Hyperosmolar coma is most often diagnosed in patients older than 50 years who suffer from mild or moderate diabetes mellitus, easily compensated by diet and special medications. It develops against the background of body dehydration as a result of taking diuretics, diseases of the vessels of the brain and kidneys. Mortality from hyperosmolar coma reaches 30%.
Causes
A hyperosmolar coma, the causes of which are related to glucose levels, is a complication of diabetes mellitus and occurs as a result of a sharp increase in blood sugar (more than 55.5 mmol / L) in combination with hyperosmolarity and lack of acetone in the blood.
The reasons for this phenomenon may be:
- sharp dehydration as a result of severe vomiting, diarrhea, burns or with prolonged treatment through the use of diuretic drugs;
- insufficiency or complete absence of insulin, both endogenous and exogenous (the reason for this phenomenon may be the lack of insulin therapy or an incorrect treatment regimen);
- increased need for insulin, which can arise as a result of gross violations of the diet, the introduction of concentrated glucose preparations, the development of an infectious disease (especially pneumonia and urinary tract infections), after operations, injuries, and taking medications that have insulin antagonist properties ( in particular, glucocorsticoids and sex hormone preparations).
Pathogenesis
Unfortunately, the mechanism of development of this pathological condition is not fully understood. It is believed that the development of this complication is affected by kidney blockage of glucose excretion, as well as increased intake of this substance in the body and its production by the liver. This inhibits the production of insulin, as well as blocking the utilization of glucose by peripheral tissues. This is all combined with the dehydration of the body.
In addition, it is believed that the presence in the human body of endogenous (formed inside the body) insulin prevents such processes as lipolysis (the breakdown of fats) and ketogenesis (the formation of germ cells). However, this insulin is not enough to suppress the amount of glucose that is produced by the liver. Therefore, the introduction of exogenous insulin is necessary.
With a sharp loss of fluid in large quantities, the BCC (volume of circulating blood) decreases, which leads to a thickening of the blood and an increase in osmolarity. This happens precisely due to an increase in the concentration of glucose, potassium and sodium ions.
Symptoms
A hyperosmolar coma develops, the symptoms of which appear in advance, within a few days or weeks. At the same time, the patient has signs that are characteristic of decompensated diabetes mellitus (sugar level cannot be regulated with drugs):
- polyuria (increased urine formation) ;
- increased thirst;
- increased dryness of the skin, mucous membranes;
- sharp weight loss;
- persistent weakness;
- the result of dehydration is a general deterioration in well-being: a decrease in the tone of the skin, eyeballs, blood pressure, temperature.
Neurological symptoms
In addition, symptoms can also be observed from the side of the nervous system:
- hallucinations;
- hemiparesis (weakening of voluntary movements);
- speech disorders, it is slurred;
- persistent cramps;
- Areflexia (lack of reflexes, one or more) or hyperlefxia (increased reflexes);
- muscle tension;
- impaired consciousness.
Symptoms appear a few days before a hyperosmolar coma develops in children or adult patients.
Possible complications
With untimely help, complications may develop. Common are:
- epileptic seizures, which may be accompanied by twitching of the eyelids, face (these manifestations may be invisible to others);
- deep vein thrombosis;
- pancreatitis (inflammation of the pancreas);
- renal failure.
Changes occur in the gastrointestinal tract, which are manifested by vomiting, bloating, abdominal pain, impaired intestinal motility (sometimes there is intestinal obstruction), but they can be almost invisible.
Vestibular disturbances are also observed.
Diagnostics
If there is a suspicion of a diagnosis of hyperosmolar coma, the diagnosis is based on laboratory tests. In particular, a blood test reveals a high level of glycemia and osmolarity. In addition, elevated sodium levels, high total whey protein, and residual nitrogen are possible . Urea levels can also be elevated. In the study of urine, ketone bodies (acetone, acetoacetic and beta-oxybutyric acid) are not detected.
In addition, there is no smell of acetone in the air exhaled by the patient and ketoacidosis (impaired carbohydrate metabolism), which are pronounced hyperglycemia and osmolarity of blood. The patient has neurological symptoms, in particular, Babinsky's pathological symptom (stop extensor reflex), increased muscle tone, bilateral nystagmus (involuntary oscillatory eye movements).
Among other surveys, there are:
- ultrasound and X-ray examination of the pancreas;
- electrocardiography;
- determination of blood glucose.
Of particular importance is the differential diagnosis. This is due to the fact that hypersmolar coma can be the result not only of diabetes mellitus, but also of hepatic-renal failure if thiazide diuretics are used.
Treatment
If a hyperosmolar coma is diagnosed, emergency care consists in eliminating dehydration, hypovolemia and restoring plasma osmolarity.
To combat the hydration of the body, a hypotonic sodium chloride solution is used. Introduced from 6 to 10 liters per day. If necessary, the amount of solution increases. Within two hours after the onset of the pathological condition, it is required to administer 2 l of a solution of sodium chloride intravenously, after which the administration passes by drip at a rate of 1 l / h. These measures are taken up to the normalization of blood osmolarity and pressure in venous vessels. A sign of elimination of dehydration is the appearance of patient consciousness.
If hyperosmolar coma is diagnosed, treatment requires a reduction in hyperoglycemia. To this end, insulin is administered intramuscularly and intravenously. At the same time, strict control of the blood sugar concentration is required. The first dose is 50 units, which is divided in half and introduced into the body in various ways. In the case of hypotension, the method of administration is only intravenous. Further, insulin is administered in the same amount by the drip method intravenously and intramuscularly. These measures are carried out until the glycemia level is 14 mmol / L.
The insulin administration schedule may be different:
- one-time 20 units intramuscularly;
- 5-8 units every 60 minutes.
In the event that the sugar level drops to 13.88 mmol / L, the hypotonic sodium chloride solution must be replaced with a glucose solution.
During the treatment of hyperosmolar coma, constant monitoring of the amount of potassium in the blood is necessary, since potassium chloride is required to remove from the pathological condition.
In order to prevent cerebral edema as a result of hypoxia, a 50 ml solution of glutamic acid is administered to patients intravenously. Heparin is also required, as the risk of thrombosis increases sharply. In this case, coagulation control is required.
As a rule, a hyperosmolar coma develops in patients with mild or moderate stages of diabetes, therefore it can be safely stated that the body is well absorbed by insulin. Therefore, it is recommended that small doses of the drug be administered.
Prevention of complications
The cardiovascular system also needs to be prevented, namely, the prevention of cardiovascular failure. For this purpose, "Cordiamin", "Strofantin", "Korglikon" are used. With reduced pressure, which is at a constant level, it is recommended to administer DOXA solution, as well as intravenous administration of plasma, hemodesis, human albumin and whole blood.
Be on the alert ...
If you are diagnosed with diabetes mellitus, you must constantly undergo examinations by the endocrinologist and follow all his instructions, in particular, monitor blood sugar. This will avoid complications of the disease.