An increase in blood sugar levels up to 31 mmol / l can be a sign of a severe complication of diabetes mellitus - hyperosmolar coma. In this condition, there is a sharp dehydration of all body tissues, carbohydrate metabolism disorders reach an extreme degree, the level of sodium and nitrogenous bases in the blood increases.
In about half of the patients, this type of diabetic coma is fatal. Most often, this pathology occurs in patients with type 2 diabetes mellitus who take small doses of glucose-lowering drugs.
Hyperosmolar state practically does not occur in diabetics under the age of 40 years, half of the patients with diabetes have not been identified before. After leaving the coma, patients need correction of the therapy - insulin can be prescribed.
Causes of coma in type 2 diabetes
The main factor that leads to a sharp increase in hyperglycemia is relative insulin deficiency. The pancreas can retain the ability to secrete insulin, but due to the fact that it does not respond to the cells, the blood sugar remains elevated.
This condition is exacerbated by dehydration with severe blood loss, including extensive abdominal surgery, injuries, burns. Dehydration may be associated with the use of large doses of diuretic drugs, saline solutions, Mannit, hemodialysis, or peritoneal dialysis.
Infectious diseases, especially with high fever, as well as pancreatitis or gastroenteritis with vomiting and diarrhea, acute circulatory disorders in the brain or heart lead to decompensation of diabetes. The situation may be aggravated by the introduction of glucose solutions, hormones, immunosuppressants, and carbohydrate intake.
Causes of disturbed water balance can be:
- Diabetes insipidus.
- Fluid restriction in patients with heart failure.
- Impaired renal function.
The reason for the violation of water balance can also be a long overheating of the body with intense sweating.
Symptoms and diagnosis
Hyperosmolar coma develops slowly. Pre-comatose period can last from 5 to 15 days. Disorders in the metabolism of carbohydrates are manifested by increasing thirst every day, abundant urine excretion, itching of the skin, increased appetite, and rapid fatigue reaching the end of motor activity.
Patients are worried about dry mouth, which becomes constant, drowsiness. The skin, tongue and mucous membranes are dry, the eyeballs are sunken, soft to the touch, pointed features. Progressing difficulty breathing and impaired consciousness.
Unlike ketoacidotic coma, which is characteristic of type 1 diabetes and develops more often in young patients, with a hyperosmolar state there is no smell of acetone from the mouth, noisy and frequent breathing, abdominal pain and tension of the anterior abdominal wall.
Typical signs of coma in the hyperosmolar state are neurological disorders:
- Convulsive syndrome.
- Epileptic seizures.
- Weakness in limbs with reduced ability to move.
- Involuntary eye movements.
- Slurred speech.
These symptoms are characteristic of acute impaired blood circulation in the brain, so such patients may be mistakenly diagnosed with a stroke.
With the progression of hyperglycemia and dehydration, cardiac activity is disturbed, blood pressure drops, frequent heartbeat occurs, urination decreases to the complete absence of urine, and vascular thrombosis occurs due to high blood concentration.
In laboratory diagnostics, high glycemia is detected - blood sugar is 31 mmol / l (can reach 55 mmol / l), ketone bodies are not detected, acid-base balance parameters are at a physiological level, sodium concentration exceeds the norm.
By urine analysis, you can detect a massive loss of glucose in the absence of acetone.
Treatment of hyperosmolar state
If blood sugar rises to 31 mmol / l, then the patient alone will not be able to compensate for metabolic disorders. All therapeutic measures should be carried out only in conditions of intensive care units or in intensive care units. This is due to the fact that we need constant medical supervision and monitoring of basic laboratory parameters.
Restoration of normal circulating blood volume refers to the main direction of treatment. As dehydration is eliminated, blood sugar will drop. Therefore, until adequate rehydration has been performed, insulin or other drugs are not prescribed.
