Журнал «Медицина неотложных состояний» 7 (62) 2014

Need in re-orientation of medical intelligence into a system scientific knowledge for practical activities is a preservation of biological integrity of the patient’s organism in the process of its nosological induced changes upon diabetic ketoacidosis state.

Purpose of research: optimization of non-drug methods of insulin resistance correction, detoxification upon diabetic decompensated ketoacidosis.

Material and methods

Design: prospective, non-randomized observational research of the 74 case of severe decompensated diabetic ketoacidosis in the last 6 years in the department of Intensive care Zaporozhye regional clinical endocrinology dispensary . The patients were divided into 3 groups:

The protective correction of insulin resistance was carried out by the algorithm: patients with high plasma hyperglycemia accompanied by insulin resistance and related to the first group, blood exfusion and hemodilution were used. In the second group, blood exfusion or plasmapheresis were used if indicated, followed by hemodilution. In the third group was used replacement therapy if indicated, hemodilution, and plasmapheresis. These methods are quite aggressive, especially in the beginning of their application. Conducting of blood exfusion, plasmapheresis and hemodilution for the patients with decompensated diabetes mellitus complicated with ketoacidosis with disintegration — BCO, can give both positive and negative results, if biomonitoring (status measurement) is not conducted.

Monitoring the overall health of the patient is required, red blood parameters should be not less than: Hв = 110–120 g/l and Ht — not less than 0,32–0,34 g/l.

During the normovolemic hemodilution, safe blood exfusion volume is calculated according to the formula:

SBEV = W х (Нt_p – Нt_f)

W — weight x 70

Нt_p — initial hematocrit

Нt_f — final hematocrit

Exfused blood is replaced with saline, crystalloids, colloids.

Estimated safe volume of disposed plasma volume is determined according to the formula:

SVDP = VCP (Volume Circulated Plasma) (GP (General protein) – 55) : GP, ml.

Revealed relationship of CI, DO₂ and VO₂ indicates the only way of oxygen supply maintenance, which is the preservation of hyperdynamic state of circulation.

The need in homostructural prosthetics re-run of BR (biological resistance), determined by the index of intravenous alteration (IIA):

IIA = 100 x (myelocyte + juvenile) + R/N + S/N ) / S/N;

Where, R/N — rod nuclear cell, %

S/N — segment nuclear cell , %

If the IIA is > 110 %, indicating the blockade of microcirculation and hypobiosis, procoagulant reprogramming of vascular endothelium requires the continuation of the BR prosthesis. Typically by the end of 5–6 days the BR prosthetics by drug-free methods of correction was terminated on stable normal dynamics background. In the same period, was restored to normal values ITE (index of transcapillary exchange), indicating that the normalization of histohematogenous permeability and transcapillary exchange.

ITE = c (1 – Нt_p) – 1;

c — is a coefficient for m = 3,12

f = 2,88

ITE = 0,9–1,1 regarded as normal microcirculation

ITE < 0,8 regarded as hypo microcirculation

ITE > 1,2 hyper microcirculation

However, one of the factor retarding the recovery of BU organism is a violation of the blood osmolarity. Estimate of osmotic mechanism for pre-serving of homeostasis was undertaken by determination of blood plasma osmolarity under calculated manner:

OSM (pl) = 1,86 (Na+ pl., mmol/ l) + (Gl., mmol/ l) +2 (urea nitrogen, mmol/l) + 5 mOsm /l. Meaningfully deviation of OSM (pl) was estimated the correctness of the chosen infusion — transfusion therapy.

Conclusions

Protective correction algorithm of homeostasis in the complex of standards of basic therapy and medication-free IC — blood exfusion, plasmapheresis, secired the lack of mortality of patients with decompensated diabetic ketoacidosis. In our studies, we do not advocate the increasing of insulin dose under the developed persistent insulin resistance.