Diabetic coma
The content of the article:
- Causes and risk factors
- Disease types
- Symptoms
- Features of the course of diabetic coma in children
- Diagnostics
- Treatment
- Possible complications and consequences
- Forecast
- Prevention
Diabetic coma is a dangerous and serious condition caused by relative or absolute insufficiency of insulin and characterized by serious metabolic disorders. Unlike hypoglycemic coma, diabetic coma develops gradually and can last for a very long time. The medical literature describes a case when the patient was in a coma for over 40 years.
Diabetic coma is a dangerous and serious complication of diabetes
Causes and risk factors
The main reason for the development of diabetic coma is insulin deficiency in the body of patients with diabetes mellitus. This leads not only to an increase in the concentration of glucose in the blood, but also to energy deficiency of peripheral tissues, which are unable to assimilate glucose without insulin.
Increasing hyperglycemia leads to increased osmotic pressure in the extracellular fluid and intracellular dehydration. As a result, the osmolarity of the blood increases, the severity of hypoglycemia increases, which causes the development of a state of shock.
Insufficiency of insulin promotes the mobilization of fatty acids from adipose tissue, which causes the formation of ketone bodies (beta-hydroxybutyric acid, acetoacetate, acetone) in the liver cells. Excessive production of acidic ketone bodies leads to a decrease in the concentration of bicarbonate and, accordingly, in the pH level of the blood, that is, metabolic acidosis is formed.
The main cause of a diabetic coma is a lack of insulin in the body.
With a rapid increase in hyperglycemia, a rapid increase in the level of blood osmolarity also occurs, which entails a violation of the excretory (excretory) function of the kidneys. As a result, patients develop hypernatremia, further increasing hyperosmolarity. Moreover, the level of bicarbonates and pH remain within the normal range, since there is no ketoacidosis.
As a result of insulin deficiency in diabetes mellitus, the activity of pyruvate dehydrogenase, the enzyme responsible for the conversion of pyruvic acid into acetyl coenzyme A, decreases. This causes the accumulation of pyruvate and its transition to lactate. A significant accumulation of lactic acid in the body leads to acidosis, which blocks the adrenergic receptors of the heart and blood vessels, reduces the contractile function of the myocardium. As a result, severe dysmetabolic and cardiogenic shock develops.
The following factors can lead to diabetic coma:
- gross errors in the diet (inclusion in the diet of a significant amount of carbohydrates, especially easily digestible ones);
- violations of the scheme of insulin therapy or taking sugar-reducing drugs;
- inadequately selected insulin therapy;
- severe nervous shock;
- infectious diseases;
- surgical interventions;
- pregnancy and childbirth.
Disease types
Depending on the characteristics of metabolic disorders, the following types of diabetic coma are distinguished:
- Ketoacidotic coma is caused by poisoning of the body and, first of all, the central nervous system with ketone bodies, as well as increasing disturbances in water-electrolyte balance and acid-base balance.
- Hyperosmolar hyperglycemic non-ketone coma is a complication of type II diabetes mellitus, characterized by pronounced intracellular dehydration and the absence of ketoacidosis.
- Hyperlacticidemic coma. Diabetes mellitus itself rarely leads to the accumulation of lactic acid in the patient's body - as a rule, an overdose of biguanides (hypoglycemic drugs) becomes the cause of lactic acidosis.
Symptoms
Each type of diabetic coma is characterized by a specific clinical picture. The main symptoms of hyperosmolar hyperglycemic non-ketogenic coma are:
- polyuria;
- severe dehydration;
- increased muscle tone;
- convulsions;
- increasing drowsiness;
- hallucinations;
- impaired speech function.
A ketoacidotic coma develops slowly. It begins with a precoma, manifested by pronounced general weakness, severe thirst, nausea, and frequent urination. If at this stage the necessary assistance is not provided, the condition worsens, the following symptoms occur:
- indomitable vomiting;
- severe abdominal pain;
- deep noisy breathing;
- the smell of rotten apples or acetone from the mouth;
- lethargy up to complete loss of consciousness.
