00e3o h\u00f2a oxy d\u01b0\u1edbi 92% trong kh\u00f4ng kh\u00ed ph\u00f2ng (gi\u1ea3 s\u1eed ch\u1ee9c n\u0103ng h\u00f4 h\u1ea5p n\u1ec1n b\u00ecnh th\u01b0\u1eddng)<\/li>\n<li>HA t\u00e2m thu d\u01b0\u1edbi 90 mm Hg<\/li>\n<li>M\u1ea1ch tr\u00ean 100 ho\u1eb7c d\u01b0\u1edbi 60 l\u1ea7n\/ph\u00fat<\/li>\n<li>Kho\u1ea3ng tr\u1ed1ng anion tr\u00ean 16 [Kho\u1ea3ng c\u00e1ch anion = (Na + + K + ) &#8211; (Cl &#8211; + HCO 3 &#8211; )]<\/li>\n<\/ul>\n<p>N\u1ebfu c\u00e1 nh\u00e2n c\u00f3 b\u1ea5t k\u1ef3 d\u1ea5u hi\u1ec7u n\u00e0o trong s\u1ed1 n\u00e0y, c\u1ea7n b\u1eaft \u0111\u1ea7u h\u1ed3i s\u1ee9c v\u00e0 \u0111i\u1ec1u tr\u1ecb ngay l\u1eadp t\u1ee9c, \u0111\u1ed3ng th\u1eddi \u00e1p d\u1ee5ng m\u1ed9t ch\u1ebf \u0111\u1ed9 theo d\u00f5i chuy\u00ean s\u00e2u. T\u00f9y thu\u1ed9c v\u00e0o ho\u00e0n c\u1ea3nh \u0111\u1ecba ph\u01b0\u01a1ng, nh\u1eefng c\u00e1 nh\u00e2n \u0111\u00e1p \u1ee9ng c\u00e1c ti\u00eau ch\u00ed v\u1ec1 m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng ho\u1eb7c nh\u1eefng ng\u01b0\u1eddi c\u1ea7n theo d\u00f5i chuy\u00ean s\u00e2u n\u00ean \u0111\u01b0\u1ee3c b\u00e1c s\u0129 t\u01b0 v\u1ea5n xem x\u00e9t v\u00e0 xem x\u00e9t \u0111\u1ec3 gi\u1edbi thi\u1ec7u nhanh ch\u00f3ng \u0111\u1ebfn m\u00f4i tr\u01b0\u1eddng C\u1ea5p 2 \/ HDU (High Dependency Unit), ho\u1eb7c n\u1ebfu b\u1ec7nh nh\u00e2n \u0111\u00f3 kh\u00f4ng c\u1ea3i thi\u1ec7n sau c\u00e1c bi\u1ec7n ph\u00e1p h\u1ed3i s\u1ee9c ban \u0111\u1ea7u. C\u0169ng c\u00f3 th\u1ec3 c\u1ea7n xem x\u00e9t nguy\u00ean nh\u00e2n ngo\u1ea1i khoa \u0111\u1ed1i v\u1edbi t\u00ecnh tr\u1ea1ng x\u1ea5u \u0111i. N\u1ebfu c\u1ea7n ph\u1ea3i ph\u1eabu thu\u1eadt, s\u1ebd c\u1ea7n c\u00f3 m\u1ed9t cu\u1ed9c th\u1ea3o lu\u1eadn \u0111a chuy\u00ean khoa c\u1ea5p cao kh\u1ea9n c\u1ea5p v\u1ec1 th\u1eddi gian t\u1ed1i \u01b0u \u0111\u1ec3 ph\u1eabu thu\u1eadt.<\/p>\n<p>\u1ede nh\u1eefng b\u1ec7nh nh\u00e2n s\u1eed d\u1ee5ng m\u00e1y b\u01a1m insulin, n\u1ebfu c\u1ea7n chuy\u1ec3n sang C\u1ea5p 2 \/ HDU ho\u1eb7c ITU, th\u00ec m\u00e1y b\u01a1m ph\u1ea3i \u0111\u01b0\u1ee3c d\u1eebng l\u1ea1i, l\u1ea5y ra v\u00e0 c\u1ea5t gi\u1eef an to\u00e0n.<\/p>\n<p>Vi\u1ec7c s\u1eed d\u1ee5ng theo d\u00f5i \u0111\u01b0\u1eddng huy\u1ebft nhanh (v\u00ed d\u1ee5, Freestyle Libre \u00ae , Dexcom G6 \u00ae , v.v.) trong nh\u1eefng tr\u01b0\u1eddng h\u1ee3p n\u00e0y kh\u00f4ng \u0111\u01b0\u1ee3c bi\u1ebft \u0111\u1ebfn. C\u1ea7n ph\u1ea3i l\u00e0m th\u00eam \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh c\u00f4ng d\u1ee5ng c\u1ee7a ch\u00fang trong tr\u01b0\u1eddng h\u1ee3p b\u1ec7nh n\u1eb7ng. C\u00e1c d\u1eef li\u1ec7u n\u00e0y c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c \u0111\u1ec3 l\u1ea1i cho \u0111\u1ebfn khi c\u00f3 s\u1eb5n, nh\u01b0ng kh\u00f4ng n\u00ean s\u1eed d\u1ee5ng d\u1eef li\u1ec7u t\u1eeb ch\u00fang \u0111\u1ec3 h\u01b0\u1edbng d\u1eabn \u0111i\u1ec1u tr\u1ecb.<\/p>\n<p>V\u00ed d\u1ee5 v\u1ec1 insulin t\u0129nh m\u1ea1ch v\u00e0 ph\u00e1c \u0111\u1ed3 truy\u1ec1n d\u1ecbch \u0111\u01b0\u1ee3c tr\u00ecnh b\u00e0y trong Ph\u1ee5 l\u1ee5c 2 .<\/p>\n<h2>4. 0\u201360 ph\u00fat: QU\u1ea2N L\u00dd NGAY L\u1eacP T\u1ee8C KHI CH\u1ea8N \u0110O\u00c1N<\/h2>\n<p>T = 0 t\u1ea1i th\u1eddi \u0111i\u1ec3m b\u1eaft \u0111\u1ea7u truy\u1ec1n d\u1ecbch t\u0129nh m\u1ea1ch. N\u1ebfu c\u00f3 v\u1ea5n \u0111\u1ec1 v\u1edbi vi\u1ec7c ti\u1ebfp c\u1eadn t\u0129nh m\u1ea1ch, c\u1ea7n y\u00eau c\u1ea7u h\u1ed7 tr\u1ee3 t\u1eed ICU ngay l\u1eadp t\u1ee9c.<\/p>\n<h3>4.1 M\u1ee5c ti\u00eau<\/h3>\n<ul>\n<li>Kh\u1eddi \u0111\u1ea7u v\u1edbi dung d\u1ecbch natri clorid 0,9% IV<\/li>\n<li>B\u1eaft \u0111\u1ea7u FRIII, nh\u01b0ng ch\u1ec9 sau khi b\u00f9 d\u1ecbch \u0111\u00e3 \u0111\u01b0\u1ee3c kh\u1edfi \u0111\u1ea7u<\/li>\n<li>Thi\u1ebft l\u1eadp ch\u1ebf \u0111\u1ed9 gi\u00e1m s\u00e1t ph\u00f9 h\u1ee3p; th\u01b0\u1eddng \u0111o BG h\u00e0ng gi\u1edd v\u00e0 \u0111o ceton h\u00e0ng gi\u1edd, k\u00e8m kali v\u00e0 bicarbonate huy\u1ebft thanh \/ m\u00e1u \u00edt nh\u1ea5t m\u1ed7i 2 gi\u1edd trong 6 gi\u1edd \u0111\u1ea7u ti\u00ean<\/li>\n<li>\u0110\u00e1nh gi\u00e1 l\u00e2m s\u00e0ng v\u00e0 sinh h\u00f3a c\u1ee7a BN<\/li>\n<li>Tham gia v\u1edbi nh\u00f3m chuy\u00ean gia v\u1ec1 b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng \u1edf giai \u0111o\u1ea1n s\u1edbm nh\u1ea5t c\u00f3 th\u1ec3<\/li>\n<li>Xem x\u00e9t gi\u1edbi thi\u1ec7u \u0111\u1ebfn m\u00f4i tr\u01b0\u1eddng C\u1ea5p 2 \/ HDU n\u1ebfu \u0111\u00e1p \u1ee9ng c\u00e1c ti\u00eau ch\u00ed v\u1ec1 m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng ho\u1eb7c n\u1ebfu kh\u00f4ng c\u00f3 s\u1eb5n c\u00e1c ph\u01b0\u01a1ng ti\u1ec7n \u0111\u1ec3 gi\u00e1m s\u00e1t chuy\u00ean s\u00e2u<\/li>\n<\/ul>\n<h3>4.2 H\u00e0nh \u0111\u1ed9ng 1 \u2014 Ti\u1ebfp c\u1eadn \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch v\u00e0 ki\u1ec3m tra ban \u0111\u1ea7u<\/h3>\n<ul>\n<li>ABC nhanh (\u0110\u01b0\u1eddng th\u1edf, H\u00f4 h\u1ea5p, Tu\u1ea7n ho\u00e0n)<\/li>\n<li>Catheter IV l\u1edbn v\u00e0 b\u1eaft \u0111\u1ea7u b\u00f9 d\u1ecbch IV (Xem H\u00e0nh \u0111\u1ed9ng 2)<\/li>\n<li>\u0110\u00e1nh gi\u00e1 l\u00e2m s\u00e0ng<\/li>\n<li>T\u1ea7n s\u1ed1 h\u00f4 h\u1ea5p, nhi\u1ec7t \u0111\u1ed9, huy\u1ebft \u00e1p, m\u1ea1ch, \u0111\u1ed9 b\u00e3o h\u00f2a oxy<\/li>\n<li>Thang \u0111i\u1ec3m H\u00f4n m\u00ea Glasgow: m\u1ed9t BN ng\u1ee7 g\u00e0 trong b\u1ed1i c\u1ea3nh nhi\u1ec5m toan ceton l\u00e0 \u0111\u00e1ng lo ng\u1ea1i nghi\u00eam tr\u1ecdng, v\u00e0 BN \u0111\u00f3 c\u1ea7n \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 ch\u0103m s\u00f3c quan tr\u1ecdng. Xem x\u00e9t \u0111\u1eb7t sonde d\u1ea1 d\u00e0y \u0111\u1ec3 b\u1ea3o v\u1ec7 \u0111\u01b0\u1eddng th\u1edf \u0111\u1ec3 ng\u0103n ch\u1eb7n h\u00edt s\u1eb7c<\/li>\n<li>Kh\u00e1m l\u00e2m s\u00e0ng \u0111\u1ea7y \u0111\u1ee7<\/li>\n<\/ul>\n<p>C\u00e1c ki\u1ec3m tra ban \u0111\u1ea7u n\u00ean bao g\u1ed3m nh\u1eefng \u0111i\u1ec1u sau:<\/p>\n<ul>\n<li>Ceton m\u00e1u<\/li>\n<li>Glucose mao m\u1ea1ch<\/li>\n<li>Glucose huy\u1ebft t\u01b0\u01a1ng t\u0129nh m\u1ea1ch<\/li>\n<li>Ur\u00ea v\u00e0 ch\u1ea5t \u0111i\u1ec7n gi\u1ea3i (bao g\u1ed3m c\u1ea3 ph\u1ed1t ph\u00e1t n\u1ebfu c\u1ea7n)<\/li>\n<li>Kh\u00ed m\u00e1u t\u0129nh m\u1ea1ch<\/li>\n<li>T\u1ed5ng ph\u00e2n t\u00edch t\u1ebf b\u00e0o m\u00e1u<\/li>\n<li>C\u1ea5y m\u00e1u (n\u1ebfu nghi ng\u1edd nhi\u1ec5m tr\u00f9ng)<\/li>\n<li>\u0110i\u1ec7n t\u00e2m \u0111\u1ed3<\/li>\n<li>X quang ph\u1ed5i n\u1ebfu c\u00f3 ch\u1ec9 \u0111\u1ecbnh l\u00e2m s\u00e0ng<\/li>\n<li>Ph\u00e2n t\u00edch n\u01b0\u1edbc ti\u1ec3u v\u00e0 c\u1ea5y n\u01b0\u1edbc ti\u1ec3u<\/li>\n<li>Monitoring tim li\u00ean t\u1ee5c<\/li>\n<li>\u0110o SpO2 li\u00ean t\u1ee5c<\/li>\n<li>Xem x\u00e9t nguy\u00ean nh\u00e2n th\u00fac \u0111\u1ea9y v\u00e0 \u0111i\u1ec1u tr\u1ecb th\u00edch h\u1ee3p<\/li>\n<li>Thi\u1ebft l\u1eadp thu\u1ed1c th\u00f4ng th\u01b0\u1eddng cho b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng<\/li>\n<li>Th\u1eed thai \u1edf ph\u1ee5 n\u1eef trong \u0111\u1ed9 tu\u1ed5i sinh \u0111\u1ebb<\/li>\n<li>X\u00e9t nghi\u1ec7m COVID-19 \u2014 \u0111\u1eb7c bi\u1ec7t \u1edf nh\u1eefng ng\u01b0\u1eddi kh\u00f4ng \u0111\u01b0\u1ee3c bi\u1ebft l\u00e0 c\u00f3 b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng tr\u01b0\u1edbc \u0111\u00e2y.