Hyperosmolar coma: causes, symptoms, diagnosis, treatment

Hyperosmolar coma is most often diagnosed inpatients older than 50 years who suffer from diabetes mild to moderate, easily compensated diet and special drugs. Develops against the background of the dehydration of the body as a result of taking diuretics, cerebrovascular and renal diseases. Mortality from hyperosmolar coma reaches a level of 30%.

Causes

Hyperosmolar coma, the causes of which are associated withglucose level, is a complication of diabetes mellitus and arises from a sharp increase in blood sugar (more than 55.5 mmol / l) in combination with hyperosmolarity and the lack of acetone in the blood.

The reasons for this phenomenon can be:

• severe dehydration due to severe vomiting, diarrhea, burns or prolonged treatment through the use of diuretics;
• insufficiency or complete absence of insulin, both endogenous and exogenous (the cause of this phenomenon may be the absence of insulin therapy or the wrong treatment regimen);
• increased need for insulin, which canarise as a result of gross violations of the diet, the introduction of concentrated glucose preparations, the development of an infectious disease (especially for pneumonia and infectious urinary tract infections), after surgery, trauma, taking medications that have the properties of insulin antagonists (in particular, glucocorticoids and preparations of sexual hormones).

Pathogenesis

Unfortunately, the mechanism for the development of thisThe pathological state is not fully understood. It is believed that the development of this complication affects kidney blockade of glucose release, as well as increased intake of this substance in the body and the production of its liver. In this case, the production of insulin is inhibited, as well as the blocking of the utilization of glucose by peripheral tissues. This all combines with the dehydration of the body.

In addition, it is considered that the presence in thethe human body endogenous (formed inside the body) insulin interferes with such processes as lipolysis (splitting of fats) and ketogenesis (the formation of sex cells). However, this insulin is not enough to suppress the amount of glucose that the liver produces. Therefore, the introduction of exogenous insulin is necessary.

With a sharp loss of liquid in large quantitiesdecreases BCC (the volume of circulating blood), which leads to a thickening of the blood and increased osmolarity. This is due to an increase in the concentration of glucose, potassium and sodium ions.

Symptoms

Develops a hyperosmolar coma, symptomswhich appear in advance, for several days or weeks. In this case, the patient has signs that are characteristic for decompensated diabetes mellitus (sugar level can not be regulated by drugs):

• polyuria (increased urine formation);
• increased thirst;
• increased dryness of the skin, mucous membranes;
• sharp weight loss;
• constant weakness;
• the consequence of dehydration is a general deterioration of well-being: a decrease in the tone of the skin, eyeballs, arterial pressure, and temperature.

Neurological symptoms

In addition, symptoms can also be observed from the nervous system:

• hallucinations;
• hemiparesis (weakening of voluntary movements);
• speech disturbance, it is made vague;
• persistent convulsions;
• areflexia (absence of reflexes, one or more) or hyperlefics (increased reflexes);
• muscle tension;
• impaired consciousness.

Symptoms appear several days before hyperosmolar coma develops in children or adult patients.

Possible complications

With untimely care, complications may develop. Frequent are:

• epileptic seizures, which can be accompanied by twitching of eyelids, faces (these manifestations may not be noticeable to others);
• deep vein thrombosis;
• pancreatitis (inflammation of the pancreas);
• renal insufficiency.

Changes occur in the gastrointestinaltract, which are manifested by vomiting, swelling, abdominal pain, impaired intestinal peristalsis (sometimes there is an intestinal obstruction), but they can be practically invisible.

There are also vestibular disorders.

Diagnostics

If there is a suspicion of a diagnosis of hyperosmolarcoma, diagnosis is based on laboratory tests. In particular, in the study of blood, a high level of glycemia and osmolarity is detected. In addition, there may be an elevated sodium level, a high total whey protein content and residual nitrogen. The level of urea can also be elevated. In the study of urine ketone bodies (acetone, acetoacetic acid and beta-butoxybutyric acid) are not determined.

In addition, there is no smell of acetone inexhaled air and ketoacidosis (violation of carbohydrate metabolism), which are sharply expressed by hyperglycemia and osmolarity of the blood. The patient has neurological symptoms, in particular, the pathological symptom of Babinsky (stop extensor reflex), increased muscle tone, bilateral nystagmus (involuntary oscillatory movements of the eyes).

Other surveys include:

• ultrasound and radiographic examination of the pancreas;
• electrocardiography;
• determination of blood glucose level.

The differentialdiagnostics. This is due to the fact that hypersmolar coma can be the result not only of diabetes, but also liver-kidney failure, provided that thiazide diuretics are taken.

Treatment

If a hyperosmolar coma is diagnosed, emergency care consists in eliminating dehydration, hypovolemia and restoration of plasma osmolarity.

To combat the hydration of the body usedhypotonic sodium chloride solution. Introduced from 6 to 10 liters per day. If necessary, the amount of solution increases. Within two hours after the onset of a pathological condition, it is required to administer 2 liters of sodium chloride solution intravenously, after which the injection is carried out by a drop route at a rate of 1 l / h. These measures are taken up to the normalization of blood osmolarity and pressure in the venous vessels. An indication of elimination of dehydration is the appearance of the patient's consciousness.

If a hyperosmolar coma is diagnosed,treatment requires reducing hyperglycemia. For this purpose, intramuscularly and intravenously, insulin is administered. At the same time, strict control of blood sugar concentration is required. The first dose is 50 units, which is divided in half and injected 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 a drip method intravenously and intramuscularly. These measures are carried out until the level of glycemia reaches 14 mmol / l.

The scheme of insulin administration may be different:

• once 20 units intramuscularly;
• 5-8 units every 60 minutes.

In the event that the sugar level has decreased to the level of 13.88 mmol / l, hypotonic sodium chloride solution must be replaced with glucose solution.

During the treatment of hyperosmolar coma, a constant control of the amount of potassium blood is necessary, since the introduction of potassium chloride is required to remove from the pathological condition.

In order to prevent cerebral edema as a resulthypoxia patients intravenously injected glutamic acid solution in an amount of 50 ml. It also requires the use of heparin, since the risk of developing thrombosis increases dramatically. At the same time, blood clotting control is required.

As a rule, hyperosmolar coma develops inpatients with mild or moderate diabetes, so you can safely say that the body is good at taking insulin. Therefore, it is recommended to enter precisely small doses of the drug.

Prevention of complications

In the prevention of cardiovascular andsystem, namely, prevention of cardiovascular failure. With this goal, "Cordiamin", "Strofantin", "Korglikon" are used. At a reduced pressure, which is at a constant level, it is recommended to administer Doxa solution, as well as intravenous injection of plasma, hemodez, human albumin and whole blood.

Be on the alert ...

If you have a diagnosis of diabetes,it is necessary to constantly undergo examinations at the endocrinologist and carry out all his prescriptions, in particular, to control the blood sugar level. This will avoid complications of the disease.