#46
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Öèòàòà:
- â ýòîì ñëó÷àå, åñëè ïàöèåíò íå êðèòè÷åí, è óðîâåíü ãëèêåìèè íå çàøêàëèâàåò, äåéñòâèòåëüíî, ñàìûé óäîáíûé è ôèçèîëîãè÷íûé ñïîñîá êîíòðîëÿ ãëèêåìèè - äèñêðåòíîå ïîäêîæíîå ââåäåíèå èíñóëèíà ïî ïîäîáðàííîé ñõåìå.  èíûõ ñëó÷àÿõ ïàöèåíò ìîæåò ïîëó÷àòü ïèòàíèå â âèäå ýíòåðàëüíûõ ôîðìóë, ò.å. äëèòåëüíîå ââåäåíèå ñïåöèàëüíûõ ñìåñåé ÷åðåç çîíä èëè ìîæåò ïîëó÷àòü ïèòàòåëüíûå ñìåñè ïàðåíòåðàëüíî. Ïîñëåäíèå äâà ñïîñîáà áîëåå ðàñïðîñòðàíåíû ó ïàöèåíòîâ ðåàíèìàöèè, íî ïàöèåíò ìîæåò ïîëó÷àòü íóòðèòèâíóþ ïîääåðæêó è âíå ÎÐÈÒ è äàæå âíå ñòàöèîíàðà. Íàïðèìåð, ýòî ìîãóò áûòü ïàöèåíòû ñ íèçêèì óðîâíåì ñîçíàíèÿ èëè ñ áóëüáàðíûìè íàðóøåíèÿìè. |
#47
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Êñòàòè, ñïàñèáî ÊÌÍ-ó ïîäêèíóë íåïëîõîé îáçîð. Òàì òîæå óêàçûâàåòñÿ íåìíîãî ïîáîëåå êðèòåðèåâ ïåðåõîäà íà ïîäêîæíîå ââåäåíèå:
Öèòàòà:
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#48
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Ó ìåíÿ âîçíèêëà ìàññà âîïðîñîâ. Ïðèçíàþñü ñðàçó, ÷òî ñàìîñòîÿòåëüíî êàê-òî óïóñòèëà èç âèäà.
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Öèòàòà:
Öèòàòà:
Èëè åñòü êàêèå-òî êðèòåðèè ïî êîòîðûì, ïàöèåíò ñ íàðóøåíèÿìè âûðàæåííûìè â òàêîé ñòåïåíè, ÷òî ïàöèåíò íóæäàåòñÿ â ïàðåíòåðàëüíîì ïèòàíèè, íî ïðè ýòîì ìîæåò íàõîäèòüñÿ â ñòàöèîíàðå èëè âíå åãî? |
#49
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Íàñêîëüêî ÿ ïîíèìàþ, ðå÷ü èäåò â ïåðâóþ î÷åðåäü î òÿæåëîì íåâðîëîãè÷åñêîì äåôèöèòå, â îñíîâíîì ýòî áîëüíûå ïîñëå ÎÍÌÊ, íóæäàþùèåñÿ íå â ÈÒ, à â ãðàìîòíî îðãàíèçîâàííîì óõîäå è ïèòàíèè, à òàêæå ËÔÊ. Îíè ìîãóò íàõîäèòüñÿ è äîìà, åñëè âîçìîæíî ñîçäàòü òàì ïîäõîäÿùèå óñëîâèÿ. Åñëè ìåñÿöàìè äåðæàòü èõ â ÎÐÈÒ, ðàáîòà îòäåëåíèÿ áóäåò ïàðàëèçîâàíà.
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Àííà, âðà÷-ýíäîêðèíîëîã Âîðîíåæ, êëèíèêà Íåïëàöåáî |
#50
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Öèòàòà:
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#51
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 ïðîäîëæåíèå òåìû î ãëþêîìåòðàõ â ÎÐèÒ.
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Meynaar, Iwan A.; van Spreuwel, Margot; Tangkau, Peter L.; Dawson, Lilian; Visser, Steven Sleeswijk; Rijks, Lode; Vlieland, Thea Vliet Critical Care Medicine. 37(10):2691-2696, October 2009. Öèòàòà:
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#52
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Ñìûñë íàçíà÷àòü èíñóëèí â 5% ãëþêîçó îíà è òàê ðàðóøàåñÿ äî âîäû è Ñ02 î÷åíü áûñòðî - ýëåìåíòàðíàÿ áèîõèìèÿ, íî ïðè òàêèõ öèôðàõ ãëèêåìèè ãëþêîç â ïðèíöûïå ðåçêî îãðàíè÷èâàåòñÿ ÷òî áûëî ñêàçàíî âûøå.  ðóêîâîäñòâå Ï. Ìàðèíî âñå åñòü.