<\/li>\n<\/ul>\n<h3>4.3 H\u00e0nh \u0111\u1ed9ng 2 \u2014 Ph\u1ee5c h\u1ed3i th\u1ec3 t\u00edch tu\u1ea7n ho\u00e0n<\/h3>\n<p>\u0110\u00e1nh gi\u00e1 m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng c\u1ee7a t\u00ecnh tr\u1ea1ng m\u1ea5t n\u01b0\u1edbc b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng m\u1ea1ch v\u00e0 huy\u1ebft \u00e1p. Theo h\u01b0\u1edbng d\u1eabn, 90 mm Hg c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng nh\u01b0 m\u1ed9t th\u01b0\u1edbc \u0111o m\u1ea5t n\u01b0\u1edbc nh\u01b0ng c\u1ea7n t\u00ednh \u0111\u1ebfn tu\u1ed5i t\u00e1c, gi\u1edbi t\u00ednh v\u00e0 thu\u1ed1c d\u00f9ng \u0111\u1ed3ng th\u1eddi.<\/p>\n<h4>4.3.1 HA t\u00e2m thu khi nh\u1eadp vi\u1ec7n d\u01b0\u1edbi 90 mm Hg<\/h4>\n<p>T\u1ee5t huy\u1ebft \u00e1p c\u00f3 kh\u1ea3 n\u0103ng l\u00e0 do kh\u1ed1i l\u01b0\u1ee3ng tu\u1ea7n ho\u00e0n th\u1ea5p, nh\u01b0ng c\u1ea7n xem x\u00e9t c\u00e1c nguy\u00ean nh\u00e2n kh\u00e1c nh\u01b0 suy tim v\u00e0 nhi\u1ec5m tr\u00f9ng huy\u1ebft.<\/p>\n<ul>\n<li>Cho 500 ml dung d\u1ecbch natri clorid 0,9% trong 10\u201315 ph\u00fat. N\u1ebfu HA t\u00e2m thu (SBP) duy tr\u00ec d\u01b0\u1edbi 90 mm Hg, \u0111i\u1ec1u n\u00e0y c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c l\u1eb7p l\u1ea1i trong khi \u0111\u01b0\u1eddng truy\u1ec1n l\u1edbn. Trong th\u1ef1c t\u1ebf, h\u1ea7u h\u1ebft c\u00e1c c\u00e1 nh\u00e2n c\u1ea7n t\u1eeb 500 \u0111\u1ebfn 1000 ml \u0111\u01b0\u1ee3c cung c\u1ea5p nhanh ch\u00f3ng.<\/li>\n<li>N\u1ebfu kh\u00f4ng c\u00f3 c\u1ea3i thi\u1ec7n v\u1ec1 m\u1eb7t l\u00e2m s\u00e0ng, h\u00e3y xem x\u00e9t l\u1ea1i c\u00e1c nguy\u00ean nh\u00e2n kh\u00e1c g\u00e2y h\u1ea1 huy\u1ebft \u00e1p v\u00e0 t\u00ecm ki\u1ebfm \u0111\u00e1nh gi\u00e1 c\u1ea5p cao ngay l\u1eadp t\u1ee9c. C\u00e2n nh\u1eafc h\u1ed9i ch\u1ea9n ITU \/ nh\u00f3m ch\u0103m s\u00f3c quan tr\u1ecdng.<\/li>\n<li>Khi HATT tr\u00ean 90 mm Hg, h\u00e3y b\u00f9 d\u1ecbch nh\u01b0 h\u00ecnh d\u01b0\u1edbi \u0111\u00e2y.<\/li>\n<\/ul>\n<h4>4.3.2 HA t\u00e2m thu khi nh\u1eadp vi\u1ec7n 90 mm Hg tr\u1edf l\u00ean<\/h4>\n<p>B\u1ea3ng 4 ph\u00e1c th\u1ea3o m\u1ed9t ch\u1ebf \u0111\u1ed9 b\u00f9 d\u1ecbch \u0111i\u1ec3n h\u00ecnh cho m\u1ed9t ng\u01b0\u1eddi l\u1edbn 70 kg tr\u01b0\u1edbc \u0111\u00e2y kh\u1ecfe m\u1ea1nh. \u0110\u00e2y ch\u1ec9 l\u00e0 m\u1ed9t h\u01b0\u1edbng d\u1eabn minh h\u1ecda. T\u1ed1c \u0111\u1ed9 truy\u1ec1n ch\u1eadm h\u01a1n n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t \u1edf ng\u01b0\u1eddi tr\u1ebb (xem C\u00e1c khu v\u1ef1c tranh c\u00e3i).<\/p>\n<p>B\u1ea2NG 4. S\u01a1 l\u01b0\u1ee3c v\u1ec1 m\u1ed9t ph\u00e1c \u0111\u1ed3 b\u00f9 d\u1ecbch \u0111i\u1ec3n h\u00ecnh cho m\u1ed9t ng\u01b0\u1eddi l\u1edbn 70 kg tr\u01b0\u1edbc \u0111\u00e2y kh\u1ecfe m\u1ea1nh<\/p>\n<table>\n<tbody>\n<tr>\n<td>Lo\u1ea1i d\u1ecbch<\/td>\n<td>L\u01b0\u1ee3ng d\u1ecbch<\/td>\n<\/tr>\n<tr>\n<td>0,9% natri clorua 1 L<\/td>\n<td>1000 ml trong gi\u1edd \u0111\u1ea7u ti\u00ean<\/td>\n<\/tr>\n<tr>\n<td>0,9% natri clorua 1 L v\u1edbi kali clorua<\/td>\n<td>1000 ml trong 2 gi\u1edd ti\u1ebfp theo<\/td>\n<\/tr>\n<tr>\n<td>0,9% natri clorua 1 L v\u1edbi kali clorua<\/td>\n<td>1000 ml trong 2 gi\u1edd ti\u1ebfp theo<\/td>\n<\/tr>\n<tr>\n<td>0,9% natri clorua 1 L v\u1edbi kali clorua<\/td>\n<td>1000 ml trong 4 gi\u1edd ti\u1ebfp theo<\/td>\n<\/tr>\n<tr>\n<td>0,9% natri clorua 1 L v\u1edbi kali clorua<\/td>\n<td>1000 ml trong 4 gi\u1edd ti\u1ebfp theo<\/td>\n<\/tr>\n<tr>\n<td>0,9% natri clorua 1 L v\u1edbi kali clorua<\/td>\n<td>1000 ml trong 6 gi\u1edd ti\u1ebfp theo<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Ghi ch\u00fa<\/p>\n<ul>\n<li>\u0110\u00e1nh gi\u00e1 l\u1ea1i t\u00ecnh tr\u1ea1ng tim m\u1ea1ch l\u00fac 12 gi\u1edd l\u00e0 b\u1eaft bu\u1ed9c, d\u1ecbch truy\u1ec1n th\u00eam c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh.<\/li>\n<li>Kali clorua c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh n\u1ebfu h\u01a1n 1 L natri clorua \u0111\u00e3 \u0111\u01b0\u1ee3c cung c\u1ea5p \u0111\u1ec3 h\u1ed3i s\u1ee9c cho nh\u1eefng BN b\u1ecb h\u1ea1 huy\u1ebft \u00e1p.<\/li>\n<\/ul>\n<h3>4.4 Th\u1eadn tr\u1ecdng trong c\u00e1c nh\u00f3m sau:<\/h3>\n<ul>\n<li>Thanh ni\u00ean t\u1eeb 18\u201325 tu\u1ed5i<\/li>\n<li>Ng\u01b0\u1eddi gi\u00e0<\/li>\n<li>C\u00f3 thai<\/li>\n<li>Suy tim ho\u1eb7c th\u1eadn<\/li>\n<li>C\u00e1c b\u1ec7nh \u0111\u1ed3ng m\u1eafc nghi\u00eam tr\u1ecdng kh\u00e1c<\/li>\n<\/ul>\n<p>Trong nh\u1eefng t\u00ecnh hu\u1ed1ng n\u00e0y, vi\u1ec7c nh\u1eadp v\u00e0o khu v\u1ef1c ch\u0103m s\u00f3c C\u1ea5p 2 \/ HDU n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t. D\u1ecbch truy\u1ec1n n\u00ean \u0111\u01b0\u1ee3c b\u00f9 m\u1ed9t c\u00e1ch th\u1eadn tr\u1ecdng.<\/p>\n<h3>4.5 H\u00e0nh \u0111\u1ed9ng 3 &#8211; B\u00f9 kali<\/h3>\n<p>H\u1ea1 kali m\u00e1u v\u00e0 t\u0103ng kali m\u00e1u l\u00e0 nh\u1eefng t\u00ecnh tr\u1ea1ng \u0111e d\u1ecda t\u00ednh m\u1ea1ng v\u00e0 th\u01b0\u1eddng g\u1eb7p trong nhi\u1ec5m toan ceton. Kali huy\u1ebft thanh th\u01b0\u1eddng cao khi nh\u1eadp vi\u1ec7n (m\u1eb7c d\u00f9 t\u1ed5ng l\u01b0\u1ee3ng kali trong c\u01a1 th\u1ec3 th\u1ea5p) nh\u01b0ng gi\u1ea3m m\u1ea1nh khi \u0111i\u1ec1u tr\u1ecb b\u1eb1ng insulin. Gi\u00e1m s\u00e1t th\u01b0\u1eddng xuy\u00ean l\u00e0 b\u1eaft bu\u1ed9c (B\u1ea3ng 5 ).<\/p>\n<p>B\u1ea2NG 5. Ch\u1ebf \u0111\u1ed9 b\u00f9 kali \u0111\u01b0\u1ee3c \u0111\u1ec1 xu\u1ea5t<\/p>\n<table style=\"border-collapse: collapse; width: 100%;\">\n<tbody>\n<tr>\n<td style=\"width: 50%;\">M\u1ee9c kali trong 24 gi\u1edd \u0111\u1ea7u ti\u00ean\u00a0(mmol \/ L)<\/td>\n<td style=\"width: 50%;\">B\u00f9 kali t\u00ednh b\u1eb1ng mmol \/ L c\u1ee7a\u00a0d\u1ecbch truy\u1ec1n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%;\">Tr\u00ean 5,5<\/td>\n<td style=\"width: 50%;\">Kh\u00f4ng<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%;\">3,5\u20135,5<\/td>\n<td style=\"width: 50%;\">40<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%;\">D\u01b0\u1edbi 3,5<\/td>\n<td style=\"width: 50%;\">\u0110\u00e1nh gi\u00e1 chuy\u00ean s\u00e2u v\u00ec c\u1ea7n cung c\u1ea5p th\u00eam kali\u00a0(xem ph\u1ea7n c\u00e1c bi\u1ebfn ch\u1ee9ng nghi\u00eam tr\u1ecdng)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<h3>4.6 H\u00e0nh \u0111\u1ed9ng 4 \u2014 B\u1eaft \u0111\u1ea7u truy\u1ec1n insulin t\u0129nh m\u1ea1ch t\u1ed1c \u0111\u1ed9 c\u1ed1 \u0111\u1ecbnh<\/h3>\n<ul>\n<li>N\u1ebfu ng\u01b0\u1eddi \u0111\u00f3 kh\u00f4ng th\u1ec3 cho bi\u1ebft tr\u1ecdng l\u01b0\u1ee3ng c\u1ee7a h\u1ecd ho\u1eb7c kh\u00f4ng c\u00f3 s\u1eb5n, h\u00e3y \u01b0\u1edbc t\u00ednh n\u00f3 b\u1eb1ng kil\u00f4gam<\/li>\n<li>N\u1ebfu l\u00e0 ph\u1ee5 n\u1eef mang thai, h\u00e3y s\u1eed d\u1ee5ng c\u00e2n n\u1eb7ng hi\u1ec7n t\u1ea1i c\u1ee7a c\u00f4 \u1ea5y v\u00e0 g\u1ecdi th\u00eam tr\u1ee3 gi\u00fap s\u1ea3n khoa c\u1ea5p cao ngay l\u1eadp t\u1ee9c<\/li>\n<li>B\u1eaft \u0111\u1ea7u FRIII li\u00ean t\u1ee5c th\u00f4ng qua m\u1ed9t m\u00e1y b\u01a1m truy\u1ec1n d\u1ecbch. Thu\u1ed1c n\u00e0y \u0111\u01b0\u1ee3c l\u00e0m t\u1eeb 50 \u0111\u01a1n v\u1ecb human soluble insulin (Actrapid \u00ae , Humulin S \u00ae ) \u0111\u01b0\u1ee3c