당뇨병성 케톤산혈증에서의 대사장애에 관한 연구

Abstract

The ketoacidosis is one of the complications in patients with diabetes mellitus and its mortality rate is much decreased after low dose insulin infusion therapy. Clinically, diabetic ketoacidosis showed metabolic abnormalities such as metabolic acidosis, fluid-electrolyte imbalance and hypophosphatemia. Many studies are now available about its mechanism or treatment for the better prognosis. This study included 20 cases of diabetic ketoacidosis who had been admitted to the Department of Internal Medicine at Ewha Womans University Hospital, from March 1982 to May 1984. We observed the correlation between serum phosphate and other metabolic abnormalities. The results obtained were as follows ; 1. Diabetic ketoacidosis was more common in female than male. The ratio of male to female was 1:1. 85. The age incidence was the highest in 6th decade (35%). The first diagnosis was 3 cases (15%). 2. The commonest precipitating cause was the infection (8 cases, 40%). 3. The requiring fluid amount was 6.0±3.0L to correct fluid-electrolyte imbalance. The mean value of serum osmolarity was 309.0±23.7mOsm/l, serum sodium 130.9±17.9mEq/l serum potassium 3.0±1.3mg/dl, urea nitrogen 30.4±20.0mg/dl, bicarbonate 10.85±8.5mEp/l and blood ketone from ++ to +++. 4. The mean value of blood glucose was 575.6±242.8mg/dl. The rate of decrease of glucose was 82.7±47.2mg/dl/hr after insulin therapy. The time of decreased blood suger level below 250mg/dl was 5.7±2.5 hr and the priming dose of insulin was 11.4±6.8u. The infusion rate of insulin was 4.9±1.56u/hr and total amount of insulin was 56.6±28.7u for correction of electrolyte imbalance. 5. In comparison of group A (serum phosphate < 2.5mg/dl, 5 cases) and group B (serum phosphate > 2.5mg/dl, 10 cases). The mean value of serum phosphate was 1.5±0.4mg/dl in group A and 3.8±0.9mg/dl in group B. The mean value of glucose was significantly higher in group A (796.6±312mg/dl) than in group B (508±164.7mg/dl) (p<0.005) and the mean value of serum pH was significantly lower in group A (7.058±0.124) than in group B (7.339±0.163) (p<0.01). However there was no significant correlation between two groups in serum osmolarity, sodium, potassium, insulin amount and correction time. 6. The common complications of ketoacidosis were infection (3 cases, 15%) and myocardial infarction (2 cases, 10%), The mortality rate was 5% (1 case) and its cause of death was sepsis with disseminated intravascular coagulation.;당뇨병성 케톤산혈증은 당뇨병의 급성대사성 합병증으로 소량정주 인슐린 요법의 도입으로 치사율이 현저히 감소되었다. 당뇨병성 케톤산혈증은 탈수, 산혈증, 전해질 이상, 저인혈증등 여러 대사장애를 일으키며 이들의 빠르고 적절한 교정이 이 질환의 예후에 영향을 주므로 이들 대사장애의 기전이나 교정방법등에 관해 많은 연구가 되고 있다. 이에 저자는 1982년 3월부터 1984년 5월까지 이화여자대학교 의과대학 부속병원 내과에 입원가료하였던 당뇨병성 케톤산혈증 20예를 혈중 인치를 중심으로 대사장애를 연구하여 다음과 같은 성적을 얻었다. 1. 남녀비는 1:1.85로 여자가 더 많았으며 연령은 50대(35%)가 가장 많았다. 당뇨의 유병기간은 1∼5년이 가장 많았고 초발견이 3예(15%)였다. 2. 유발요인은 감염이 8예( 40% )로 가장 많았다. 3. 수액대사교정에 필요한 총수액량은 6.0 ± 3.0 L이었고, 입원당시 혈액삼투압은 309. 0 ± 23.7 mOSm/ℓ , Na^(+)130.9 ± 17 mEq/ℓ, K^(+) 4.9±0.9mEq/ℓ, P 3.0 ± 1.3㎎/dℓ, Urea nitrogen 30.4 ± 20.0 ㎎/dℓ, HCO_(3) 10.85±8.5mEq/ℓ이었고 혈중케톤은 □∼□를 보였다. 4. 입원당시 혈당치는 575.6 ± 242.8 ㎎/dℓ이었고 인슐린 치료로 혈당의 감소 속도는 82.7 ± 47.2 ㎎/dℓ였으며 혈당치가 250㎎/dℓ로 하강하기까지의 시간은 5.7±2.5시간이었고 인슐린 Priming dose는 11 . 4 ± 6.8U, 인슐린 정주속도는 4.9 ± 1. 56 U/hr 이었고 대사장애 교정에 필요한 인슐린 총량은 56.6 ± 28.7U , 의식의 회복시간은 4.7 ± 2.3 시간이었다. 5. 혈청 인 농도에 따라 2. 5 ㎎/dℓ이하인 A군( 5예 ) , 2.5 ㎎/dℓ이상인 B군( 10예 )에서, A군의 인 농도는 1.5 ± 0.4㎎/dℓ , B군 3.8±0.9 ㎎/dℓ이었다. A군의 입원당시 혈당치는 796.6 ± 312㎎/dℓ , B군 508 ± 164.7㎎/dℓ, 혈정 pH는 A군 7.058 ± 0.124, B군 7.339 ±0.163으로 각각 P < 0.005, p < 0. 01로 유의한 차이를 보였다. 혈청삼투압, Na^(+), K^(+),투여한 인슐린양 및 대사장애 교정시간에는 양군간에 차이가 없었고, 저혈청인농도를 보였던 5예에서 용혈현상은 없었다. 6. 케톤산혈증의 합병증은 감염 3예( 15%), 삼근경색증 2예 (10%)였으며 치사율은 5 % ( 1예 )로 사인은 패혈증 및 범발성혈관내응고증이었다.