Escolar Documentos
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ISSN: 0120-5552
saluduninorte@uninorte.edu.co
Universidad del Norte
Colombia
Hernndez-Ruiz, Eder A.; Castrilln-Estrada, Jaime A.; Acosta-Vlez, Juan G.; Castrilln-Estrada,
David F.
Diabetes Mellitus en el servicio de urgencias: manejo de las complicaciones agudas en adultos
Salud Uninorte, vol. 24, nm. 2, julio-diciembre, 2008, pp. 273-293
Universidad del Norte
Barranquilla, Colombia
Resumen
1
Mdico, Hospital Universidad del Norte. ederhernandez@hotmail.com
2
Residente de segundo ao de Medicina Interna, Universidad del Norte. jaimeandres727@hotmail.com
3
Mdico, Universidad del Norte. juan_acosta2@hotmail.com
4
Residente de primer ao de Anestesiologa, Universidad del CES. davidfelipe1007@yahoo.com
Vol. 24, N 2, 2008
Correspondencia: Universidad del Norte, Km 5 va a Puerto Colombia, A.A. 1569, Barranquilla (Colombia). ISSN 0120-5552
Diabetes Mellitus (DM) is a high prevalence disease, recognized as a public health problem
because of its high morbidity and mortality rates. Some studies have expose that the lack
of adherence to treatment is one of the main triggers for acute complications in diabetic
patients. Those complications are the acute hyperglycemic crises, which are two clinical
entities: Diabetic Ketoacidosis (DKA) and the Hyperglycemic Hyperosmolar State (HHS),
which are potentially fatal metabolic complications in the short term and which can be found
overlapping. They have established some specic diagnostic criteria in order to perform
a correct differential diagnosis, which allows proper treatment, however, morbidity and
mortality remain signicantly high. Hypoglycemia is also a medical emergency, which
if not treated on time, can cause permanent neurological damage and even death. Thats
why it is important to create clear guidelines to treat these complications, in all services, in
order to provide emergency medical care. New researchs have been developed to nd new
diagnostic and therapeutics strategies would allow a more integrated management of the
DM and its complications, for the sake of improving patients life quality.
Key words: Diabetes Mellitus, Diabetic Ketoacidosis, Hyperglycemic Hyperosmolar
State, Hypoglycemia.
La diuresis osmtica desencadenada por estos Aliento cetnico: Los altos niveles de acetona
eventos siopatolgicos lleva a una prdida en plasma ocasionan que al ser exhalada
considerable de minerales y electrolitos (So- se presente un olor a fruta caracterstico.
dio, Potasio, Calcio, Magnesio, Cloro y Fos-
fato), algunos de los cuales se pueden reponer Deshidratacin: Debida a la prdida de
rpidamente con el manejo mdico, como el volumen y reejada principalmente en
Na, K y el Cl y otros cuya reposicin puede sequedad de las mucosas y disminucin
tomar das o semanas (21). en la turgencia de la piel.
Por otra parte, dado que la insulina estimula Dolor abdominal: Se presenta hasta en un
la reabsorcin de agua y sodio en el tbulo 30% de los pacientes. De especial cuidado
distal renal y de fosfato en el tbulo proximal, por tres razones:
su dcit contribuye a mayor prdida renal
de agua y electrolitos (22). 1. Puede ser originado por la misma CAD,
o corresponder a una patologa que pue-
PRESENTACIN CLNICA da constituir un factor desencadenante
para la CAD.