pha v\u1edbi dung d\u1ecbch natri clorid 0,9% cho \u0111\u1ee7 50 ml. T\u1ed1t nh\u1ea5t, thu\u1ed1c n\u00e0y n\u00ean \u0111\u01b0\u1ee3c cung c\u1ea5p d\u01b0\u1edbi d\u1ea1ng gi\u1ea3i ph\u00e1p l\u00e0m s\u1eb5n<\/li>\n<li>Truy\u1ec1n v\u1edbi t\u1ed1c \u0111\u1ed9 c\u1ed1 \u0111\u1ecbnh 0,1 \u0111\u01a1n v\u1ecb \/ kg \/ gi\u1edd (t\u1ee9c l\u00e0 7 ml \/ gi\u1edd n\u1ebfu c\u00e2n n\u1eb7ng l\u00e0 70 kg) (xem B\u1ea3ng 3 )<\/li>\n<li>Ch\u1ec9 ti\u00eam b\u1eafp insulin li\u1ec1u bolus (stat) (0,1 \u0111\u01a1n v\u1ecb \/ kg) n\u1ebfu c\u00f3 s\u1ef1 ch\u1eadm tr\u1ec5 trong vi\u1ec7c thi\u1ebft l\u1eadp FRIII<\/li>\n<li>N\u1ebfu BN th\u01b0\u1eddng d\u00f9ng insulin n\u1ec1n t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i (v\u00ed d\u1ee5: glargine, degludec, detemir ho\u1eb7c insulin isophane c\u1ee7a ng\u01b0\u1eddi), h\u00e3y ti\u1ebfp t\u1ee5c \u0111i\u1ec1u n\u00e0y \u1edf li\u1ec1u th\u00f4ng th\u01b0\u1eddng v\u00e0 th\u1eddi gian b\u00ecnh th\u01b0\u1eddng<\/li>\n<li>Insulin c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c truy\u1ec1n c\u00f9ng \u0111\u01b0\u1eddng v\u1edbi \u0111\u01b0\u1eddng truy\u1ec1n b\u00f9 d\u1ecbch v\u1edbi \u0111i\u1ec1u ki\u1ec7n ph\u1ea3i s\u1eed d\u1ee5ng \u0111\u1ea7u n\u1ed1i ch\u1eef Y v\u1edbi van m\u1ed9t chi\u1ec1u ch\u1ed1ng siphon (one way, anti-siphon valve) v\u00e0 \u0111\u00e3 \u0111\u1eb7t m\u1ed9t \u0111\u01b0\u1eddng truy\u1ec1n l\u1edbn. Tuy nhi\u00ean, 2 \u0111\u01b0\u1eddng truy\u1ec1n IV l\u1edbn l\u00e0 kh\u00f4n ngoan.<\/li>\n<\/ul>\n<h2>5. 60 ph\u00fat \u2013 6 gi\u1edd<\/h2>\n<h3>5.1 M\u1ee5c ti\u00eau<\/h3>\n<ul>\n<li>Lo\u1ea1i b\u1ecf ceton m\u00e1u v\u00e0 ng\u0103n ch\u1eb7n qu\u00e1 tr\u00ecnh t\u1ea1o ceton<\/li>\n<li>\u0110\u1ea1t \u0111\u01b0\u1ee3c t\u1ed1c \u0111\u1ed9 gi\u1ea3m ceton \u00edt nh\u1ea5t 0,5 mmol \/ L \/ h<\/li>\n<li>Trong tr\u01b0\u1eddng h\u1ee3p kh\u00f4ng c\u00f3 m\u00e1y \u0111o ceton, bicarbonate n\u00ean t\u0103ng 3,0 mmol \/ L \/ h v\u00e0 BG n\u00ean gi\u1ea3m 3,0 mmol \/ L \/ h<\/li>\n<li>Duy tr\u00ec kali huy\u1ebft thanh \u1edf m\u1ee9c b\u00ecnh th\u01b0\u1eddng<\/li>\n<li>Tr\u00e1nh h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft<\/li>\n<li>Xem x\u00e9t gi\u1edbi thi\u1ec7u \u0111\u1ebfn m\u00f4i tr\u01b0\u1eddng ch\u0103m s\u00f3c C\u1ea5p \u0111\u1ed9 2 (HDU) n\u1ebfu \u0111\u00e1p \u1ee9ng c\u00e1c ti\u00eau ch\u00ed v\u1ec1 m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng sau khi h\u1ed3i s\u1ee9c ban \u0111\u1ea7u ho\u1eb7c n\u1ebfu kh\u00f4ng c\u00f3 s\u1eb5n c\u00e1c ph\u01b0\u01a1ng ti\u1ec7n \u0111\u1ec3 theo d\u00f5i chuy\u00ean s\u00e2u<\/li>\n<\/ul>\n<h3>5.2 H\u00e0nh \u0111\u1ed9ng 1 \u2014 \u0110\u00e1nh gi\u00e1 l\u1ea1i v\u00e0 theo d\u00f5i c\u00e1c d\u1ea5u hi\u1ec7u quan tr\u1ecdng<\/h3>\n<ul>\n<li>Trong th\u1eddi gian n\u00e0y, c\u00e1c BN n\u00ean \u0111\u01b0\u1ee3c theo d\u00f5i ban \u0111\u1ea7u h\u00e0ng gi\u1edd \u0111\u1ec3 \u0111\u1ea3m b\u1ea3o r\u1eb1ng \u0111ang ti\u1ebfn tri\u1ec3n t\u1ed1t trong vi\u1ec7c gi\u1ea3m n\u1ed3ng \u0111\u1ed9 ceton v\u00e0 \/ ho\u1eb7c glucose<\/li>\n<li>C\u00e2n nh\u1eafc \u0111\u1eb7t \u1ed1ng th\u00f4ng ti\u1ec3u n\u1ebfu BN ti\u1ec3u kh\u00f4ng t\u1ef1 ch\u1ee7 \u0111\u01b0\u1ee3c ho\u1eb7c kh\u00f4ng ti\u1ec3u \u0111\u01b0\u1ee3c (t\u1ee9c l\u00e0 kh\u00f4ng c\u00f3 n\u01b0\u1edbc ti\u1ec3u trong v\u00f2ng 60 ph\u00fat)<\/li>\n<li>C\u00e2n nh\u1eafc vi\u1ec7c \u0111\u1eb7t \u1ed1ng th\u00f4ng m\u0169i-d\u1ea1 d\u00e0y n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh b\u1ecb ch\u01b0\u1edbng b\u1ee5ng ho\u1eb7c n\u00f4n li\u00ean t\u1ee5c<\/li>\n<li>N\u1ebfu \u0111\u1ed9 b\u00e3o h\u00f2a oxy gi\u1ea3m th\u00ec ti\u1ebfn h\u00e0nh \u0111o kh\u00ed m\u00e1u \u0111\u1ed9ng m\u1ea1ch v\u00e0 y\u00eau c\u1ea7u ch\u1ee5p X quang ph\u1ed5i l\u1eb7p l\u1ea1i.<\/li>\n<li>Quan s\u00e1t th\u01b0\u1eddng xuy\u00ean v\u00e0 l\u1eadp bi\u1ec3u \u0111\u1ed3 \u0110i\u1ec3m c\u1ea3nh b\u00e1o s\u1edbm (EWS) khi th\u00edch h\u1ee3p<\/li>\n<li>Th\u01b0\u1eddng xuy\u00ean \u0111\u00e1nh gi\u00e1 thang \u0111i\u1ec3m H\u00f4n m\u00ea Glasgow, n\u1ebfu \u0111i\u1ec3m n\u00e0y gi\u1ea3m xu\u1ed1ng th\u00ec n\u00ean xem x\u00e9t ch\u1ee5p \u1ea3nh n\u00e3o kh\u1ea9n c\u1ea5p<\/li>\n<li>Duy tr\u00ec bi\u1ec3u \u0111\u1ed3 c\u00e2n b\u1eb1ng ch\u1ea5t l\u1ecfng ch\u00ednh x\u00e1c, l\u01b0\u1ee3ng n\u01b0\u1edbc ti\u1ec3u t\u1ed1i thi\u1ec3u kh\u00f4ng \u0111\u01b0\u1ee3c d\u01b0\u1edbi 0,5 ml \/ kg \/ h<\/li>\n<li>Theo d\u00f5i tim li\u00ean t\u1ee5c \u1edf nh\u1eefng ng\u01b0\u1eddi b\u1ecb nhi\u1ec5m toan ceton n\u1eb7ng<\/li>\n<li>Cung c\u1ea5p heparin tr\u1ecdng l\u01b0\u1ee3ng ph\u00e2n t\u1eed th\u1ea5p d\u1ef1 ph\u00f2ng theo h\u01b0\u1edbng d\u1eabn c\u1ee7a NICE 61<\/li>\n<\/ul>\n<h3>5.3 H\u00e0nh \u0111\u1ed9ng 2 \u2014 Xem l\u1ea1i c\u00e1c th\u00f4ng s\u1ed1 chuy\u1ec3n h\u00f3a<\/h3>\n<ul>\n<li>\u0110o ceton m\u00e1u v\u00e0 \u0111\u01b0\u1eddng huy\u1ebft mao m\u1ea1ch h\u00e0ng gi\u1edd (L\u01b0u \u00fd: n\u1ebfu m\u00e1y \u0111o ghi &#8216;BG tr\u00ean 20 mmol \/ L&#8217; ho\u1eb7c &#8216;Hi&#8217;, m\u00e1u t\u0129nh m\u1ea1ch ph\u1ea3i \u0111\u01b0\u1ee3c g\u1eedi \u0111\u1ebfn ph\u00f2ng x\u00e9t nghi\u1ec7m h\u00e0ng gi\u1edd ho\u1eb7c \u0111o b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng m\u00e1u t\u0129nh m\u1ea1ch trong m\u00e1y ph\u00e2n t\u00edch kh\u00ed m\u00e1u cho \u0111\u1ebfn khi n\u1ed3ng \u0111\u1ed9 glucose m\u00e1u n\u1eb1m trong gi\u1edbi h\u1ea1n \u0111o c\u1ee7a m\u00e1y POCT)<\/li>\n<li>C\u00e1c k\u1ebft qu\u1ea3 \u0111o \u0111\u01b0\u1eddng huy\u1ebft h\u00e0ng gi\u1edd n\u00ean \u0111\u01b0\u1ee3c ghi tr\u1ef1c ti\u1ebfp v\u00e0o h\u1ec7 th\u1ed1ng b\u1ec7nh l\u00fd c\u1ee7a b\u1ec7nh vi\u1ec7n. Trong tr\u01b0\u1eddng h\u1ee3p kh\u00f4ng th\u1ec3 th\u1ef1c hi\u1ec7n \u0111\u01b0\u1ee3c \u0111i\u1ec1u n\u00e0y (v\u00ed d\u1ee5, v\u1edbi c\u00e1c m\u00e1y \u0111o \u0111\u01b0\u1eddng huy\u1ebft kh\u00f4ng n\u1ed1i m\u1ea1ng), k\u1ebft qu\u1ea3 ph\u1ea3i \u0111\u01b0\u1ee3c ghi l\u1ea1i trong ghi ch\u00fa<\/li>\n<li>Xem l\u1ea1i \u0111\u00e1p \u1ee9ng v\u1edbi FRIII h\u00e0ng gi\u1edd b\u1eb1ng c\u00e1ch t\u00ednh to\u00e1n t\u1ed1c \u0111\u1ed9 thay \u0111\u1ed5i m\u1ee9c gi\u1ea3m ceton (ho\u1eb7c t\u0103ng bicarbonate ho\u1eb7c gi\u1ea3m glucose)<\/li>\n<li>\u0110\u00e1nh gi\u00e1 s\u1ef1 ph\u00e2n gi\u1ea3i c\u1ee7a nhi\u1ec5m toan ceton\n<ul>\n<li>N\u1ebfu c\u00f3 k\u1ebft qu\u1ea3 \u0111o ceton trong m\u00e1u v\u00e0 ceton trong m\u00e1u kh\u00f4ng gi\u1ea3m \u00edt nh\u1ea5t 0,5 mmol \/ L \/ h, h\u00e3y g\u1ecdi b\u00e1c s\u0129 l\u00e2m s\u00e0ng \u0111\u1ec3 t\u0103ng t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin l\u00ean 1,0 \u0111\u01a1n v\u1ecb \/ h m\u1ed7i gi\u1edd cho \u0111\u1ebfn khi ceton gi\u1ea3m \u1edf t\u1ed1c \u0111\u1ed9 m\u1ee5c ti\u00eau (c\u0169ng ki\u1ec3m tra b\u01a1m ti\u00eam insulin c\u00f3 ho\u1ea1t \u0111\u1ed9ng v\u00e0 \u0111\u01b0\u1ee3c k\u1ebft n\u1ed1i kh\u00f4ng, c\u0169ng nh\u01b0 l\u01b0\u1ee3ng th\u1ec3 t\u00edch insulin c\u00f2n l\u1ea1i trong m\u00e1y b\u01a1m c\u00f3 \u0111\u00fang kh\u00f4ng) *<\/li>\n<li>N\u1ebfu kh\u00f4ng c\u00f3 m\u00e1y \u0111o ceton m\u00e1u, h\u00e3y d\u00f9ng bicarbonat