Diabetic hyperosmolar coma: diagnosis and aggressive treatment

2021-07-31 11:31 PM

Hyperosmolar coma, a very serious complication of diabetes, is common in patients with type 2 diabetes

Hyperosmolarity is the most serious acute complication of diabetes. Hyperosmolarity is often associated with more severe hyperglycemia but no ketoacidosis.

Hyperosmolar coma is a very serious complication of diabetes, common in patients with type 2 diabetes. The disease has a high mortality rate.

Definite diagnosis

Clinical symptoms

Consciousness disturbances ranging from lethargy to deep coma.

Signs of severe dehydration: dry skin, slow loss of skin folds, rapid pulse, low blood pressure, ...

Symptoms of trigger factors (infection, stroke,...).

Subclinical symptoms

Hyperglycemia is usually > 40 mmol/l.

Plasma osmolality > 350mOsm/l.

Arterial blood gas: pH > 7.3, bicarbonate > 15mmol/l.

No or very little ketonuria.

Serum sodium is usually elevated > 145 mmol/l but may still be normal.

Differential diagnosis

Diabetic ketoacidosis and hyperosmolar coma (see Table 1).

Table of  Differentiate between diabetic ketoacidosis and hyperosmolar coma

*Estimated osmotic pressure = 2 x [(sodium (mmol/l)] + glucose (mmol/l)].

Anion gap = (Na + ) - (Cl - + HCO 3 - )

Hyperosmolarity without hyperglycemia in excessive alcohol drinkers.

Hyperosmolarity in peritoneal dialysis patients with hypertonic sugar solutions.

Hypoglycemic coma in diabetic patients.

Lactic acidosis in diabetics.

Diabetes insipidus causes dehydration, hypernatremia.

Diagnosis of the decompensated cause of diabetic hyperosmolar coma

Infection.

Non-compliance with treatment regimen (stopping or reducing insulin dose).

Failure to adhere to a diabetic diet.

Excessive use of diuretics.

Cerebral vascular accident.

Treatment

Rule

First aid A, B, C.

Immediately place a large intravenous line, then a central venous catheter.

Monitor capillary blood sugar every 3 hours to adjust insulin dose, electrolytes every 6 hours until the patient is stable.

Diagnosis and treatment of favorable causes of hyperosmolar coma (pneumonia, urinary tract infection, cerebrovascular accident, ...).

Fluid compensation

Begin an infusion of 1 liter of 0.9% sodium chloride over 1 hour. The estimated water shortage is about 8-10 liters.

If there is severe hypovolemia causing hypotension: infusion of 0.9% sodium chloride 1 liter/hour until systolic blood pressure is above 90 mmHg.

If dehydration is mild, calculate sodium correction:

+ Corrected blood sodium = measured blood sodium value + 1.6mmol/l for each 5.6mmol of glucose increase.

+ Normal or increased sodium concentration: 0.45% sodium chloride infusion 250- 500ml/hour depending on dehydration. When blood glucose is 16.5mmol/l, add 5% glucose with 0.45% sodium chloride, infusion rate 150 - 250ml/hour.

+ Reduced sodium concentration: 0.9% sodium chloride infusion 250 - 500ml/hour depending on dehydration. When blood glucose is 16.5mmol/l, add 5% glucose with 0.45% sodium chloride at a rate of 150-250ml/hour.

Insulin

Insulin 0.1 units/kg IV followed by a continuous intravenous infusion of 0.1 units/kg/hour.

If blood glucose does not fall by 3.0 mmol/l within the first hour, the insulin dose can be doubled.

When blood glucose reaches 16.5mmol/l, reduce insulin to 0.02 - 0.05 units/kg/hour. Ensure blood glucose 11 - 16.5mmol/l until the patient is in love.

Compensate potassium

If renal function is normal (urine > 50ml/hour).

If serum potassium is <3.5mmol/l, use insulin and intravenous infusion of 20-30mmol kall/hour until the serum potassium level is >3.5mmol/l.

If the initial potassium concentration is between 3.5 - 5.3mmol/l, add 20 - 30mmol/l of intravenous fluid to ensure that the serum potassium concentration is maintained between 4-5mmol/l.

If baseline potassium is > 5.3mmol/l, without potassium replacement, check serum potassium every 2 hours.

When the patient is stable and able to eat, switch to subcutaneous insulin. Continue IV insulin infusion 1-2 hours after subcutaneous insulin injection to ensure adequate blood insulin levels.

Treat the cause of the decompensation

Give antibiotics if there is evidence of infection.

Use anticoagulants to prevent thrombosis.

Prevention

Patients with diabetes must be closely and systematically monitored for disease progression, changes in consciousness, and blood sugar monitoring. Guide a reasonable diet, use insulin exactly as prescribed by the doctor.

Examination, detection, and treatment of comorbidities such as infections, cardiovascular diseases.