Las alteraciones metablicas propias de la
CAD se pueden desarrollar en cuestin de 2. Suele estar relacionado con la severidad
horas, generalmente menos de 24, aunque de la acidosis
pueden existir sntomas asociados a un con-
Tabla 1
Criterios Diagnsticos de la cetoacidosis diabetica (CAD) y
el estado hiperglicmico hiperosmolar (EHH)
CAD
Variables EHH
Leve Moderada Severa
Glucosa Plasmtica > 250 > 250 > 250 > 600
pH arterial 7.25 a 7.30 7.00 a 7.24 < 7.00 > 7.30
Bicarbonato 15 a 18 10 a < 15 < 10 > 15
Cetonas urinarias o sricas Positiva Positiva Positiva Baja o negativa
Osmolaridad srica Variable Variable Variable > 320
Brecha aninica > 10 > 12 > 12 >14
Alteracin del estado de Alerta, som- Estupor,
Alerta Estupor, coma
conciencia noliento coma
Adaptado de referencias: 5,9
Los parmetros actualizados por la ADA en 3. LEUCOCITOSIS: Los pacientes con CAD o
el 2006 han sido aplicados en la mayora de EHH suelen presentarla debido a hemocon-
pases del mundo, incluyendo, por supues- centracin o cetosis. Sin embargo, valores su-
to, los pases de Amrica, la mayor parte periores a 25000/mm3 sugieren la presencia
del continente europeo, africano y asitico de un proceso infeccioso y requieren mayores
(25). Estos criterios enfatizan en las concen- estudios. De igual forma, una elevacin de los
traciones de glicemia necesarias para pro- neutrlos en banda indica infeccin con un
ducir hiperosmolaridad y alteraciones del es- 100% de sensibilidad y 80% de especicidad
tado de conciencia, las cuales habitualmente (5,16,26).
deben superar los 600 mg/dL (9).
4. HIPONATREMIA DILUCIONAL: Los niveles
Otros paraclnicos que se deben realizar elevados de glucosa en sangre generan un
cuando a exista una indicacin especca gradiente osmtico que contribuye al paso de
son (5,16): agua del espacio intracelular al extracelular.
Este hecho se observa principalmente en c-
- Electrocardiograma lulas que usan el transportador dependiente
- Radiografa de trax de insulina GLUT-4, como son las clulas
- Cultivos de esputo, orina y/o sangre musculares y adipositos. Todo este proceso
- Hemoglobina glicosilada (HbA1C) suele generar un estado de hiponatremia
- Prueba de embarazo en mujeres en edad dilucional. El clculo de la osmolaridad
frtil srica es muy importante para realizar el
diagnstico de CAD o EHH y se obtiene de
En el contexto de la CAD y del EHH resulta la siguiente manera: Osmolaridad srica =
de gran importancia hacer especial nfasis (2 [Na + K] (mEq/L) + glucosa (mg/dL)/18 +
en los siguientes aspectos: BUN(mg/dL)/2.8.
Tabla 2
Reposicin de potasio para cada nivel srico
Kalemia Reposicin
K < 3.3 mEq/L 20-30 mEq/L hasta K >3.3 mEq/L
K > 3.3 - < 5.3 20-30 mEq/L en cada litro de SSN
mEq/L Mantener niveles entre 4 - 5 mEq/L
No aDMinistrar K
K > o = 5.3 mEq/L
Vericar niveles cada 2 horas
Fuente: Adaptado de referencias: 5,9
sionar mltiples efectos negativos, como
Una vez resuelta la CAD y siempre que el empeoramiento de la hipokalemia y acidosis
paciente tolere la va oral, se inicia esquema paradjica del sistema nervioso central. Sin
con insulina va SC. Se debe continuar la embargo, se considera su uso solo cuando el
infusin endovenosa hasta 1 a 2 horas despus pH < 7 de la siguiente forma:
del inicio de la va SC para garantizar niveles
plasmticos adecuados de insulina.
Tabla 3
Sntomas de hipoglicemia
Autonmicos Neuroglicopnicos
Sudoracin Confusin
Palpitaciones Dicultades en el habla
Temblor Mareo
Hambre Comportamiento extrao
Frialdad distal Incoordinacin
Tabla 4
Tratamiento de Hipoglucemia en diabetes
Clnica Tratamiento
Carbohidratos simples via
Hipoglicemia asintomtica/ oral (20 gramos)
sintomtica no severa Carbohidratos complejos
(harina) posterior
50 ml de DAD 50% (lavar con
solucin salina para prevenir
Hipoglicemia severa tromboebitis)
100-200 ml DAD 10%
Glucagn 0.5-1mg IM*
Si inconsciencia >30min Manitol al 20% 40ml IV
sospechar edema cerebral Dexametasona 10mg IV
* No disponible en Colombia para uso generalizado
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