t\u0129nh m\u1ea1ch. N\u1ebfu bicarbonate kh\u00f4ng t\u0103ng \u00edt nh\u1ea5t 3,0 mmol \/ L \/ h, h\u00e3y g\u1ecdi b\u00e1c s\u0129 l\u00e2m s\u00e0ng \u0111\u1ec3 t\u0103ng t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin l\u00ean 1 \u0111\u01a1n v\u1ecb \/ h, t\u0103ng d\u1ea7n h\u00e0ng gi\u1edd cho \u0111\u1ebfn khi bicarbonate t\u0103ng v\u1edbi t\u1ed1c \u0111\u1ed9 n\u00e0y *<\/li>\n<li>Ho\u1eb7c s\u1eed d\u1ee5ng glucose huy\u1ebft t\u01b0\u01a1ng. N\u1ebfu glucose kh\u00f4ng gi\u1ea3m \u00edt nh\u1ea5t 3,0 mmol \/ L \/ h, h\u00e3y g\u1ecdi b\u00e1c s\u0129 l\u00e2m s\u00e0ng \u0111\u1ec3 t\u0103ng t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin th\u00eam 1,0 \u0111\u01a1n v\u1ecb \/ gi\u1edd, t\u0103ng d\u1ea7n h\u00e0ng gi\u1edd cho \u0111\u1ebfn khi glucose gi\u1ea3m \u1edf t\u1ed1c \u0111\u1ed9 n\u00e0y. M\u1ee9c \u0111\u1ed9 glucose kh\u00f4ng ph\u1ea3i l\u00e0 m\u1ed9t ch\u1ec9 s\u1ed1 ch\u00ednh x\u00e1c \u0111\u1ec3 ph\u00e2n gi\u1ea3i toan trong nhi\u1ec5m toan ceton, v\u00ec v\u1eady vi\u1ec7c ph\u00e2n gi\u1ea3i toan ph\u1ea3i \u0111\u01b0\u1ee3c x\u00e1c minh b\u1eb1ng ph\u00e2n t\u00edch kh\u00ed m\u00e1u t\u0129nh m\u1ea1ch *<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>\u0110o kh\u00ed m\u00e1u t\u0129nh m\u1ea1ch \u0111\u1ec3 t\u00ecm pH, bicarbonate v\u00e0 kali \u1edf 60 ph\u00fat, 2 gi\u1edd v\u00e0 m\u1ed7i 2 gi\u1edd sau \u0111\u00f3<\/li>\n<li>N\u1ebfu kali n\u1eb1m ngo\u00e0i ph\u1ea1m vi tham chi\u1ebfu (4,0\u20135,5 mmol \/ L), h\u00e3y \u0111\u00e1nh gi\u00e1 m\u1ee9c \u0111\u1ed9 th\u00edch h\u1ee3p c\u1ee7a vi\u1ec7c b\u00f9 kali v\u00e0 ki\u1ec3m tra h\u00e0ng gi\u1edd. N\u1ebfu n\u00f3 v\u1eabn b\u1ea5t th\u01b0\u1eddng sau m\u1ed9t gi\u1edd n\u1eefa, h\u00e3y t\u00ecm ki\u1ebfm l\u1eddi khuy\u00ean y t\u1ebf c\u1ea5p cao ngay l\u1eadp t\u1ee9c (xem H\u00e0nh \u0111\u1ed9ng 3)<\/li>\n<li>Ti\u1ebfp t\u1ee5c FRIII cho \u0111\u1ebfn khi k\u1ebft qu\u1ea3 \u0111o ceton d\u01b0\u1edbi 0,6 mmol \/ L, pH t\u0129nh m\u1ea1ch tr\u00ean 7,3 v\u00e0 \/ ho\u1eb7c bicarbonate t\u0129nh m\u1ea1ch tr\u00ean 18 mmol \/ L (xem ph\u1ea7n C)<\/li>\n<li>Kh\u00f4ng d\u1ef1a v\u00e0o \u0111\u1ed9 thanh th\u1ea3i ceton trong n\u01b0\u1edbc ti\u1ec3u \u0111\u1ec3 ch\u1ec9 ra s\u1ef1 ph\u00e2n gi\u1ea3i c\u1ee7a nhi\u1ec5m toan ceton v\u00ec ch\u00fang s\u1ebd v\u1eabn c\u00f2n khi t\u00ecnh tr\u1ea1ng nhi\u1ec5m ceton \u0111\u00e3 \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft<\/li>\n<li>N\u1ebfu glucose gi\u1ea3m xu\u1ed1ng d\u01b0\u1edbi 14,0 mmol \/ L, b\u1eaft \u0111\u1ea7u d\u00f9ng glucose 10% \u1edf 125 ml \/ h c\u00f9ng v\u1edbi dung d\u1ecbch natri clorid 0,9%. Ngo\u00e0i ra, c\u00e2n nh\u1eafc gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n insulin t\u0129nh m\u1ea1ch xu\u1ed1ng 0,05 \u0111\u01a1n v\u1ecb \/ kg \/ h.<\/li>\n<li>Theo d\u00f5i v\u00e0 b\u00f9 kali v\u00ec n\u00f3 c\u00f3 th\u1ec3 gi\u1ea3m nhanh (Insulin t\u0129nh m\u1ea1ch v\u00e0 dextrose t\u0129nh m\u1ea1ch n\u00ean \u0111\u01b0\u1ee3c truy\u1ec1n qua ch\u1ea1c ba ch\u1eef Y) **<\/li>\n<\/ul>\n<h3>5.4 H\u00e0nh \u0111\u1ed9ng 3 \u2014 X\u00e1c \u0111\u1ecbnh v\u00e0 x\u1eed l\u00fd c\u00e1c y\u1ebfu t\u1ed1 k\u1ebft t\u1ee7a<\/h3>\n<h3>5.5 H\u00e0nh \u0111\u1ed9ng 4 \u2014 S\u1eed d\u1ee5ng insulin t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i<\/h3>\n<p>Nh\u1eefng ng\u01b0\u1eddi m\u1eafc b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng m\u1edbi \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n n\u00ean \u0111\u01b0\u1ee3c ti\u00eam insulin n\u1ec1n t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i (v\u00ed d\u1ee5: glargine, detemir ho\u1eb7c degludec \u2014 ho\u1eb7c insulin human NPH, t\u00f9y thu\u1ed9c v\u00e0o ch\u00ednh s\u00e1ch c\u1ee7a \u0111\u1ecba ph\u01b0\u01a1ng) v\u1edbi li\u1ec1u 0,25 \u0111\u01a1n v\u1ecb \/ kg ti\u00eam d\u01b0\u1edbi da m\u1ed7i ng\u00e0y m\u1ed9t l\u1ea7n \u0111\u1ec3 gi\u1ea3m nhi\u1ec5m ceton d\u1ed9i l\u1ea1i (rebound ketosis) khi h\u1ecd \u0111\u01b0\u1ee3c ng\u1eebng FRIII.<\/p>\n<h2>6. 6\u201312 gi\u1edd<\/h2>\n<h3>6.1 M\u1ee5c ti\u00eau<\/h3>\n<p>M\u1ee5c \u0111\u00edch trong kho\u1ea3ng th\u1eddi gian n\u00e0y l\u00e0 th\u1ef1c hi\u1ec7n nh\u1eefng \u0111i\u1ec1u sau:<\/p>\n<ul>\n<li>\u0110\u1ea3m b\u1ea3o r\u1eb1ng c\u00e1c th\u00f4ng s\u1ed1 l\u00e2m s\u00e0ng v\u00e0 sinh h\u00f3a \u0111ang \u0111\u01b0\u1ee3c c\u1ea3i thi\u1ec7n \u1edf t\u1ed1c \u0111\u1ed9 ch\u00ednh x\u00e1c<\/li>\n<li>Ti\u1ebfp t\u1ee5c b\u00f9 d\u1ecbch IV<\/li>\n<li>Ti\u1ebfp t\u1ee5c s\u1eed d\u1ee5ng insulin<\/li>\n<li>\u0110\u00e1nh gi\u00e1 c\u00e1c bi\u1ebfn ch\u1ee9ng c\u1ee7a \u0111i\u1ec1u tr\u1ecb, v\u00ed d\u1ee5, qu\u00e1 t\u1ea3i d\u1ecbch, ph\u00f9 n\u00e3o<\/li>\n<li>Ti\u1ebfp t\u1ee5c x\u1eed l\u00fd c\u00e1c y\u1ebfu t\u1ed1 th\u00fac \u0111\u1ea9y khi c\u1ea7n thi\u1ebft<\/li>\n<li>Tr\u00e1nh h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft<\/li>\n<li>Xem x\u00e9t chuy\u1ec3n \u0111\u1ebfn m\u00f4i tr\u01b0\u1eddng ch\u0103m s\u00f3c C\u1ea5p 2 (HDU) n\u1ebfu \u0111\u00e1p \u1ee9ng c\u00e1c ti\u00eau ch\u00ed v\u1ec1 m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng m\u1eb7c d\u00f9 \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb \u0111\u1ea7y \u0111\u1ee7, ho\u1eb7c n\u1ebfu t\u00ecnh tr\u1ea1ng l\u00e2m s\u00e0ng x\u1ea5u \u0111i ho\u1eb7c n\u1ebfu kh\u00f4ng c\u00f3 s\u1eb5n c\u00e1c ph\u01b0\u01a1ng ti\u1ec7n \u0111\u1ec3 theo d\u00f5i chuy\u00ean s\u00e2u<\/li>\n<\/ul>\n<h3>6.2 H\u00e0nh \u0111\u1ed9ng 1 \u2014 \u0110\u00e1nh gi\u00e1 l\u1ea1i b\u1ec7nh nh\u00e2n v\u00e0 theo d\u00f5i c\u00e1c d\u1ea5u hi\u1ec7u quan tr\u1ecdng<\/h3>\n<ul>\n<li>N\u1ebfu BN kh\u00f4ng c\u1ea3i thi\u1ec7n nh\u01b0 mong \u0111\u1ee3i, h\u00e3y t\u00ecm l\u1eddi khuy\u00ean s\u1edbm c\u1ee7a chuy\u00ean gia<\/li>\n<li>Th\u01b0\u1eddng xuy\u00ean \u0111\u00e1nh gi\u00e1 thang \u0111i\u1ec3m H\u00f4n m\u00ea Glasgow, n\u1ebfu \u0111i\u1ec3m n\u00e0y gi\u1ea3m xu\u1ed1ng th\u00ec n\u00ean xem x\u00e9t ch\u1ee5p h\u00ecnh \u1ea3nh n\u00e3o kh\u1ea9n c\u1ea5p<\/li>\n<li>\u0110\u1ea3m b\u1ea3o \u0111\u00e3 \u0111\u01b0\u1ee3c gi\u1edbi thi\u1ec7u \u0111\u1ebfn nh\u00f3m chuy\u00ean gia v\u1ec1 b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng<\/li>\n<li>Xem x\u00e9t chuy\u1ec3n \u0111\u1ebfn m\u00f4i tr\u01b0\u1eddng ch\u0103m s\u00f3c C\u1ea5p 2 (HDU) n\u1ebfu \u0111\u00e1p \u1ee9ng c\u00e1c ti\u00eau ch\u00ed v\u1ec1 m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng ho\u1eb7c n\u1ebfu kh\u00f4ng c\u00f3 s\u1eb5n c\u00e1c ph\u01b0\u01a1ng ti\u1ec7n \u0111\u1ec3 gi\u00e1m s\u00e1t chuy\u00ean s\u00e2u<\/li>\n<\/ul>\n<h3>6.3 H\u00e0nh \u0111\u1ed9ng 2 \u2014 Xem x\u00e9t c\u00e1c th\u00f4ng s\u1ed1 sinh h\u00f3a v\u00e0 chuy\u1ec3n h\u00f3a<\/h3>\n<ul>\n<li>V\u00e0o th\u1eddi \u0111i\u1ec3m 6 gi\u1edd, ki\u1ec3m tra pH t\u0129nh m\u1ea1ch, bicarbonate, kali, c\u0169ng nh\u01b0 ceton v\u00e0 glucose m\u00e1u<\/li>\n<li>S\u1ef1 kh\u1ecfi nhi\u1ec5m toan ceton \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 ceton d\u01b0\u1edbi 0,6 mmol \/ L v\u00e0 pH t\u0129nh m\u1ea1ch tr\u00ean 7,3 (kh\u00f4ng s\u1eed d\u1ee5ng bicarbonate nh\u01b0 m\u1ed9t ch\u1ea5t thay th\u1ebf \u1edf giai \u0111o\u1ea1n n\u00e0y v\u00ec t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan t\u0103ng clo m\u00e1u k\u1ebft h\u1ee3p v\u1edbi l\u01b0\u1ee3ng l\u1edbn natri clorua 0,9% s\u1ebd l\u00e0m gi\u1ea3m m\u1ee9c bicarbonate)<\/li>\n<\/ul>\n<p>N\u1ebfu t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan ceton \u0111\u00e3 \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft, h\u00e3y chuy\u1ec3n \u0111\u1ebfn ph\u1ea7n E.