Hyperosmolar coma. Hyperosmolar coma in diabetes mellitus: emergency care, causes and treatment Hyperosmolar coma emergency care algorithm

Diabetes is a disease of the 21st century. All more people find out if they have it terrible disease. However, a person can live well with this disease, the main thing is to follow all the prescriptions of doctors.

Unfortunately, in severe cases, diabetes a person may develop a hyperosmolar coma.

What's this?

Hyperosmolar coma is a complication of diabetes mellitus, in which there is a serious metabolic disorder. This condition is characterized by the following:

• hyperglycemia - a sharp and strong increase in blood glucose levels;
• hypernatremia - an increase in the level of sodium in the blood plasma;
• hyperosmolarity - an increase in the osmolarity of blood plasma, i.e. the sum of the concentrations of all active particles per 1 liter. blood greatly exceeds normal value(from 330 to 500 mosmol/l at a rate of 280-300 mosmol/l);
• dehydration - dehydration of cells, which occurs as a result of the fact that fluid tends to the intercellular space to reduce the level of sodium and glucose. It occurs throughout the body, even in the brain;
• the absence of ketoacidosis - the acidity of the blood does not increase.

Hyperosmolar coma most often occurs in people over 50 years of age and accounts for approximately 10% of all types of coma in diabetes mellitus. If you do not provide emergency care to a person in such a state, then this can lead to death.

The reasons

There are a number of reasons that can lead to this species coma. Here is some of them:

• Dehydration of the patient's body. This can be vomiting, diarrhea, decreased fluid intake, long-term use of diuretics. Burns of a large surface of the body, disturbances in the functioning of the kidneys;
• Lack or at all lack of adequate insulin;
• Unrecognized diabetes. Sometimes a person does not even suspect the presence of this disease in himself, so he is not treated and does not follow a certain diet. As a result, the body cannot cope and coma may occur;
• Increased need for insulin, for example, when a person violates the diet by eating foods containing a large amount of carbohydrates. Also, this need may arise when colds, diseases of the genitourinary system of an infectious nature, with prolonged use of glucocorticosteroids or medicines replaceable sex hormones;
• Taking antidepressants;
• Diseases arising as complications after the underlying disease;
• Surgical interventions;
• Acute infectious diseases.

Symptoms

Hyperosmolar coma, like any disease, has its own signs by which it can be recognized. In addition, this condition develops gradually. Therefore, some symptoms predict the occurrence of hyperosmolar coma in advance. The signs are the following:

• A few days before the coma, a person has a sharp thirst, constant dryness in the mouth;
• The skin becomes dry. The same applies to the mucous membranes;
• The tone of soft tissues decreases;
• A person constantly has weakness, lethargy. Constantly want to sleep, which leads to a coma;
• The pressure drops sharply, tachycardia may occur;
• The development of polyuria increased urine production;
• There may be speech problems, hallucinations;
• May rise muscle tone, convulsions or paralysis occur, but the tone eyeballs, on the contrary, may fall;
• Very rarely, epileptic seizures can occur.

Diagnostics

In blood tests, a specialist determines elevated levels of glucose and osmolarity. In this case, ketone bodies are absent.

The diagnosis is also based on visible symptoms. In addition, the age of the patient and the course of his disease are taken into account.

For this the patient must take tests to determine glucose, sodium and potassium in the blood. Urine is also given to determine the level of glucose in it. In addition, doctors may prescribe ultrasound and X-ray of the pancreas and its endocrine part and electrocardiography.

Treatment

Emergency care for hyperosmolar coma is, first of all, to eliminate dehydration of the body. Then it is necessary to restore the osmolarity of the blood and bring the glucose level back to normal.

A patient who develops a hyperosmolar coma urgently need to be transported to the intensive care unit or intensive care . After the diagnosis is made and treatment is started, the condition of such a patient is under constant control:

• Once an hour, an express blood test must be done;
• Twice a day, ketone bodies are determined in the blood;
• Several times a day, an analysis is made to determine the level of potassium and sodium;
• A couple of times a day check the acid-base state;
• The amount of urine that is formed in a certain time is constantly monitored until dehydration is eliminated;
• ECG monitoring and blood pressure;
• Every two days is general analysis urine and blood;
• They can take x-rays of the lungs.

