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Disfuncin De
Disfuncin De La
La Clula
Clula Beta
Beta
Unger. Diabetes 44:863-869 1995 / McGarry .Diabetologia 42:128-138,1999
MX DE RESISTENCIA A LA INSULINA Y
ATEROGENESIS POR LOS AGL
Insulina
AGL
AGL
acylCoA
DAG
Glut 4 ROS
Translocacion a
Superficie celular
Captacin de Proinflamatorio
Glucosa Proaterogenico
Normal Diabetes tipo 2
Insulino
resistencia
Insulino
Secrecin
GLUCEMIA
80
60
40
Diabetes Tipo 2
20 Diabetes DiabetesFase III
Hiperglicemia
ITG Tipo 2 Tipo 2
Postprandial
Fase I Fase II
0
12 0 2 6 10 14
10 6 2
Aos desde el diagnstico
+
Resistencia Resistencia
Hi a la insulina a la insulina o
pe
rin i sm
Salida de su uli
n
+ Captacin de la
glucosa lin
ism r ins
heptica o ipe glucosa
H
dependiente de
insulina
Aumento en la
secrecin de la
insulina
+ estimula
Entrada = Salida Glucosa sangunea normal
inhibe
Diabetes Tipo 2 Descompensada
(lesin de los islotes de
Langerhans + resistencia a la
insulina) 300 mg/l
200 Tejidos perifricos
GLUCOSA
100 (msculo/grasa)
PLASMTICA
+
Resistencia Resistencia
a la insulina a la insulina
Salida de + Captacin de la
glucosa glucosa
heptica dependiente de
insulina
Secrecin
inadecuada
de insulina
+ estimula
Entrada > Salida Hiperglicemia
inhibe
S t r e s s , in fe c c i n y / o d o s is in s u fic ie n t e d e in s u lin a
D e fic ie n c ia In c re m e n to : D e fic ie n c ia
a b s o lu t a d e G lu c a g o n , C a t e c o la m in a s r e la t iv a d e
in s u lin a C o r t is o l, H o r m . c r e c im . in s u lin a
D is m in u c io n d e In c re m e n to d e
S n t e s is P r o t e ic a P r o t e lis is
F lu jo in c r e m e n t a d o In c re m e n to d e
d e A G L h a c ia e l s u b s tra to s
H g a d o g lu c o n e o g n e s is
H ip e r lip id e m ia
D is m in u c i n d e A u m e n to d e A u m e n to d e
la u t iliz a c i n G lu c o n e o g n e s is G lic o g e n o lis is
d e la g lu c o s a
H IP E R G L IC E M IA
G lu c o s u r ia ( D iu r e s is O s m t ic a )
P r d id a d e a g u a y e le c t r o lit o s
D e s h id r a t a c i n
D is m in u c i n d e la in g e s t a
d e l q u id o s
A lt e r a c i n F u n c i n R e n a l
H IP E R G L IC E M IA H IP E R O S M O L A R ID A D
S t r e s s , in fe c c i n y / o d o s is in s u fic ie n t e d e in s u lin a
D e fic ie n c ia In c re m e n to : D e fic ie n c ia
a b s o lu t a d e G lu c a g o n , C a t e c o la m in a s r e la t iv a d e
in s u lin a C o r t is o l, H o r m . c r e c im . in s u lin a
D is m in u c io n d e In c re m e n to d e
S n t e s is P r o t e ic a P r o t e lis is
F lu jo in c r e m e n t a d o In c re m e n to d e
d e A G L h a c ia e l s u b s tra to s
H g a d o g lu c o n e o g n e s is
T r ia c ilg lic e r o l
H ip e r lip id e m ia
I n c r e m e n t o d e la D is m in u c i n d e la
L ip lis is y R e s e r v a A la c a lin a
C e t o g n e s is
D is m in u c i n d e A u m e n to d e A u m e n to d e
la u t iliz a c i n G lu c o n e o g n e s is G lic o g e n o lis is
d e la g lu c o s a
H IP E R G L IC E M IA C E T O A C ID O S IS
CAD EHH
AGUA TOTAL(L) 6 9
AGUA (ml/kg) 100 100 200
Na (mEq/kg) 7 - 10 5 13
Cl (mEq/kg) 3-5 5 15
K (mEq/kg) 3-5 46
FOSFATOS(mmol/kg) 5-7 37
MAGNESIO(mEq/kg) 1-2 12
CALCIO(mEq/kg) 1-2 12
Arieff and Carroll ADA
Plasma glucose, mg/dL >600 >600
Arterial pH N/A >7.30
Serum bicarbonate, mEq/L N/A >18
Urine or serum ketones by
nitroprussiate test 0 to 2 pluses Negative or small
(acetoacetate)
Serum -hydroxybutyrate,
N/A <3 mmol/L
mmol/L
Total serum osmolality,
>350 N/A
mOsm/kg*
Effective serum
N/A >320
osmolality, mOsm/L**
Anion gap, mEq/L N/A Variable
Variable; most patients
Mental status N/A present with stupor,
coma
Pathogenesis of HHS.