<\/p>\n<p>N\u1ebfu t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan ceton v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft, h\u00e3y tham kh\u1ea3o H\u00e0nh \u0111\u1ed9ng 2 trong Ph\u1ea7n B.<\/p>\n<h2>7. 12\u201324 gi\u1edd<\/h2>\n<h3>7.1 K\u1ef3 v\u1ecdng<\/h3>\n<p>\u0110\u1ebfn 24 gi\u1edd, t\u00ecnh tr\u1ea1ng nhi\u1ec5m ceton m\u00e1u v\u00e0 toan m\u00e1u \u0111\u00e3 \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft \u1edf h\u1ea7u h\u1ebft m\u1ecdi BN 45<\/p>\n<h3>7.2 M\u1ee5c ti\u00eau<\/h3>\n<ul>\n<li>\u0110\u1ea3m b\u1ea3o r\u1eb1ng c\u00e1c th\u00f4ng s\u1ed1 l\u00e2m s\u00e0ng v\u00e0 sinh h\u00f3a \u0111ang \u0111\u01b0\u1ee3c c\u1ea3i thi\u1ec7n ho\u1eb7c \u0111\u00e3 b\u00ecnh th\u01b0\u1eddng h\u00f3a<\/li>\n<li>Ti\u1ebfp t\u1ee5c truy\u1ec1n d\u1ecbch qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh kh\u00f4ng \u0103n u\u1ed1ng \u0111\u01b0\u1ee3c<\/li>\n<li>N\u1ebfu BN kh\u00f4ng \u0103n u\u1ed1ng \u0111\u01b0\u1ee3c v\u00e0 kh\u00f4ng c\u00f3 ceton m\u00e1u, h\u00e3y chuy\u1ec3n sang VRIII theo h\u01b0\u1edbng d\u1eabn c\u1ee7a \u0111\u1ecba ph\u01b0\u01a1ng ho\u1eb7c theo guideline JBDS 63<\/li>\n<li>\u0110\u00e1nh gi\u00e1 l\u1ea1i c\u00e1c bi\u1ebfn ch\u1ee9ng c\u1ee7a \u0111i\u1ec1u tr\u1ecb, v\u00ed d\u1ee5, qu\u00e1 t\u1ea3i d\u1ecbch<\/li>\n<li>Th\u01b0\u1eddng xuy\u00ean \u0111\u00e1nh gi\u00e1 thang \u0111i\u1ec3m H\u00f4n m\u00ea Glasgow, n\u1ebfu \u0111i\u1ec3m n\u00e0y gi\u1ea3m xu\u1ed1ng th\u00ec n\u00ean xem x\u00e9t ch\u1ee5p \u1ea3nh n\u00e3o kh\u1ea9n c\u1ea5p<\/li>\n<li>Ti\u1ebfp t\u1ee5c x\u1eed l\u00fd m\u1ecdi y\u1ebfu t\u1ed1 th\u00fac \u0111\u1ea9y n\u1ebfu c\u1ea7n<\/li>\n<li>Chuy\u1ec3n sang insulin ti\u00eam d\u01b0\u1edbi da n\u1ebfu b\u1ec7nh nh\u00e2n \u0103n u\u1ed1ng b\u00ecnh th\u01b0\u1eddng. \u0110\u1ea3m b\u1ea3o r\u1eb1ng insulin ti\u00eam d\u01b0\u1edbi da \u0111\u01b0\u1ee3c b\u1eaft \u0111\u1ea7u tr\u01b0\u1edbc khi ng\u1eebng ti\u00eam insulin. T\u1ed1t nh\u1ea5t, h\u00e3y ti\u00eam d\u01b0\u1edbi da insulin t\u00e1c d\u1ee5ng nhanh v\u00e0o b\u1eefa \u0103n v\u00e0 ng\u01b0ng insulin IV 30\u201360 ph\u00fat sau \u0111\u00f3<\/li>\n<\/ul>\n<h3>7.3 H\u00e0nh \u0111\u1ed9ng 1 \u2014 \u0110\u00e1nh gi\u00e1 l\u1ea1i b\u1ec7nh nh\u00e2n v\u00e0 theo d\u00f5i c\u00e1c d\u1ea5u hi\u1ec7u quan tr\u1ecdng<\/h3>\n<h3>7.4 H\u00e0nh \u0111\u1ed9ng 2 \u2014 Xem l\u1ea1i c\u00e1c th\u00f4ng s\u1ed1 sinh h\u00f3a v\u00e0 chuy\u1ec3n h\u00f3a<\/h3>\n<ul>\n<li>V\u00e0o th\u1eddi \u0111i\u1ec3m 12 gi\u1edd, ki\u1ec3m tra pH t\u0129nh m\u1ea1ch, bicarbonate, kali, c\u0169ng nh\u01b0 ceton v\u00e0 glucose trong m\u00e1u<\/li>\n<li>S\u1ef1 kh\u1ecfi nhi\u1ec5m toan ceton \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 ceton d\u01b0\u1edbi 0,6 mmol\/L v\u00e0 pH t\u0129nh m\u1ea1ch tr\u00ean 7,3<\/li>\n<\/ul>\n<p>N\u1ebfu t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan ceton \u0111\u00e3 \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft, h\u00e3y chuy\u1ec3n \u0111\u1ebfn ph\u1ea7n E.<\/p>\n<p>N\u1ebfu t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan ceton v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft, h\u00e3y tham kh\u1ea3o H\u00e0nh \u0111\u1ed9ng 2 trong Ph\u1ea7n B v\u00e0 t\u00ecm ki\u1ebfm l\u1eddi khuy\u00ean c\u1ee7a b\u00e1c s\u0129 chuy\u00ean khoa cao c\u1ea5p n\u1ebfu kh\u1ea9n c\u1ea5p.<\/p>\n<h4>7.4.1 T\u1ea1i sao kh\u00f4ng th\u1ec3 d\u1ef1a v\u00e0o bicacbonat \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 s\u1ef1 kh\u1ecfi c\u1ee7a DKA<\/h4>\n<p>Kh\u00f4ng \u0111\u01a1n \u0111\u1ed9c d\u1ef1a v\u00e0o bicarbonat \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 kh\u1ea3 n\u0103ng ph\u00e2n gi\u1ea3i nhi\u1ec5m toan ceton t\u1ea1i th\u1eddi \u0111i\u1ec3m n\u00e0y do c\u00f3 th\u1ec3 t\u0103ng clo m\u00e1u th\u1ee9 ph\u00e1t do l\u01b0\u1ee3ng th\u1ec3 t\u00edch cao c\u1ee7a dung d\u1ecbch natri clorid 0,9% c\u0169ng ch\u1ee9a kali clorid. Nhi\u1ec5m toan chuy\u1ec3n h\u00f3a t\u0103ng clo m\u00e1u s\u1ebd l\u00e0m gi\u1ea3m bicarbonat v\u00e0 do \u0111\u00f3 d\u1eabn \u0111\u1ebfn kh\u00f3 kh\u0103n trong vi\u1ec7c \u0111\u00e1nh gi\u00e1 li\u1ec7u nhi\u1ec5m ceton \u0111\u00e3 h\u1ebft ch\u01b0a. Nhi\u1ec5m toan t\u0103ng clo m\u00e1u c\u00f3 th\u1ec3 g\u00e2y co m\u1ea1ch th\u1eadn v\u00e0 l\u00e0 nguy\u00ean nh\u00e2n g\u00e2y thi\u1ec3u ni\u1ec7u.<\/p>\n<h4>7.4.2 K\u1ef3 v\u1ecdng<\/h4>\n<p>Nh\u1eefng ng\u01b0\u1eddi b\u1ecb nhi\u1ec5m toan ceton n\u00ean \u0103n u\u1ed1ng v\u00e0 tr\u1edf l\u1ea1i ch\u1ebf \u0111\u1ed9 insulin b\u00ecnh th\u01b0\u1eddng c\u1ee7a h\u1ecd. N\u1ebfu k\u1ef3 v\u1ecdng n\u00e0y kh\u00f4ng \u0111\u01b0\u1ee3c \u0111\u00e1p \u1ee9ng trong kho\u1ea3ng th\u1eddi gian n\u00e0y, \u0111i\u1ec1u quan tr\u1ecdng l\u00e0 ph\u1ea3i x\u00e1c \u0111\u1ecbnh v\u00e0 \u0111i\u1ec1u tr\u1ecb c\u00e1c l\u00fd do kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb \u2014 v\u00ed d\u1ee5, vi\u00eam d\u1ea1 d\u00e0y. \u0110i\u1ec1u b\u1ea5t th\u01b0\u1eddng l\u00e0 nhi\u1ec5m toan ceton kh\u00f4ng \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft v\u1ec1 m\u1eb7t sinh h\u00f3a sau 24 gi\u1edd v\u1edbi ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb th\u00edch h\u1ee3p v\u00e0 n\u1ebfu g\u1eb7p ph\u1ea3i, c\u1ea7n c\u00f3 \u00fd ki\u1ebfn c\u1ee7a b\u00e1c s\u0129 chuy\u00ean khoa \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng c\u1ea5p cao.<\/p>\n<h3>7.5 E. Chuy\u1ec3n \u0111\u1ed5i th\u00e0nh insulin d\u01b0\u1edbi da<\/h3>\n<p>BN n\u00ean \u0111\u01b0\u1ee3c chuy\u1ec3n sang ch\u1ebf \u0111\u1ed9 ti\u00eam d\u01b0\u1edbi da th\u00edch h\u1ee3p khi sinh h\u00f3a \u1ed5n \u0111\u1ecbnh (ceton m\u00e1u d\u01b0\u1edbi 0,6 mmol \/ L, pH tr\u00ean 7,3) v\u00e0 h\u1ecd \u0111\u00e3 s\u1eb5n s\u00e0ng v\u00e0 c\u00f3 th\u1ec3 \u0103n \u0111\u01b0\u1ee3c. 63 Vi\u1ec7c chuy\u1ec3n \u0111\u1ed5i th\u00e0nh insulin ti\u00eam d\u01b0\u1edbi da \u0111\u01b0\u1ee3c qu\u1ea3n l\u00fd l\u00fd t\u01b0\u1edfng b\u1edfi nh\u00f3m chuy\u00ean gia \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng. N\u1ebfu nh\u00f3m n\u00e0y kh\u00f4ng c\u00f3 m\u1eb7t, h\u00e3y xem Ph\u1ee5 l\u1ee5c 1 . N\u1ebfu BN m\u1edbi \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n, \u0111i\u1ec1u c\u1ea7n thi\u1ebft l\u00e0 h\u1ecd ph\u1ea3i \u0111\u01b0\u1ee3c m\u1ed9t th\u00e0nh vi\u00ean c\u1ee7a nh\u00f3m chuy\u00ean gia kh\u00e1m tr\u01b0\u1edbc khi xu\u1ea5t vi\u1ec7n.