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中华妇幼临床医学杂志(电子版) ›› 2018, Vol. 14 ›› Issue (06) : 724 -729. doi: 10.3877/cma.j.issn.1673-5250.2018.06.016

所属专题: 文献

论著

儿童糖尿病酮症酸中毒临床诊治分析
卿松1, 吴瑾2,(), 袁传杰2, 刘颖2, 黄倬2, 陈洪波2   
  1. 1. 610017 成都市第二人民医院儿科
    2. 610041 成都,四川大学华西第二医院小儿遗传代谢内分泌科
  • 收稿日期:2018-09-12 修回日期:2018-11-14 出版日期:2018-12-01
  • 通信作者: 吴瑾

Clinical diagnosis and treatment of children with diabetic ketoacidosis

Song Qing1, Jin Wu2,(), Chuanjie Yuan2, Ying Liu2, Zhuo Huang2, Hongbo Chen2   

  1. 1. Department of Pediatrics, Chengdu Second People′s Hospital, Chengdu 610017, Sichuan Province, China
    2. Department of Pediatric Endocrinology, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
  • Received:2018-09-12 Revised:2018-11-14 Published:2018-12-01
  • Corresponding author: Jin Wu
  • About author:
    Corresponding author: Wu Jin, Email:
  • Supported by:
    Project of Science and Technology Plan of Science & Technology Department of Sichuan Province(2018JY0590)
引用本文:

卿松, 吴瑾, 袁传杰, 刘颖, 黄倬, 陈洪波. 儿童糖尿病酮症酸中毒临床诊治分析[J]. 中华妇幼临床医学杂志(电子版), 2018, 14(06): 724-729.

Song Qing, Jin Wu, Chuanjie Yuan, Ying Liu, Zhuo Huang, Hongbo Chen. Clinical diagnosis and treatment of children with diabetic ketoacidosis[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2018, 14(06): 724-729.

目的

探讨儿童糖尿病酮症酸中毒(DKA)的临床特点、诊治经过及治疗效果。

方法

选择2015年2月1日至2017年12月31日,四川大学华西第二医院儿科收治的70例DKA患儿为研究对象。其中,男性患儿为25例,女性为45例;年龄为10个月11天至14岁7个月;18例(25.7%)患儿有糖尿病家族史。采用回顾性分析方法,收集所有患儿的临床表现、实验室辅助检查结果、治疗与转归等临床病例资料。对于患儿各种临床表现所占比例、实验室辅助检查结果异常比例等计数资料,采用率(%)表示。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》要求。

结果

对本组70例DKA患儿的分析结果如下。①临床表现:60例(85.7%)表现为多饮、多食、多尿,其中伴体重下降,消化道疾病症状(呕吐、腹泻、腹痛),精神状态差和(或)乏力,意识障碍(嗜睡或昏迷),呼吸道疾病症状(发热、咽痛、咳嗽、胸闷气促或呼吸困难)与腋下包块者,分别为22例(31.4%)、22例(31.4%)、13例(18.6%)、15例(21.4%)、29例(41.4%)与1例(1.4%);6例(8.6%)表现为多饮、多尿,2例(2.9%)表现为多饮、乏力,2例(2.9%)表现为多饮、体重下降。所有患儿(100.0%)均存在皮肤干燥和(或)皮肤弹性降低等脱水体征,16例(22.9%)伴呼吸深、快及呼出气有酮味(烂苹果味)。②辅助检查结果:30例(42.9%)患儿白细胞计数增高,30例(42.9%)血清C反应蛋白(CRP)水平增高。所有患儿(100.0%)静脉血糖、血清β-羟丁酸浓度均增高,分别为13.4~41.6 mmol/L(正常参考值为3.9~11.1 mmol/L)、≥3.00 mmol/L(正常参考值为0.03~0.30 mmol/L),尿酮体均呈阳性(2+~4+),静脉血pH值为6.89~7.28。所有患儿(100.0%)糖化血红蛋白(HbA1c)水平均增高,65例(92.9%)C肽水平降低,6例(8.6%)血K浓度降低,25例(35.7%)血Na浓度降低,8例(11.4%)肝功能异常,32例(45.7%)肾功能异常,31例(44.3%)甲状腺功能异常。③治疗与转归:所有患儿(100.0%)均接受补液、纠正内环境紊乱、输注胰岛素、去除诱因及抗菌药物抗感染治疗、防治脑水肿等综合治疗后,血糖均控制良好,血清β-羟丁酸浓度下降至≤1 mmol/L,静脉血pH值>7.30,尿糖与尿酮体检查结果均转为阴性,电解质紊乱得到纠正,受损脏器功能均恢复,而且均治愈出院。