Intense thirst is one of the signs of an approaching ketoacidotic coma
Hyperlactatacidemic coma develops rapidly. Her signs:
- rapidly growing weakness;
- threadlike pulse (frequent, weak filling);
- drop in blood pressure;
- pronounced pallor of the skin;
- nausea, vomiting;
- disturbances of consciousness up to its complete loss.
Features of the course of diabetic coma in children
Diabetic coma is most often observed among children of older preschool and school age with diabetes mellitus. Its development is preceded by a pathological condition called precoma. It manifests itself clinically:
- anxiety followed by drowsiness;
- headache;
- cramping abdominal pain;
- nausea, vomiting;
- decreased appetite;
- polyuria;
- a strong feeling of thirst.
As metabolic disorders increase, blood pressure decreases, and the pulse rate increases. Breathing becomes deep and noisy. The skin loses its elasticity. In severe cases, consciousness is completely lost.
In children, the development of diabetic coma is preceded by a decrease in blood pressure and an increase in heart rate
In infants, diabetic coma develops very quickly, bypassing the state of precoma. Her first symptoms:
- constipation;
- polyuria;
- polyphagia (the child greedily takes the breast and sucks it, taking frequent sips);
- increased thirst.
Soaked diapers become hard when dry, which is associated with a high glucose content in the urine (glucosuria).
Diagnostics
The clinical picture of a diabetic coma is not always clear. Laboratory research is of decisive importance in its diagnosis, which determines:
- glycemic level;
- the presence of ketone bodies in blood plasma;
- arterial blood pH;
- the concentration of electrolytes in plasma, primarily sodium and potassium;
- plasma osmolarity value;
- fatty acid levels;
- the presence or absence of acetone in the urine;
- the concentration of lactic acid in the blood serum.
Treatment
Patients with diabetic coma are treated in the intensive care unit. The therapy regimen for each type of coma has its own characteristics. So, with ketoacidotic coma, insulin therapy, correction of water-electrolyte and acid-base disorders are carried out.
Therapy for hyperosmolar hyperglycemic non-ketogenic coma includes:
- intravenous administration of a significant volume of hypotonic sodium chloride solution for the purpose of hydration;
- insulin therapy;
- intravenous administration of potassium chloride under the control of ECG and blood electrolytes;
- prevention of cerebral edema (intravenous administration of glutamic acid, oxygen therapy).
Intravenous sodium bicarbonate in hyperlactacidemic coma helps fight excess lactic acid
Treatment of hyperlactacidemic coma begins with the fight against excess lactic acid, for which a solution of sodium bicarbonate is injected intravenously. The required amount of solution, as well as the rate of administration, are calculated using special formulas. Bicarbonate is injected necessarily under the control of potassium concentration and blood pH. In order to reduce the severity of hypoxia, oxygen therapy is performed. Insulin therapy is indicated for all patients with lactacidemic coma - even with normal blood glucose levels.
Possible complications and consequences
Diabetic coma is a serious pathology that can lead to life-threatening complications:
- hypo- or hyperkalemia;
- aspiration pneumonia;
- respiratory distress syndrome;
- swelling of the brain;
- pulmonary edema;
- thrombosis and thromboembolism, including thromboembolism of the pulmonary artery.
Forecast
The prognosis for diabetic coma is serious. The mortality rate in ketoacidotic coma even in specialized centers reaches 10%. In hyperosmolar hyperglycemic non-ketogenic coma, the mortality rate is about 60%. The highest mortality is observed in hyperlactacidemic coma - up to 80%.
Prevention
Prevention of diabetic coma is aimed at maximizing compensation for diabetes mellitus:
- adherence to a diet with restriction of carbohydrates;
- regular moderate physical activity;
- prevention of spontaneous changes in the scheme of insulin administration or taking hypoglycemic drugs prescribed by an endocrinologist;
- timely treatment of infectious diseases;
- correction of insulin therapy in the preoperative period, in pregnant women, postpartum women.
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Elena Minkina Doctor anesthesiologist-resuscitator About the author
Education: graduated from the Tashkent State Medical Institute, specializing in general medicine in 1991. Repeatedly passed refresher courses.
Work experience: anesthesiologist-resuscitator of the city maternity complex, resuscitator of the hemodialysis department.
The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!