Alcohol, laxatives,
alkalies, salicylate, oxygen
inhalations, castor oil and
Preinsulin era
NS/3% NS (s.c.) citrate of potassium,
(13,14)
camphor and ether,
caffeine, circulatory
stimulants
20100 units i.v. or s.c.
bolus followed by 20 Routine gastric lavage,
NS (s.c. or i.v.) at
19301950 (17,27) units s.c. every 3060 cleansing enema, blood
variable rates
min depending on transfusion
glucosuria
2 units/kg bolus of NS followed by
19501970s crystalline insulin; up hypotonic solution 30
Gastric aspiration
(29,88,89) to 920 units in the first mL/kg or 600800 cc
7h m2
NS at 11.5 L over the Add 20 mEq potassium to
50 units i.v. bolus
Early 1970s first 2 h, followed by the second or third liter of
followed by 5080
(54,68,90) hypotonic solution at fluid when potassium level
units/h i.v. or s.c.
100 mL/h is <6.0 mEq/L
NS at 12 L over the Risk of hypokalemia
Low-dose insulin
first 2 h, followed by NS during insulin treatment
regimens. Regular
or half NS. Add identified. Early
Late 1970s (60,71) insulin 0.1 units/kg i.v.
dextrose-containing potassium replacement
followed by 0.10.3
solutions when glucose when serum potassium
units/h i.v., s.c., or i.m.
250 mg/dL <5.5 mEq/L
F lu id o s E V In s u l i n a P o ta s i o B i c a rb o n a to
F lu id o s E V
D e t e r m in a r e s t a d o
d e h id r a t a c i n
C h o q u e h ip o v o l m ic o H ip o t e n s i n m o d e r a d a C h o q u e c a r d io g n ic o
A d m in is t r a r 0 . 9 % C lN a ( 1 L / h ) E v a lu a r N a s r ic o M o n it o r e o H e m o d in m ic o
y / o E x p a n s o r e s p la s m t ic o s c o r r e g id o
A lt o B a jo
N o rm a l
C lN a 0 . 4 5 % C lN a 0 . 9 %
( 4 - 1 4 m l/ k g / h ) ( 4 - 1 4 m l/ k g / m in )
S e g n e s ta d o S e g n e s ta d o
d e h id r a t a c io n d e h id r a t a c io n
Cuando la glicemia llegue a 250mg/dl, cambiar el fluido a Dextrosa 5% con ClNa 0.45% a 150-250ml/h con
adcuada cantidad de insulina (0.05-0.1U/kg/h en infusion EV 5-10 U SC cada 2 horas) para mantener el
nivel de glicemia entre 150-200mg/dl hasta que el control metablico sea alcanzado.
I n s u lin a r e g u la r
V a E V V a S C /IM
0 . 1 5 U / k g b o lo 0 . 4 U / k g 1 / 2 E V b o lo ,
1 /2 IM S C
I n fu s i n : 0 . 1 U / k g / h E V S C IM : 0 .1 U /k g /h
S i g lic e m ia n o c a e 5 0 - 7 0 m g / d l S i g lic e m ia n o c a e 5 0 - 7 0 m g / d l
e n la p r im e r a h o r a e n la p r im e r a h o r a
D o b la r d o s is d e in s u lin a A d m in is t r a r b o lo s E V d e
h a s t a lo g r a r d is m in u ir in s u lin a ( 1 0 U ) h a s t a
c ifr a s d e g lic e m ia lo g r a r d is m in u ir g lic e m ia
Cuando la glicemia llegue a 250mg/dl, cambiar el fluido a Dextrosa 5% con ClNa 0.45% a 150-250ml/h con
adcuada cantidad de insulina (0.05-0.1U/kg/h en infusion EV 5-10 U SC cada 2 horas) para mantener el
nivel de glicemia entre 150-200mg/dl hasta que el control metablico sea alcanzado.