<\/p>\n<h3>7.6 Tham gia c\u1ee7a nh\u00f3m chuy\u00ean gia \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng<\/h3>\n<p>N\u1ebfu h\u1ecd ch\u01b0a tham gia, th\u00ec h\u1ecd n\u00ean \u0111\u01b0\u1ee3c th\u00f4ng b\u00e1o v\u00e0 BN \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 trong v\u00f2ng 24 gi\u1edd sau khi nh\u1eadp vi\u1ec7n. S\u1ef1 tham gia c\u1ee7a nh\u00f3m chuy\u00ean gia \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng l\u00e0 quan tr\u1ecdng \u0111\u1ec3 cho ph\u00e9p gi\u00e1o d\u1ee5c l\u1ea1i, gi\u1ea3m nguy c\u01a1 t\u00e1i ph\u00e1t v\u00e0 t\u1ea1o \u0111i\u1ec1u ki\u1ec7n theo d\u00f5i th\u00edch h\u1ee3p. C\u00e1c b\u1ec7nh vi\u1ec7n n\u00ean t\u1ea1o \u0111i\u1ec1u ki\u1ec7n cho c\u00e1c nh\u00f3m \u0111i\u1ec1u tr\u1ecb b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng cung c\u1ea5p \u0111i\u1ec1u tr\u1ecb \u0111\u1ea7y \u0111\u1ee7 \u0111\u1ec3 cho ph\u00e9p b\u1ea5t k\u1ef3 ai nh\u1eadp vi\u1ec7n v\u00ec nhi\u1ec5m toan ceton \u0111\u1ec1u \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 trong v\u00f2ng 24 gi\u1edd sau khi nh\u1eadp vi\u1ec7n.<\/p>\n<h2>8. SINH L\u00dd B\u1ec6NH C\u1ee6A NHI\u1ec4M TOAN CETON<\/h2>\n<p>Nhi\u1ec5m toan ceton l\u00e0 m\u1ed9t tr\u1ea1ng th\u00e1i chuy\u1ec3n h\u00f3a r\u1ed1i lo\u1ea1n ph\u1ee9c t\u1ea1p, \u0111\u1eb7c tr\u01b0ng b\u1edfi t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft, t\u0103ng ceton huy\u1ebft v\u00e0 nhi\u1ec5m toan. Nhi\u1ec5m toan ceton th\u01b0\u1eddng x\u1ea3y ra do h\u1eadu qu\u1ea3 c\u1ee7a s\u1ef1 thi\u1ebfu h\u1ee5t insulin t\u01b0\u01a1ng \u0111\u1ed1i ho\u1eb7c tuy\u1ec7t \u0111\u1ed1i \u0111i k\u00e8m v\u1edbi s\u1ef1 gia t\u0103ng c\u00e1c hormone \u0111i\u1ec1u h\u00f2a ng\u01b0\u1ee3c (v\u00ed d\u1ee5: glucagon, cortisol, hormone t\u0103ng tr\u01b0\u1edfng, catecholamine). Lo\u1ea1i m\u1ea5t c\u00e2n b\u1eb1ng n\u1ed9i ti\u1ebft t\u1ed1 n\u00e0y l\u00e0m t\u0103ng qu\u00e1 tr\u00ecnh t\u1ea1o glucone \u1edf gan v\u00e0 qu\u00e1 tr\u00ecnh ph\u00e2n gi\u1ea3i glycogenolysis d\u1eabn \u0111\u1ebfn t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft nghi\u00eam tr\u1ecdng. T\u0103ng c\u01b0\u1eddng ph\u00e2n gi\u1ea3i lipid l\u00e0m t\u0103ng c\u00e1c axit b\u00e9o t\u1ef1 do trong huy\u1ebft thanh, sau \u0111\u00f3 \u0111\u01b0\u1ee3c chuy\u1ec3n h\u00f3a nh\u01b0 m\u1ed9t ngu\u1ed3n n\u0103ng l\u01b0\u1ee3ng thay th\u1ebf trong qu\u00e1 tr\u00ecnh t\u1ea1o ceton.24 \u0110i\u1ec1u n\u00e0y d\u1eabn \u0111\u1ebfn s\u1ef1 t\u00edch t\u1ee5 m\u1ed9t l\u01b0\u1ee3ng l\u1edbn c\u00e1c th\u1ec3 ceton v\u00e0 sau \u0111\u00f3 l\u00e0 nhi\u1ec5m toan chuy\u1ec3n h\u00f3a. Ceton bao g\u1ed3m aceton, 3-beta-hydroxybutyrate v\u00e0 acetoacetate. Ceton ch\u1ee7 y\u1ebfu trong m\u00e1u l\u00e0 3-beta-hydroxybutyrate. M\u00f4 t\u1ea3 chi ti\u1ebft h\u01a1n v\u1ec1 sinh l\u00fd b\u1ec7nh c\u1ee7a nhi\u1ec5m toan ceton c\u00f3 s\u1eb5n \u1edf nh\u1eefng t\u00e0i li\u1ec7u kh\u00e1c.<\/p>\n<p>C\u00f3 m\u1ed9t s\u1ed1 c\u01a1 ch\u1ebf g\u00e2y ra t\u00ecnh tr\u1ea1ng c\u1ea1n ki\u1ec7t d\u1ecbch trong nhi\u1ec5m toan ceton. Ch\u00fang bao g\u1ed3m b\u00e0i ni\u1ec7u th\u1ea9m th\u1ea5u do t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft, n\u00f4n m\u1eeda &#8211; th\u01b0\u1eddng li\u00ean quan \u0111\u1ebfn nhi\u1ec5m toan ceton &#8211; v\u00e0 cu\u1ed1i c\u00f9ng, kh\u00f4ng th\u1ec3 u\u1ed1ng n\u01b0\u1edbc do m\u1ee9c \u0111\u1ed9 \u00fd th\u1ee9c gi\u1ea3m. S\u1ef1 chuy\u1ec3n d\u1ecbch v\u00e0 suy gi\u1ea3m ch\u1ea5t \u0111i\u1ec7n gi\u1ea3i m\u1ed9t ph\u1ea7n li\u00ean quan \u0111\u1ebfn b\u00e0i ni\u1ec7u th\u1ea9m th\u1ea5u. T\u0103ng kali m\u00e1u v\u00e0 h\u1ea1 kali m\u00e1u c\u1ea7n \u0111\u01b0\u1ee3c ch\u00fa \u00fd \u0111\u1eb7c bi\u1ec7t.<\/p>\n<h2>9. D\u1ecaCH T\u1ec4 H\u1eccC V\u00c0 CHI PH\u00cd<\/h2>\n<p>M\u1eb7c d\u00f9 nhi\u1ec5m toan ceton ch\u1ee7 y\u1ebfu x\u1ea3y ra \u1edf nh\u1eefng ng\u01b0\u1eddi m\u1eafc b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng tu\u00fdp 1, kho\u1ea3ng m\u1ed9t ph\u1ea7n ba tr\u01b0\u1eddng h\u1ee3p x\u1ea3y ra \u1edf nh\u1eefng ng\u01b0\u1eddi m\u1eafc b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng tu\u00fdp 2. Tuy nhi\u00ean, \u0111i\u1ec1u tr\u1ecb ban \u0111\u1ea7u l\u00e0 gi\u1ed1ng nhau cho c\u1ea3 hai. T\u1ef7 l\u1ec7 m\u1eafc b\u1ec7nh th\u1ef1c s\u1ef1 r\u1ea5t kh\u00f3 x\u00e1c \u0111\u1ecbnh. \u1ede V\u01b0\u01a1ng qu\u1ed1c Anh, t\u1ef7 l\u1ec7 nhi\u1ec5m toan ceton cao nh\u1ea5t \u1edf nh\u1eefng ng\u01b0\u1eddi t\u1eeb 18 \u0111\u1ebfn 24 tu\u1ed5i. 23 C\u00e1c d\u1eef li\u1ec7u kh\u00e1c \u0111\u00e3 g\u1ee3i \u00fd r\u1eb1ng t\u1ef7 l\u1ec7 nhi\u1ec5m toan ceton dao \u0111\u1ed9ng trong kho\u1ea3ng 8,0 \u0111\u1ebfn 51,3 tr\u01b0\u1eddng h\u1ee3p tr\u00ean 1000 b\u1ec7nh nh\u00e2n-n\u1eb1m \u1edf nh\u1eefng ng\u01b0\u1eddi m\u1eafc b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng tu\u00fdp 1. 65 Tuy nhi\u00ean, \u1edf Trung Qu\u1ed1c, t\u1ef7 l\u1ec7 m\u1eafc b\u1ec7nh \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o l\u00e0 cao t\u1edbi 263 tr\u00ean 1000 b\u1ec7nh nh\u00e2n-n\u0103m.66 , 67 Nhi\u1ec5m toan ceton c\u0169ng l\u00e0 m\u1ed9t t\u00ecnh tr\u1ea1ng t\u1ed1n k\u00e9m \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb. D\u1eef li\u1ec7u t\u1eeb c\u00e1c cu\u1ed9c kh\u1ea3o s\u00e1t qu\u1ed1c gia \u1edf V\u01b0\u01a1ng qu\u1ed1c Anh cho th\u1ea5y chi ph\u00ed cho m\u1ed9t \u0111\u1ee3t \u01b0\u1edbc t\u00ednh tr\u1ecb gi\u00e1 \u00a3 2064 \u1edf ng\u01b0\u1eddi l\u1edbn v\u00e0 \u00a3 1387 \u1edf nh\u1eefng ng\u01b0\u1eddi t\u1eeb 11 \u0111\u1ebfn 18 tu\u1ed5i. \u0110i\u1ec1u tr\u1ecb nhi\u1ec5m toan ceton \u1edf Hoa K\u1ef3 \u0111\u1eaft h\u01a1n \u0111\u00e1ng k\u1ec3 v\u1edbi m\u1ed9t \u0111\u1ee3t \u01b0\u1edbc t\u00ednh tr\u1ecb gi\u00e1 ~ 26.566 \u0111\u00f4 la.<\/p>\n<h2>10. T\u1eec VONG V\u00c0 T\u00c0N T\u1eacT<\/h2>\n<p>\u1ede V\u01b0\u01a1ng qu\u1ed1c Anh v\u00e0 c\u00e1c qu\u1ed1c gia ph\u00e1t tri\u1ec3n kh\u00e1c, trong khi t\u1ef7 l\u1ec7 t\u1eed vong do nhi\u1ec5m toan ceton v\u1eabn &lt; 1%, 45 , 71 th\u00ec \u0111\u00e2y l\u00e0 nguy\u00ean nh\u00e2n t\u1eed vong h\u00e0ng \u0111\u1ea7u \u1edf nh\u1eefng ng\u01b0\u1eddi d\u01b0\u1edbi 58 tu\u1ed5i m\u1eafc b\u1ec7nh T1DM. 72 C\u00f3 l\u1ebd kh\u00f4ng c\u00f3 g\u00ec \u0111\u00e1ng ng\u1ea1c nhi\u00ean khi t\u1ef7 l\u1ec7 t\u1eed vong t\u0103ng theo tu\u1ed5i v\u00e0 v\u1edbi s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a c\u00e1c b\u1ec7nh \u0111i k\u00e8m t\u1eeb tr\u01b0\u1edbc.<\/p>\n<p>T\u1ef7 l\u1ec7 t\u1eed vong v\u1eabn c\u00f2n cao, h\u01a1n 40% \u1edf m\u1ed9t s\u1ed1 n\u01b0\u1edbc c\u00f3 thu nh\u1eadp th\u1ea5p v\u00e0 trung b\u00ecnh. T\u1ef7 l\u1ec7 t\u1eed vong cao n\u00e0y cho th\u1ea5y s\u1ef1 c\u1ea7n thi\u1ebft c\u1ee7a vi\u1ec7c ch\u1ea9n \u0111o\u00e1n s\u1edbm v\u00e0 th\u1ef1c hi\u1ec7n c\u00e1c ch\u01b0\u01a1ng tr\u00ecnh ph\u00f2ng ng\u1eeba hi\u1ec7u qu\u1ea3.<\/p>\n<p>Ph\u00f9 n\u00e3o v\u1eabn l\u00e0 nguy\u00ean nh\u00e2n t\u1eed vong ph\u1ed5 bi\u1ebfn nh\u1ea5t, \u0111\u1eb7c bi\u1ec7t \u1edf tr\u1ebb nh\u1ecf v\u00e0 thanh thi\u1ebfu ni\u00ean. C\u00e1c nguy\u00ean nh\u00e2n ch\u00ednh g\u00e2y t\u1eed vong \u1edf ng\u01b0\u1eddi tr\u01b0\u1edfng th\u00e0nh bao g\u1ed3m h\u1ea1 kali m\u00e1u nghi\u00eam tr\u1ecdng, h\u1ed9i ch\u1ee9ng suy h\u00f4 h\u1ea5p \u1edf ng\u01b0\u1eddi l\u1edbn v\u00e0 c\u00e1c b\u1ec7nh \u0111\u1ed3ng m\u1eafc, c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan ceton nh\u01b0 vi\u00eam ph\u1ed5i, nh\u1ed3i m\u00e1u c\u01a1 tim c\u1ea5p v\u00e0 nhi\u1ec5m tr\u00f9ng huy\u1ebft.