In order not to aggravate violations of the electrolyte composition of the blood before the start of infusion therapy, it is necessary to determine the content of sodium ions in the blood (in meq / l). It depends on which of the solutions will be used for the dropper. There may be such options:
- Concentration of sodium is higher than 165, salt solutions are contraindicated. Correction of dehydration with 2% glucose begins.
- Sodium is contained in the blood from 145 to 165, in this case, 0.45% hypotonic sodium chloride solution is prescribed.
- After sodium lowering to 145, 0.9% physiological sodium chloride solution is recommended for treatment.
During the first hour, as a rule, it is necessary to drip 1.5 liters of the selected solution, for 2-3 hours, 500 ml, and then from 250 to 500 ml for each subsequent hour. The amount of fluid injected may exceed its elimination by 500-750 ml. With symptoms of heart failure, the rehydration rate should be reduced.
What to do if after the complete compensation of dehydration is carried out, and the sugar in the blood remains elevated? In such a situation, the prescription of short-acting genetically engineered insulin preparations is indicated. Unlike diabetic ketoacidosis, the state of hyperosmolarity does not require high doses of the hormone.
Initially, insulin therapy is administered 2 U of the hormone into the infusion system intravenously (into the connecting tube of the dropper). If after 4-5 hours from the start of therapy the reduction of sugar to 14-15 mmol / l is not achieved, then the dose can be gradually increased.
It is dangerous to introduce more than 6 units of insulin per hour, especially with the simultaneous appointment of a hypotonic solution of sodium chloride. This leads to a rapid drop in the osmolarity of the blood, the liquid from the blood begins to flow into the tissue according to the laws of osmosis (the concentration of salts in them is higher), causing irreversible swelling of the lungs and brain, resulting in death.
Prevention of hyperosmolar coma
What to do to prevent the development of severe complications of diabetes, including such life-threatening conditions as hyperosmolar coma. The most important condition is the constant monitoring of blood sugar and timely seeking medical assistance.
Ketoacidotic and hyperosmolar comas are characterized by a gradual increase in glycemia, therefore, already with sugar levels above 12-15 mmol / l and the impossibility of lowering them and the recommended level, an endocrinologist should be visited.
Glycemia measurement is recommended for type 2 diabetes at least 1 time per day, if tablets are prescribed and at least 4 times for insulin therapy. Once a week, all diabetics, regardless of the type of diabetes mellitus, the treatment being carried out and the level of sugar, it is necessary to make a complete glycemic profile - measurements are taken before and after meals.
Before the visit, it is recommended to reduce the amount of carbohydrate foods and animal fats in the diet and drink a sufficient amount of regular water, completely abandon coffee, strong tea, and especially smoking and alcoholic beverages.
In drug treatment, corrections are made only in consultation with the doctor. It is not desirable to take self-medication from the group of diuretics and hormones, sedatives and antidepressants.
Patients with uncompensated course of type 2 diabetes mellitus are prescribed:
- Long-acting insulin injections 1-2 times a day while taking sugar-lowering tablets.
- Long-acting insulin, metformin and short insulin in the main meal.
- The prolonged preparation of insulin 1 time a day, injections of a short 3 times 30 minutes before a meal.
For the prevention of uncontrolled hyperglycemia, patients with diabetes mellitus of the second type should be transferred to combination or insulin monotherapy with low efficacy of tablets to reduce sugar. In this case, the criterion may be an increase in the level of glycated hemoglobin above 7%.
Insulin can be prescribed to patients with long-term type 2 diabetes, signs of neuropathy, damage to the kidneys and retina, with the addition of infectious or acute concomitant diseases of internal organs, injuries and operations, pregnancy, the need to use hormonal drugs, large doses of diuretics.
Since the clinical manifestations of hyperosmolar coma are similar to acute vascular pathologies of the brain, it is recommended to check blood sugar and urine levels in all patients with suspected stroke or symptoms that cannot be explained only by neurological abnormalities.
About hyperosmolar coma described in the video in this article.