P o t a s io
S u s p e n d e r in s u lin a y A d m in is t r a r 2 0 - 3 0 m E q / L d e K N o a d m in is t r a r K , y
a d m in is t r a r 4 0 m E q K / h e n c a d a lit r o d e flu id o E V r e a liz a r d o s a je c a d a 2 h
E v a lu a r n e c e s id a d d e B ic a r b o n a t o
p H < 6 .9 p H 6 .9 -7 .0 p H > 7 .0
D ilu ir B ic a r b o n a t o ( 1 0 0 m m o l) D ilu ir B ic a r b o n a t o ( 5 0 m m o l) N o d a r B ic a r b o n a t o
en 400 m l agua. en 200m l agua.
I n fu s i n a 2 0 0 m l/ h I n fu s i n a 2 0 0 m l/ h
R e p e t ir a d m in is t r a c io n d e R e p e t ir a d m in is t r a c io n d e
B ic a r b o n a t o c a d a 2 h o r a s B ic a r b o n a t o c a d a 2 h o r a s
h a s t a lle g a r a u n p h > 7 . 0 h a s t a lle g a r a u n p h > 7 . 0
E v a lu a c io n in ic ia l c o m p le t a . I n ic ia r flu id o s E V : 1 L / h d e C lN a 0 . 9 %
F lu id o s E V I n s u lin a P o t a s io
F lu id o s E V
D e t e r m in a r e s t a d o
d e h id r a t a c i n
C h o q u e h ip o v o l m ic o H ip o t e n s i n m o d e r a d a C h o q u e c a r d io g n ic o
A d m in is t r a r 0 . 9 % C lN a ( 1 L / h ) E v a lu a r N a s r ic o M o n it o r e o H e m o d in m ic o
y / o E x p a n s o r e s p la s m t ic o s c o r r e g id o
A lt o B a jo
N o rm a l
C lN a 0 . 4 5 % C lN a 0 . 9 %
( 4 - 1 4 m l/ k g / h ) ( 4 - 1 4 m l/ k g / m in )
S e g n e s ta d o S e g n e s ta d o
d e h id r a t a c io n d e h id r a t a c io n
Cuando la glicemia llegue a 300mg/dl, cambiar el fluido a Dextrosa 5% con ClNa 0.45% a 150-250ml/h con
adecuada cantidad de insulina (0.05-0.1U/kg/h en infusion EV 5-10 U SC cada 2 horas) para mantener el
nivel de glicemia entre 250-300mg/dl hasta que la osm. plasm. sea >=300mOsm/Kg y el pac. Est alerto.
I n s u lin a r e g u la r
V a E V
0 . 1 5 U / k g b o lo
I n fu s i n : 0 . 1 U / k g / h E V
S i g lic e m ia n o c a e 5 0 - 7 0 m g / d l
e n la p r im e r a h o r a
D o b la r d o s is d e in s u lin a
h a s t a lo g r a r d is m in u ir
c ifr a s d e g lic e m ia
Cuando la glicemia llegue a 300mg/dl, cambiar el fluido a Dextrosa 5% con ClNa 0.45% a 150-250ml/h con
adecuada cantidad de insulina (0.05-0.1U/kg/h en infusion EV 5-10 U SC cada 2 horas) para mantener el
nivel de glicemia entre 250-300mg/dl hasta que la osm. plasm. sea >=300mOsm/Kg y el pac. est alerto.
P o t a s io
S u s p e n d e r in s u lin a y A d m in is t r a r 2 0 - 3 0 m E q K N o a d m in is t r a r K , y
a d m in is t r a r 4 0 m E q K / h e n c a d a lit r o d e flu id o r e a liz a r d o s a je c a d a 2 h
E V , p a ra m a n te n e r u n
K s r ic o 4 - 5 m E q / L
ATP : ADENOSINA HMP: HEXOSA
TRIFOSFATO. MONOFOSFATO
CoA: ACETIL CoA. PC: PIRUVATO
F 1,6 : FRUCTOSA 1,6. CARBOXILASA
G-1-P: GLUCOSA -1- PFK:
FOSFATASA. FOSFOFRUCTOQUINASA.
G-6-P: GLUCOSA-6- PK:PIRUVATO QUINASA
FOSFATASA. PEP: FOSFOENOLPIRUVATO
GH: HORMONA DEL TCA: CICLO DE LOS ACIDOS
CRECIMIENTO. TRICARBOXILICOS (CICLO
HK: HEXOQUINASA. DE KREBS)
TG: TRIGLICERIDOS O
TRIACILGLICEROL