<\/p>\n<h2>11. TU N TH\u1ee6 C\u00c1C H\u01af\u1edaNG D\u1eaaN<\/h2>\n<p>C\u00e1c cu\u1ed9c ki\u1ec3m tra l\u1eb7p \u0111i l\u1eb7p l\u1ea1i c\u1ee7a nhi\u1ec1u \u0111\u01a1n v\u1ecb \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng \u1edf t\u1ea5t c\u1ea3 c\u00e1c qu\u1ed1c gia thu\u1ed9c V\u01b0\u01a1ng qu\u1ed1c Anh \u0111\u00e3 li\u00ean t\u1ee5c ch\u1ee9ng t\u1ecf vi\u1ec7c tu\u00e2n th\u1ee7 k\u00e9m c\u00e1c h\u01b0\u1edbng d\u1eabn c\u1ee7a \u0111\u1ecba ph\u01b0\u01a1ng (ho\u1eb7c qu\u1ed1c gia) trong vi\u1ec7c qu\u1ea3n l\u00fd nhi\u1ec5m toan ceton. C\u00f3 hai v\u1ea5n \u0111\u1ec1 ch\u00ednh c\u1ea7n \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft:<\/p>\n<ol>\n<li>C\u00e1c guidelines ph\u1ea3i \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n<\/li>\n<li>C\u00e1c guidelines ph\u1ea3i \u0111\u01b0\u1ee3c ki\u1ec3m tra \u2014 C\u00e1c ti\u00eau ch\u00ed \u0111\u00e1nh gi\u00e1 c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c t\u00ecm th\u1ea5y tr\u00ean m\u1ea1ng. C\u00e1c guidelines ph\u1ea3i \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 th\u01b0\u1eddng xuy\u00ean. \u0110\u00e2y l\u00e0 m\u1ed9t t\u00e0i li\u1ec7u &#8216;tr\u1ef1c ti\u1ebfp&#8217; v\u00e0 ph\u1ea3n h\u1ed3i cho c\u00e1c t\u00e1c gi\u1ea3 \u0111\u01b0\u1ee3c hoan ngh\u00eanh v\u00e0 khuy\u1ebfn kh\u00edch.<\/li>\n<\/ol>\n<h2>PH\u1ee4 L\u1ee4C 1<\/h2>\n<h3>Kh\u1edfi \u0111\u1ed9ng l\u1ea1i insulin d\u01b0\u1edbi da cho nh\u1eefng ng\u01b0\u1eddi \u0111\u00e3 d\u00f9ng insulin tr\u01b0\u1edbc \u0111\u00e2y<\/h3>\n<p>Ch\u1ebf \u0111\u1ed9 \u0111i\u1ec1u tr\u1ecb tr\u01b0\u1edbc \u0111\u00f3 c\u1ee7a ng\u01b0\u1eddi \u0111\u00f3 th\u01b0\u1eddng n\u00ean \u0111\u01b0\u1ee3c b\u1eaft \u0111\u1ea7u l\u1ea1i n\u1ebfu HbA1c g\u1ea7n \u0111\u00e2y nh\u1ea5t c\u1ee7a h\u1ecd cho th\u1ea5y m\u1ee9c \u0111\u1ed9 ki\u1ec3m so\u00e1t c\u00f3 th\u1ec3 ch\u1ea5p nh\u1eadn \u0111\u01b0\u1ee3c, ngh\u0129a l\u00e0 HbA1c &lt; 64 mmol \/ mmol (&lt; 8,0%)<\/p>\n<p>V\u1edbi t\u1ea5t c\u1ea3 c\u00e1c ph\u00e1c \u0111\u1ed3, kh\u00f4ng n\u00ean ng\u1eebng truy\u1ec1n insulin t\u0129nh m\u1ea1ch \u00edt nh\u1ea5t 30\u201360 ph\u00fat sau khi ti\u00eam li\u1ec1u d\u01b0\u1edbi da c\u00f9ng v\u1edbi b\u1eefa \u0103n.<\/p>\n<p>N\u1ebfu h\u1ecd \u0111ang s\u1eed d\u1ee5ng insulin n\u1ec1n bolus<\/p>\n<ul>\n<li>N\u00ean c\u00f3 s\u1ef1 ch\u1ed3ng l\u1ea5p\/g\u1ed1i \u0111\u1ea7u (overlap) gi\u1eefa insulin truy\u1ec1n v\u00e0 l\u1ea7n ti\u00eam insulin t\u00e1c d\u1ee5ng nhanh \u0111\u1ea7u ti\u00ean. Insulin t\u00e1c d\u1ee5ng nhanh n\u00ean \u0111\u01b0\u1ee3c ti\u00eam c\u00f9ng b\u1eefa \u0103n v\u00e0 ng\u1eebng truy\u1ec1n insulin v\u00e0 d\u1ecbch t\u0129nh m\u1ea1ch 30\u201360 ph\u00fat sau \u0111\u00f3<\/li>\n<li>N\u1ebfu ng\u01b0\u1eddi \u0111\u00f3 tr\u01b0\u1edbc \u0111\u00f3 \u0111\u00e3 s\u1eed d\u1ee5ng insulin t\u00e1c d\u1ee5ng d\u00e0i nh\u01b0 glargine, degludec, detemir ho\u1eb7c human isophane, th\u00ec \u0111i\u1ec1u n\u00e0y n\u00ean \u0111\u01b0\u1ee3c ti\u1ebfp t\u1ee5c v\u00e0 do \u0111\u00f3, h\u00e0nh \u0111\u1ed9ng duy nh\u1ea5t l\u00e0 b\u1eaft \u0111\u1ea7u l\u1ea1i insulin t\u00e1c d\u1ee5ng ng\u1eafn b\u00ecnh th\u01b0\u1eddng c\u1ee7a h\u1ecd v\u00e0o b\u1eefa \u0103n ti\u1ebfp theo.<\/li>\n<li>N\u1ebfu insulin n\u1ec1n \u0111\u00e3 b\u1ecb d\u1eebng do nh\u1ea7m l\u1eabn, kh\u00f4ng n\u00ean ng\u1eebng truy\u1ec1n insulin cho \u0111\u1ebfn khi m\u1ed9t s\u1ed1 d\u1ea1ng insulin n\u1ec1n \u0111\u00e3 \u0111\u01b0\u1ee3c ti\u00eam. N\u1ebfu insulin n\u1ec1n th\u01b0\u1eddng \u0111\u01b0\u1ee3c d\u00f9ng m\u1ed9t l\u1ea7n m\u1ed7i ng\u00e0y v\u00e0o bu\u1ed5i t\u1ed1i v\u00e0 \u00fd \u0111\u1ecbnh l\u00e0 chuy\u1ec3n th\u00e0nh insulin d\u01b0\u1edbi da v\u00e0o bu\u1ed5i s\u00e1ng, h\u00e3y cho m\u1ed9t n\u1eeda li\u1ec1u insulin n\u1ec1n h\u00e0ng ng\u00e0y th\u00f4ng th\u01b0\u1eddng nh\u01b0 isophane (t\u1ee9c l\u00e0 Insulatard \u00ae , Humulin I \u00ae , Insuman basal \u00ae ) v\u00e0o bu\u1ed5i s\u00e1ng. \u0110i\u1ec1u n\u00e0y s\u1ebd cung c\u1ea5p insulin n\u1ec1n c\u1ea7n thi\u1ebft cho \u0111\u1ebfn khi insulin analogue t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c b\u1eaft \u0111\u1ea7u l\u1ea1i. Ki\u1ec3m tra n\u1ed3ng \u0111\u1ed9 ceton v\u00e0 glucose m\u00e1u th\u01b0\u1eddng xuy\u00ean. N\u1ebfu h\u1ecd s\u1eed d\u1ee5ng insulin h\u1ed7n h\u1ee3p c\u1ed1 \u0111\u1ecbnh hai l\u1ea7n m\u1ed7i ng\u00e0y<\/li>\n<li>Ti\u00eam l\u1ea1i insulin d\u01b0\u1edbi da tr\u01b0\u1edbc b\u1eefa \u0103n s\u00e1ng ho\u1eb7c tr\u01b0\u1edbc b\u1eefa \u0103n t\u1ed1i. Kh\u00f4ng thay \u0111\u1ed5i b\u1ea5t k\u1ef3 th\u1eddi \u0111i\u1ec3m n\u00e0o kh\u00e1c. Duy tr\u00ec truy\u1ec1n insulin trong 30\u201360 ph\u00fat sau khi ti\u00eam insulin d\u01b0\u1edbi da N\u1ebfu h\u1ecd \u0111ang s\u1eed d\u1ee5ng CSII (continous subcutaneous insulin infusion : insulin d\u01b0\u1edbi da truy\u1ec1n li\u00ean t\u1ee5c)<\/li>\n<li>\u0110\u1ea3m b\u1ea3o s\u1ef1 s\u1eb5n c\u00f3 c\u1ee7a c\u00e1c ngu\u1ed3n cung c\u1ea5p \/ v\u00e0 ho\u1eb7c v\u1eadt t\u01b0 ti\u00eau hao c\u1ea7n thi\u1ebft<\/li>\n<li>\u0110\u1ea3m b\u1ea3o r\u1eb1ng c\u00e1 nh\u00e2n \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 l\u00e0 c\u00f3 th\u1ec3 s\u1eed d\u1ee5ng CSII<\/li>\n<li>N\u1ebfu h\u1ecd \u0111\u01b0\u1ee3c cho l\u00e0 c\u00f3 th\u1ec3 s\u1eed d\u1ee5ng m\u00e1y b\u01a1m, h\u00e3y \u0111\u1ec1 xu\u1ea5t CSII \u1edf t\u1ed1c \u0111\u1ed9 c\u01a1 b\u1ea3n th\u00f4ng th\u01b0\u1eddng. Ti\u1ebfp t\u1ee5c truy\u1ec1n insulin t\u0129nh m\u1ea1ch cho \u0111\u1ebfn khi bolus b\u1eefa \u0103n \u0111\u01b0\u1ee3c cho. Kh\u00f4ng b\u1eaft \u0111\u1ea7u l\u1ea1i CSII v\u00e0o th\u1eddi \u0111i\u1ec3m tr\u01b0\u1edbc khi \u0111i ng\u1ee7<\/li>\n<\/ul>\n<h3>T\u00ednh li\u1ec1u insulin ti\u00eam d\u01b0\u1edbi da \u1edf nh\u1eefng ng\u01b0\u1eddi ch\u01b0a t\u1eebng s\u1eed d\u1ee5ng insulin<\/h3>\n<p><b>\u01af\u1edbc t\u00ednh t\u1ed5ng li\u1ec1u insulin h\u00e0ng ng\u00e0y<\/b><\/p>\n<p>\u01af\u1edbc t\u00ednh n\u00e0y d\u1ef1a tr\u00ean m\u1ed9t s\u1ed1 y\u1ebfu t\u1ed1, bao g\u1ed3m \u0111\u1ed9 nh\u1ea1y c\u1ea3m c\u1ee7a BN v\u1edbi insulin, m\u1ee9c \u0111\u1ed9 ki\u1ec3m so\u00e1t \u0111\u01b0\u1eddng huy\u1ebft, kh\u00e1ng insulin, c\u00e2n n\u1eb7ng v\u00e0 tu\u1ed5i t\u00e1c. TDD c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c t\u00ednh b\u1eb1ng c\u00e1ch nh\u00e2n tr\u1ecdng l\u01b0\u1ee3ng c\u1ee7a b\u1ec7nh nh\u00e2n (t\u00ednh b\u1eb1ng kg) v\u1edbi 0,5\u20130,75 \u0111\u01a1n v\u1ecb. S\u1eed d\u1ee5ng 0,75 \u0111\u01a1n v\u1ecb \/ kg cho nh\u1eefng ng\u01b0\u1eddi \u0111\u01b0\u1ee3c cho l\u00e0 kh\u00e1ng insulin nhi\u1ec1u h\u01a1n, \u0111\u00f3 l\u00e0 thanh thi\u1ebfu ni\u00ean, b\u00e9o ph\u00ec.<\/p>\n<p>Th\u00ed d\u1ee5: M\u1ed9t ng\u01b0\u1eddi n\u1eb7ng 72 kg s\u1ebd c\u1ea7n kho\u1ea3ng 72 \u00d7 0,5 \u0111\u01a1n v\u1ecb ho\u1eb7c 36 \u0111\u01a1n v\u1ecb trong 24 gi\u1edd.<\/p>\n<h3>T\u00ednh to\u00e1n li\u1ec1u bolus n\u1ec1n (QDS)<\/h3>\n<p><b>Ph\u00e1c \u0111\u1ed3<\/b><\/p>\n<p>Cho 50% t\u1ed5ng li\u1ec1u v\u00e0o b\u1eefa \u0103n t\u1ed1i d\u01b0\u1edbi d\u1ea1ng insulin t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i, v\u00e0 chia \u0111\u1ec1u li\u1ec1u c\u00f2n l\u1ea1i cho tr\u01b0\u1edbc b\u1eefa \u0103n s\u00e1ng, tr\u01b0\u1edbc b\u1eefa \u0103n tr\u01b0a v\u00e0 tr\u01b0\u1edbc b\u1eefa \u0103n t\u1ed1i.