一位糖尿病酮酸血症（DKA）病人正接受短效胰島素（regular insulin）持續靜脈輸注與 0.9% 生理食鹽水。血糖由 420 mg/dL 降至 240 mg/dL，但血清重碳酸鹽為 14 mEq/L、靜脈血 pH 7.24，血中酮體仍升高。護理師應預期哪一項處置？
A client with diabetic ketoacidosis (DKA) is receiving a continuous intravenous infusion of regular insulin and 0.9% sodium chloride. The blood glucose has decreased from 420 mg/dL to 240 mg/dL, but the serum bicarbonate is 14 mEq/L, the venous pH is 7.24, and blood ketones remain elevated. Which intervention should the nurse anticipate?
- AStop the insulin infusion now that the blood glucose is below 250 mg/dL血糖已低於 250 mg/dL，停止胰島素輸注
- BAdd dextrose to the intravenous fluids and continue the insulin infusion at a reduced rate在靜脈輸液中加入葡萄糖，並以調降後的速率繼續胰島素輸注正確答案
- CIncrease the insulin infusion rate to bring the blood glucose to normal more quickly提高胰島素輸注速率，讓血糖更快降到正常
- DHold the intravenous fluids until the blood glucose is below 200 mg/dL暫停靜脈輸液，直到血糖低於 200 mg/dL
- B在靜脈輸液中加入葡萄糖，並以調降後的速率繼續胰島素輸注
正確答案是 B。DKA 治療的目標不只是降血糖，而是關閉酮體生成、矯正酸血症與脫水。依 2024 年 ADA/EASD/JBDS/AACE/DTS 高血糖危象共識，當血糖降到 250 mg/dL 以下但酮酸血症尚未解除（酮體仍高、重碳酸鹽偏低、pH 未回到 7.3）時，應在靜脈輸液中加入 5–10% 葡萄糖，並把胰島素輸注速率調降（約 0.05 單位/公斤/小時），維持血糖約 200 mg/dL，讓胰島素持續抑制酮體生成直到酮酸血症解除。A：酮酸血症未解除前停用胰島素會使酮體再生、DKA 反彈。C：血糖已降到目標區間，再加速會造成低血糖與滲透壓驟變，增加腦水腫風險。D：DKA 病人仍處於脫水狀態，靜脈輸液必須持續以矯正體液不足與灌流，不可暫停。護理另需監測血鉀，血清鉀低於 5.0 mEq/L 時依醫囑補鉀，並每小時追蹤血糖與生命徵象。來源：Umpierrez et al., Hyperglycemic Crises in Adults With Diabetes: A Consensus Report（Diabetes Care, 2024）；ADA Hyperglycemic Crises Consensus（Kitabchi et al., 2009）。
- A血糖已低於 250 mg/dL，停止胰島素輸注
錯誤。酮酸血症尚未解除（酮體仍高、重碳酸鹽 14 mEq/L、pH 7.24），此時停用胰島素會使酮體再生、DKA 反彈。
- B · 正確答案在靜脈輸液中加入葡萄糖，並以調降後的速率繼續胰島素輸注
正確。血糖低於 250 mg/dL 而酮酸血症未解除時，應加入 5–10% 葡萄糖並以調降的速率繼續胰島素輸注，維持血糖約 200 mg/dL 直到酸血症矯正。
- C提高胰島素輸注速率，讓血糖更快降到正常
錯誤。血糖已在目標區間，提高輸注速率會造成低血糖與滲透壓驟變，增加腦水腫風險。
- D暫停靜脈輸液，直到血糖低於 200 mg/dL
錯誤。DKA 病人仍嚴重脫水，靜脈輸液必須持續矯正體液不足與灌流，不可為了等血糖數值而暫停。
美國多數醫院有護理師主導的胰島素輸注流程（nurse-driven insulin infusion protocol），護理師可依流程調整速率並加上葡萄糖輸液；台灣多由醫師逐次開立調整醫囑。但兩地 DKA 處置準則一致：血糖低於 250 mg/dL 就加葡萄糖，酮酸血症解除才停止輸注。
English explanation
Option B is correct. The goal of DKA treatment is not simply to lower the glucose but to shut off ketone production and correct the acidosis and dehydration. According to the 2024 ADA/EASD/JBDS/AACE/DTS consensus on hyperglycemic crises, once the blood glucose falls below 250 mg/dL while ketoacidosis persists (ketones still elevated, bicarbonate low, pH not yet 7.3), dextrose 5% to 10% is added to the intravenous fluids and the insulin infusion is reduced to about 0.05 units/kg/hr, maintaining the glucose at about 200 mg/dL so insulin can keep suppressing ketogenesis until the acidosis resolves. Option A is incorrect because stopping insulin before ketoacidosis resolves allows ketone production to resume and DKA to rebound. Option C is incorrect because the glucose is already in the target range; a faster decline risks hypoglycemia and abrupt osmotic shifts that increase the risk of cerebral edema. Option D is incorrect because the client is still volume depleted and intravenous fluids must continue to restore perfusion; they are never held to wait for a glucose value. The nurse also monitors potassium, replacing it as prescribed when the serum level falls below 5.0 mEq/L, and checks glucose and vital signs hourly. Source: Umpierrez et al., Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (Diabetes Care, 2024); ADA Hyperglycemic Crises Consensus (Kitabchi et al., 2009).
最近修訂：2026-10-06