结论

儿童DKA的临床表现多样、病情进展快,易并发多器官功能异常。对儿童DKA的早期诊断,并及时予以补液、纠正内环境紊乱、胰岛素及合理抗感染等综合治疗,是成功救治该病患儿的关键。

Objective

To analyze and summarize the clinical characteristics, diagnosis and treatment of children with diabetic ketoacidosis (DKA).

Methods

From February 1, 2015 to December 31, 2017, a total of 70 children with DKA who were admitted to Department of Pediatrics, West China Second University Hospital, Sichuan University were selected as research subjects.Among them, 25 cases were boys, and 45 cases were girls. They were aged from 10 months and 11 days to 14 years and 7 months, and 18 cases (25.7%) had a family history of diabetes. Clinical data of all research subjects, such as clinical manifestations, laboratory examination results, treatment and outcomes were collected by retrospective analysis method. The proportion of different clinical manifestations, and proportion of abnormal results of laboratory examination were expressed by rate (%). The procedures followed in this study were in line with the World Medical Association Declaration of Helsinki revised in 2013.

Results

The analysis results of 70 children with DKA were as follows. ①Clinical manifestations: 60 cases (85.7%) showed polydipsia, polyphagia and polyuria, among them, 22 cases (31.4%) with weight loss, 22 cases (31.4%) with symptoms of gastrointestinal tract diseases (vomiting, diarrhea, abdominal pain), 13 cases (18.6%) with poor mental and/or fatigue, 15 cases (21.4%) with disturbance of consciousness (sleepiness or coma), 29 cases (41.4%) with symptoms of respiratory tract diseases (fever, sore throat, cough, oppression in chest, shortness of breath or dyspnea), and 1 case (1.4%) with mass under armpit. And 6 cases (8.6%) showed polydipsia and polyuria, 2 cases (2.9%) showed polydipsia and fatigue, and 2 cases (2.9%) showed polydipsia and weight loss. All children (100.0%) had signs of dehydration such as dry skin and/or decreased skin elasticity, and 16 cases (22.9%) were accompanied with deep breathing and ketone smell (rotten apple flavor) in breath. ②Laboratory examination results: 30 cases (42.9%) had increased white blood cell counts; 30 cases (42.9%) had increased serum C reactive protein (CRP) levels; increased concentrations of venous blood glucose and serum β-hydroxybutyrate were found in all children, which were 13.4-41.6 mmol/L (normal reference range was 3.9-11.1 mmol/L) and ≥3.00 mmol/L (normal reference range was 0.03-0.30 mmol/L), respectively. All children (100.0%) were with positive urine ketone body (2+ to 4+ ), and their venous blood pH values of venous blood were 6.89-7.28. The hemoglobin A1c (HbA1c) level increased in all children, 65 cases (92.9%) with C peptide levels decreased, 6 cases (8.6%) with blood K+ concentration decreased, 25 cases (35.7%) with blood Na+ concentration decreased, 8 cases (11.4%) had abnormal liver function, 32 cases (45.7%) had abnormal renal function, and 31 cases (44.3%) had abnormal thyroid function. ③Treatments and outcomes: after receiving combined modality therapy, such as fluid replacement, correction of internal environment disorders, infusion of insulin, removal of incentives and anti-infective treatment of antibiotics, prevention and treatment of cerebral edema, blood glucose of all children were controlled well, and serum β-hydroxybutyric acid concentrations all were ≤ 1 mmol/L, venous blood pH values all were >7.30, urine sugar and urine ketone body all were negative, electrolyte disorders were corrected, functions of damaged were recovered, and all children were cured and discharged from hospital.

Conclusions

The clinical manifestations of children with DKA are diversified, its pathogenetic conditions develop rapidly, and multiple organ dysfunction is easy to occur. Early diagnosis and prompt fluid infusion, correction of internal environment disorders, insulin therapy and rational anti-infection are the keys to successful treatment of children with DKA.