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#53
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Öèòàòà:
Óâàæàåìûé Anton, ìíå êàæåòñÿ, ñìûñë ââåäåíèÿ ãëþêîçû ñ èíñóëèíîì âñ¸-òàêè åñòü. Äåëî â òîì, ÷òî â ñòðåññîâîì ñîñòîÿíèè, à ëþáîå òÿæ¸ëîå ñîñòîÿíèå åñòü ñòðåññîâîå, ãèðåðãëèêåìèÿ áóäåò îáÿçàòåëüíî, òàê êàê ãëþêîçà ïåðåñòà¸ò óñâàèâàòüñÿ êëåòêàìè (âñ¸ äëÿ ñåðäöà è ãîëîâíîãî ìîçãà!), ïîýòîìó åé íóæíî â ýòîì ïîìî÷ü. Ñâîåé ãëþêîçû â ïå÷åíè (ãëèêîãåí) î÷åíü ìàëî, ñëåäîâàòåëüíî å¸ íóæíî äîáàâëÿòü èçâíå. Áåç èíñóëèíà îíà â êëåòêó íå ïåðåéä¸ò, ïîýòîìó äîáàâëÿåì è åãî. Âìåñòå ýòî áóäåò ñïîñîáñòâîâàòü ïåðåâîäó êàëèÿ â êëåòêó. Òàê ÷òî ãëþêîçà ïðîäóêò íå áåñïîëåçíûé, íóæíî ëèøü ãðàìîòíî èì ïîëüçîâàòüñÿ - ñêîðîñòü ââåäåíèÿ è ò.ï.. Äàæå ïðè âûâåäåíèè áîëüíûõ èç êåòîàöèäîòè÷åñêîé êîìû óæå ïðè ñàõàðå êðîâè â 11 - 16 ììîëü/ë ïîäêëþ÷àþò ãëþêîçó. Ñ óâàæåíèåì, ß. |
#55
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#56
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Öèòàòà:
Dextrose Solutions In the days before the introduction of enteral and parenteral nutrition, dextrose was added to intravenous fluids to provide calories. One gram of dextrose provides 3.4 kilocalories (kcal) when fully metabolized, so a 5% dextrose solution (50 grams dextrose per liter) provides 170 kcal per liter. Daily infusion of 3 liters of a 5% dextrose (D5) solution will then provide about 500 kcal per day, which is enough nonprotein calories to limit the breakdown of endogenous proteins to meet daily caloric requirements. This protein-sparing effect is responsible for the early popularity of D5 infusion fluids. However, with the advent of effective enteral and parenteral nutrition regimens, the popularity of D5 infusion fluids is no longer justified. Adverse Effects Routine or aggressive use of dextrose-containing fluids can be harmful in a number of ways, as explained next. Dextrose and Osmolality The addition of dextrose to intravenous fluids increases osmolarity (50 g of dextrose adds 278 mOsm to an intravenous fluid). For a 5% dextrose-in-water solution (D5W), the added dextrose brings the osmolality close to that of plasma. When dextrose is added to isotonic saline (D5 normal saline), the infusion fluid becomes hypertonic to plasma (560 mOsm/L), and, if glucose utilization is impaired (as is common in critically ill patients), the hypertonic infusion creates an undesirable osmotic force that can promote cell dehydration. 5% Dextrose in Water (D5W) As shown in Figure 13.2, 5% dextrose in water (D5W) is a relatively ineffective fluid for expanding the plasma volume. Less than 10% of the infused volume of D5W remains in the vascular compartment. The total increase in extracellular fluid volume (plasma plus interstitial fluid) is much less than the infused volume of D5W because 2/3 of the infused volume ends up inside cells. Therefore the predominant effect of D5W infusions is cellular swelling. Enhanced Lactate Production In healthy subjects, only 5% of an infused glucose load will result in lactate formation, but in critically ill patients with tissue hypoperfusion, as much as 85% of glucose metabolism is diverted to lactate production (10). This latter effect is demonstrated in Figure 13.4. In this case, tissue hypoperfusion was induced by aortic clamping during abdominal aortic aneurysm surgery (11). Patients received intraoperative fluids to maintain normal cardiac filling pressures using either a Ringer's solution or a 5% dextrose solution. When the dextrose-containing fluid was infused, the serum lactate levels began to rise after the aorta was cross-clamped, and the increase in circulating lactate levels persisted throughout the remainder of the surgery. These results indicate that, when circulatory flow is compromised, infusion of 5% dextrose solutions can result in metabolic acid production instead of metabolic energy production. Adverse Effects of Hyperglycemia Hyperglycemia has several deleterious effects in critically ill patients, including immune suppression (12), increased risk of infection (13), aggravation of ischemic brain injury (14), and an increased mortality (13,15). The association between hyperglycemia and increased mortality is supported by studies showing that aggressive use of insulin to prevent hyperglycemia is associated with improved survival in ICU patients (13). The mechanism for the mortality-lowering effect of tight glycemic control is unclear at present. About 20% of patients admitted to ICUs are diabetic (12), and as many as 90% of patients will develop hyperglycemia at some time during their ICU stay (13). Considering the high risk of hyperglycemia in ICU patients, and the numerous adverse consequences of hyperglycemia, infusion of dextrose-containing fluids should be avoided whenever possible. In fact, considering the overall potential for harm with dextrose infusions, it seems that the routine use of 5% dextrose solutions should be abandoned in critically ill patients. |