<\/p>\n<table style=\"border-collapse: collapse; width: 100%;\">\n<tbody>\n<tr>\n<td style=\"width: 20%;\"><\/td>\n<td style=\"width: 20%;\">Tr\u01b0\u1edbc b\u1eefa \u0103n s\u00e1ng<\/td>\n<td style=\"width: 20%;\">Tr\u01b0\u1edbc b\u1eefa\u00a0\u0103n tr\u01b0a<\/td>\n<td style=\"width: 20%;\">Tr\u01b0\u1edbc b\u1eefa\u00a0\u0103n t\u1ed1i<\/td>\n<td style=\"width: 20%;\">Gi\u1edd \u0111i\u00a0ng\u1ee7<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 20%;\">Insulin t\u00e1c d\u1ee5ng nhanh, v\u00ed d\u1ee5 nh\u01b0 aspart (v\u00ed d\u1ee5,\u00a0Novorapid \u00ae ) \/ glulisine (v\u00ed d\u1ee5, Apidra \u00ae ) \/\u00a0lispro (v\u00ed d\u1ee5, Humalog \u00ae )<\/td>\n<td style=\"width: 20%;\">6 \u0111\u01a1n v\u1ecb<\/td>\n<td style=\"width: 20%;\">6 \u0111\u01a1n v\u1ecb<\/td>\n<td style=\"width: 20%;\">6 \u0111\u01a1n v\u1ecb<\/td>\n<td style=\"width: 20%;\"><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 20%;\">Insulin t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i, v\u00ed d\u1ee5, glargine (v\u00ed d\u1ee5,\u00a0Lantus \u00ae ), detemir (v\u00ed d\u1ee5, Levemir \u00ae ) ho\u1eb7c\u00a0degludec (v\u00ed d\u1ee5, Tresiba \u00ae )<\/td>\n<td style=\"width: 20%;\"><\/td>\n<td style=\"width: 20%;\"><\/td>\n<td style=\"width: 20%;\">18 \u0111\u01a1n v\u1ecb<\/td>\n<td style=\"width: 20%;\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>N\u00ean d\u00f9ng li\u1ec1u insulin d\u01b0\u1edbi da t\u00e1c d\u1ee5ng nhanh \u0111\u1ea7u ti\u00ean tr\u01b0\u1edbc b\u1eefa \u0103n s\u00e1ng ho\u1eb7c b\u1eefa tr\u01b0a. Ch\u1ec9 d\u00f9ng li\u1ec1u \u0111\u1ea7u ti\u00ean tr\u01b0\u1edbc b\u1eefa \u0103n t\u1ed1i n\u1ebfu c\u00f3 th\u1ec3 \u0111\u1ea3m b\u1ea3o vi\u1ec7c theo d\u00f5i th\u00edch h\u1ee3p. Kh\u00f4ng chuy\u1ec3n \u0111\u1ed5i sang ch\u1ebf \u0111\u1ed9 ti\u00eam d\u01b0\u1edbi da v\u00e0o th\u1eddi \u0111i\u1ec3m tr\u01b0\u1edbc khi \u0111i ng\u1ee7.<\/p>\n<p>\u0110\u1ed1i v\u1edbi nh\u1eefng ng\u01b0\u1eddi m\u1edbi \u0111i\u1ec1u tr\u1ecb b\u1eb1ng insulin, nhu c\u1ea7u v\u1ec1 li\u1ec1u l\u01b0\u1ee3ng c\u00f3 th\u1ec3 gi\u1ea3m trong v\u00f2ng v\u00e0i ng\u00e0y v\u00ec t\u00ecnh tr\u1ea1ng kh\u00e1ng insulin li\u00ean quan \u0111\u1ebfn nhi\u1ec5m toan ceton \u0111\u00e3 h\u1ebft. C\u1ea7n c\u00f3 s\u1ef1 gi\u00e1m s\u00e1t ch\u1eb7t ch\u1ebd c\u1ee7a nh\u00f3m chuy\u00ean gia v\u1ec1 b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng.<\/p>\n<h3>T\u00ednh to\u00e1n ch\u1ebf \u0111\u1ed9 hai l\u1ea7n m\u1ed7i ng\u00e0y (BD):<\/h3>\n<p>N\u1ebfu s\u1eed d\u1ee5ng ch\u1ebf \u0111\u1ed9 insulin tr\u1ed9n s\u1eb5n hai l\u1ea7n m\u1ed7i ng\u00e0y, h\u00e3y cho hai ph\u1ea7n ba t\u1ed5ng li\u1ec1u h\u00e0ng ng\u00e0y v\u00e0o b\u1eefa s\u00e1ng, ph\u1ea7n ba c\u00f2n l\u1ea1i d\u00f9ng v\u00e0o b\u1eefa \u0103n t\u1ed1i.<\/p>\n<h2>T\u00c0I LI\u1ec6U THAM KH\u1ea2O<\/h2>\n<ol>\n<li>Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009; 32: 1335- 1343.<\/li>\n<li>Dhatariya KK, Umpierrez GE. Guidelines for management of diabetic ketoacidosis: time to revise? Lancet Diabetes Endocrinol. 2017; 5: 321- 323.<\/li>\n<li>Dhatariya K, Nunney I, Iceton G. Institutional factors in the management of adults with diabetic ketoacidosis in the UK: results of a national survey. Diabet Med. 2016; 33: 269- 270.<\/li>\n<li>NHS Digital. National Diabetes Inpatient Audit (NaDIA) &#8211; 2019, 2020. Available from https:\/\/digital.nhs.uk\/data-and-information\/publications\/statistical\/national-diabetes-inpatient-audit\/2019 [Last accessed 22nd December 2021]<\/li>\n<li>Diabetes UK. Diabetes inpatient and hospital care: making hospitals for people with diabetes. 2018.<\/li>\n<li>Peters AL, Buschur EO, Buse JB, Cohan P, Diner JC, Hirsch IB. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015; 38: 1687- 1693.<\/li>\n<li>Macfarlane J, Dhatariya K. The incidence of euglycemic diabetic ketoacidosis in adults with type 1 diabetes in the UK prior to the widespread use of sodium glucose co-transporter 2 inhibitors. Mayo Clin Proc. 2019; 94: 1909- 1910.<\/li>\n<li>Janssens B, Caerels S, Mathieu C. SGLT inhibitors in type 1 diabetes: weighing efficacy and side effects. Ther Adv Endocrinol Metab. 2020; 11:2042018820938545.<\/li>\n<li>Dhatariya KK. Defining and characterising diabetic ketoacidosis in adults. Diabetes Res Clin Pract. 2019; 155:107797.<\/li>\n<li>Smiley D, Chandra P, Umpierrez GE. Update on diagnosis, pathogenesis and management of ketosis-prone Type 2 diabetes mellitus. Diabetes Manag (Lond). 2011; 1: 589- 600.<\/li>\n<li>Umpierrez GE, DiGirolamo M, Tuvlin JA, Isaacs SD, Bhoola SM, Kokko JP. Differences in metabolic and hormonal milieu in diabetic- and alcohol-induced ketoacidosis. J Crit Care. 2000; 15: 52- 59.<\/li>\n<li>Sherwood LM, Parris EE, Cahill GF. Starvation in man. N Engl J Med. 1970; 282: 668- 675.<\/li>\n<li>Kamel KS, Lin SH, Cheema-Dhadli S, Marliss EB, Halperin ML. Prolonged total fasting: a feast for the integrative physiologist. 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Emerg Med J. 2007; 24: 569- 571.<\/li>\n<li>Levetan CS, Salas JR, Wilets IF, Zumoff B. Impact of endocrine and diabetes team consultation on hospital length of stay for patients with diabetes. Am J Med. 1995; 99: 22- 28.<\/li>\n<li>Sampson MJ, Crowle T, Dhatariya K, et al. Trends in bed occupancy for inpatients with diabetes before and after the introduction of a diabetes inpatient specialist nurse service. Diabet Med. 2006; 23: 1008- 1015.<\/li>\n<li>NHS Improvement. 2019\/20 National Tariff Payment System \u2013 A consultation notice: Annex DtD. Guidance on best practice tariffs. 2019. Available from https:\/\/improvement.nhs.uk\/documents\/484\/Annex_DtD_Best_practice_tariffs.pdf [Last accessed 22nd December 2021]<\/li>\n<li>Price H, Thomsett K, Newton I, Alderson S, Hillson R. Developing best practice tariffs for diabetic ketoacidosis and hypoglycaemia. Pract Diabetes. 2013; 30: 6- 8.<\/li>\n<li>Zhong VW, Juhaeri J, Mayer-Davis EJ. Trends in hospital admission for diabetic ketoacidosis in adults with type 1 and type 2 diabetes in England, 1998\u20132013: a retrospective cohort study. Diabetes Care. 2018; 41: 1870- 1877.<\/li>\n<li>Dhatariya KK, Glaser NS, Codner E, Umpierrez GE. Diabetic Ketoacidosis. Nat Rev Dis Primers. 2020; 6: 40.<\/li>\n<li>Garrett C, Moulton CD, Choudhary P, Amiel S, Fonagy P, Ismail K. The psychopathology of recurrent diabetic ketoacidosis: a case-control study. Diabet Med. 2021; 38:e14505.<\/li>\n<li>Lacy ME, Gilsanz P, Eng CW, Beeri MS, Karter AJ, Whitmer RA. Recurrent diabetic ketoacidosis and cognitive function among older adults with type 1 diabetes: findings from the Study of Longevity in Diabetes. BMJ Open Diabetes Res Care. 2020; 8:e001173.<\/li>\n<li>Mays JA, Jackson KL, Derby TA, et al. An evaluation of recurrent diabetic ketoacidosis, fragmentation of care, and mortality across Chicago, Illinois. Diabetes Care. 2016; 39: 1671- 1676.<\/li>\n<li>Dhatariya KK, Vellanki P. 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