[1]
Schober E, Rami B, Waldhoer T, et al. Diabbetic ketoacidosis at diagnosis in Austrian children in 1989-2008: a population-based analysis[J]. Diabetologia, 2010, 53(6): 1057-1061.
[2]
中华医学会儿科学分会内分泌遗传代谢学组, 《中华儿科杂志》编辑委员会. 儿童糖尿病酮症酸中毒诊疗指南(2009年版)[J]. 中华儿科杂志,2009, 47(6): 421-425.
[3]
Acerini C, Craig ME, de Beaufort C, et al. Introduction to ISPAD clinical practice consensus guidelines 2014 compendium[J]. Pediatr Diabetes, 2014, 15(Suppl 20): 1-3.
[4]
中华医学会儿科学会. 儿科内分泌与代谢性疾病诊疗规范[M]. 北京:人民卫生出版社,2016: 196-202 .
[5]
陈晓波. 糖尿病酮症酸中毒电解质紊乱预防及治疗[J]. 中国小儿急救医学,2016, 23(10): 678-681.
[6]
卢宇,费小蔷,杨淑芳,等. 血β-羟丁酸和尿酮在糖尿病酮症诊断中的应用[J]. 中国糖尿病杂志,2015, 23(3): 254-256.
[7]
侯敬茹,辛颖. 初发1型糖尿病患儿酮症酸中毒的影响因素分析[J]. 中华实用临床儿科杂志,2015, 30(8): 587.
[8]
赵彦,杨斌,黄乐,等. 1型糖尿病并低三碘甲状腺氨酸综合征201例[J]. 实用儿科临床杂志,2012, 27(8): 594-595.
[9]
银羽. 儿童糖尿病酮症酸中毒误诊18例分析[J]. 临床医学,2013, 33(7): 115.
[10]
魏雪梅,付丹,张琴. 以酮症酸中毒为首发症状的小儿糖尿病32例临床分析[J]. 海南医学,2014, 24(8): 1189-1191.
[11]
米佳,曹棨. 儿童糖尿病酮症酸中毒的临床特征与治疗进展[J]. 中国综合临床,2014, 30(2): 220-222.
[12]
曹莉. 儿童糖尿病合并酮症酸中毒17例临床特点分析[J]. 中国中西医结合儿科学,2013, 5(4): 356-357.
[13]
桂永浩, 薛辛东. 儿科学[M]. 3版. 北京:人民卫生出版社,2015: 445.
[14]
母得志. 儿科临床实践(习)导引与图解[M]. 北京:人民卫生出版社,2014: 377.
[15]
介李璞,张玉珏. 婴儿糖尿病酮症酸中毒1例[J]. 中国优生优育,2014, 20(1): 63-64.
[16]
Szypowska A, Skórka A. The risk factors of ketoacidosis in children with newly diagnosed type 1 diabetes mellitus[J]. Pediatr Diabetes, 2011, 12(4 Pt 1): 302-306.
[17]
Goyal JP, Shah VB. Duration of intravenous fluid therapy in children with diabetic ketoacidosis[J]. Indian J Pediatr, 2010, 77(1): 112.
[18]
刘莹,巩纯秀,吴迪,等. 糖尿病酮症酸中毒患儿抗菌药物使用干预效果分析[J]. 中华儿科杂志,2017, 55(6): 415-418.
[19]
蔡冬春,翁立坚. 儿童糖尿病酮症酸中毒并发脑水肿相关危险因素[J]. 当代医学,2015, 21(9): 112-113.
[20]
蔡雪,黄顺坛,黄汉伟. 重症糖尿病酮症酸中毒的诊治体会[J]. 实用临床医学,2014, 15(2): 10-11.
[21]
王海玲,王艳红. 11例儿童时期糖尿病酮症酸中毒的救治体会[J]. 当代医学,2013, 19(25): 115-116.
[22]
贾广红,冯燕. 儿童糖尿病酮症酸中毒18例救治体会[J]. 山东医药,2014, 54(36): 108-109.
[23]
王兰英,彭建霞,杨慧,等. 胰岛素持续皮下输注治疗儿童1型糖尿病疗效及安全性的观察[J]. 中国糖尿病杂志,2014, 22(11): 997-999.
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