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케톤산증 환자에서 호기말 이산화탄소 분압을 이용한 비 침습적 대사성 산증의 감시

  • 김도현 (대학원 의학과 응급의학전공)

초록/요약

= Abstract = Use of End-tidal CO2 for Non-invasive Monitoring of Metabolic Acidosis in Patients with Ketoacidosis Do Hyoun Kim, M.D. (Director: Professor Sung Woo Lee, M.D., Ph.D.) Major in Emergency Medicine, Department of Medical Science Graduate School, Korea University, Seoul, Korea Purpose We sought to compare the degree of concordance between Paco2 and Petco2, as well as between measured Hco3- and calculated Hco3- level for patients presenting to the emergency department with ketoacidosis. Calculated Hco3- level was determined through Petco2. We then investigated whether continuous noninvasive monitoring of patients with ketoacidosis was feasible, and searched for possible limitations in its use. Subjects and Method Patients over 18 years of age who had visited the emergency department of Korea University Medical Center for ketoacidosis due to either uncontrolled diabetes or alcohol abuse, from May 2005 to April 2006, and from November 2010 to August 2011, were included in the study. The diagnostic criteria for diabetic ketoacidosis are as follows: (1) pH ≤ 7.3 (2) Blood sugar > 250 mg/dL (3) Serum HCO3- < 15 mEq/L (4) presence of ketonuria. Alcoholic ketoacidosis, in addition, was diagnosed using the following criteria: (1) Low, normal, or slightly increased blood sugar (2) Nausea, vomiting, and binge drinking leading to decreased intake (3) Wide anion gap metabolic acidosis not explained otherwise (4) presence of ketonemia or ketonuria. Along with recording of demographic data, vital signs, and sampling for routine blood chemistry and arterial blood gas analysis, subjects were further monitored for continuous Petco2 levels. When necessary, blood gas analysis was performed repeatedly, along with recording of vital signs and Petco2. Through Bland-Altman analysis, we first compared the degree of concordance between Paco2 and Petco2. A difference of ± 5 mmHg is known to exist normally between Paco2 and Petco2. For cases displaying abnormally high degree of disconcordance, multivariate analysis was performed to identify factors contributing to such abnormal gap between Paco2 and Petco2. We then excluded patients with the independent factors identified above, and assessed the degree of concordance between measured HCO3- and calculated HCO3- level. Calculated HCO3- level was determined through Petco2, based on the following formula: Paco2 = 1.5 ⅹ(HCO3-) + 8 → calculated HCO3- ≒ (Petco2 &#8211; 8)/1.5. With treatment of subjects and subsequent normalization of acid-base status, we proceeded to compare serial levels of measured and calculated HCO3-, whose pattern in rise and fall were expected to be similar. Results A total of 74 patients were initially included in the study, and 44 were subsequently diagnosed with diabetic or alcoholic ketoacidosis. A total of 84 blood gas measurements were made, with successful concomitant Petco2 measurements. The difference between Paco2 and Petco2 (median, 25-75%) was 1.5 (-1.3 &#8211; 5.83) mmHg, and in 57 out of 84 measurements (67.9%), the gap was found to lie within the normally observable range of ± 5 mmHg. Univariate analysis performed on the group of patients in whom the gap was abnormally high showed a tendency towards older age, lower blood pressure, and presence of significant lung diseases, as compared to the group with normal gap. Multiple regression of these three factors revealed that the presence of lung disease was an independent factor predictive of an abnormal gap between Paco2 and Petco2 (Odd ratio 1.859, 95% CI; 1.225-1.974, p=0.024). After exempting the data for 9 cases of blood gas measurements previously sampled from patients with lung disease, calculated HCO3- level was determined from Petco2 for the remaining 75 cases of measurements, and then compared to the corresponding measured HCO3- level. The difference between measured HCO3- and calculated HCO3- level (median, 25-75%) was 0.63 (-2.3 &#8211; 2.9) mEq/L, and a high degree of concordance was also noted on the Bland-Altmann graph. Furthermore, serially checked levels of measured HCO3- (mEq/L) showed a tendency to rise as time passed, reflecting an improvement in the acid base balance with treatment: 9.56 ± 5.43, 10.91 ± 5.30, 14.15 ± 7.49, 15.85 ± 6.67. Likewise, a similar rising pattern was noted for calculated HCO3- level serially checked for each corresponding measured HCO3- level (mEq/L): 9.68 ± 6.14, 11.33 ± 5.71, 11.47 ± 6.42, 14.34 ± 6.54, thus reflecting a high degree of concordance between measured HCO3- and calculated HCO3- levels. Conclusion In patients with ketoacidosis who have no known lung disease, Petco2 accurately reflects arterial Pco2. Calculated HCO3- level, which can determined through Petco2, showed a high degree of concordance with measured HCO3- level. By using Petco2 and calculated HCO3- level, we were able to successfully monitor the acid base status of patients non-invasively during the period of treatment in the emergency department.

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서론 ∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙8


대상과방법∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙10


결과∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙12


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결론∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙20


참고문헌∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙21

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