Sodium chloride is used for rehydration. It is administered intravenously using a dropper in certain amounts. The concentration is selected depending on how much sodium is contained in the blood. If the level is high enough, then a glucose solution is used.

In addition, a dextrose solution is used, which is also imported intravenously.

In addition, a patient in a state of hyperosmolar coma is given insulin therapy. Short-acting insulin is used, which is administered intravenously.

Emergency First Aid

But what about a person if his loved one has a hyperosmolar coma completely unexpectedly (this happens when a person does not pay attention to the symptoms).

You need to act as follows:

• Be sure to ask someone to call a doctor;
• The patient should be well covered or overlaid with heating pads. This is done in order to reduce heat loss;
• It is necessary to control body temperature, the state of breathing;
• It is necessary to check the condition of the eyeballs, skin tone;
• Control glucose levels;
• If you have experience then you can put a dropper with saline solution. 60 drops should pass per minute. The volume of the solution is 500 ml.

Complications

Hyperosmolar coma often occurs in people over 50 years of age. Therefore, some complications can sometimes arise. For example:

• With rapid rehydration and a decrease in glucose cerebral edema may occur;
• Due to the fact that this condition often occurs in older people, the development of heart problems and the occurrence of pulmonary edema are likely;
• If the glucose level drops very quickly, then a sharp drop in blood pressure is possible;
• The use of potassium can lead to its high content in the body, which can be a threat to human life.

Forecast

Hyperosmolar coma is considered a serious complication of diabetes mellitus. Death occurs in about 50% of cases of this condition. After all, most often it appears at an age when, in addition to diabetes, a person can have many other diseases. And they can be the cause of a difficult recovery.

With timely assistance, the prognosis is favorable, the most important thing is that after leaving this state, the patient should follow all the doctor's instructions and adhere to healthy eating and lifestyle in general. And his close people need to know the rules of emergency care in order to provide it in time if necessary.

Diabetes mellitus is a disease with dangerous complications.

Etiology and pathogenesis

The etiology of hyperosmolar coma is associated with a person's lifestyle. It is observed mainly in people with and more often in the elderly, in children - in the absence of parental control. The main factor causing it is a sharp increase in blood sugar in the presence of hyperosmolarity and the absence of acetone in the blood.

The reasons for this condition can be:

• large losses of fluid by the body as a result of prolonged use of diuretics, diarrhea or vomiting, with burns;
• insufficient amount of insulin as a result of a violation or failure to comply with it;
• high need for insulin, it can be provoked malnutrition, infectious disease, injury, taking certain medications, or administering glucose concentrates.

The pathogenesis of the process is not completely clear. It is known that it greatly increases, and the production of insulin, on the contrary, falls. At the same time, the utilization of glucose in the tissues is blocked, and the kidneys stop processing it and excreting it in the urine.

If at the same time there is a large loss of fluid by the body, then the volume of circulating blood decreases, it becomes thicker and osmolar due to an increase in the concentration of glucose, as well as sodium and potassium ions.

Symptoms of hyperosmolar coma

Hyperosmolar coma is a gradual process that develops over several weeks.

Its symptoms gradually increase and appear in the form of:

• increased urine production;
• increased thirst;
• strong weight loss in a short time;
• constant weakness;
• high dryness of the skin and mucous membranes;
• general deterioration in well-being.

The general deterioration is expressed in the unwillingness to move, a drop in blood pressure and temperature, and a decrease in skin tone.

At the same time, there are neurological signs, manifested in:

• weakening or excessive strengthening of reflexes;
• hallucinations;
• speech disorders;
• the appearance of seizures;
• impaired consciousness;
• violation of voluntary movements.

In the absence of adequate measures, stupor and coma can occur, which in 30 percent of cases lead to death.

In addition, as complications are observed:

• epileptic seizures;
• inflammation ;
• deep vein thrombosis;
• kidney failure.

Diagnostic measures

Diagnosis is necessary for the correct diagnosis and treatment of hyperosmolar coma in diabetes mellitus. It includes two main groups of methods: history taking with examination of the patient and laboratory tests.

Examination of the patient includes an assessment of his condition according to the above symptoms. One of important points is the smell of acetone in the air exhaled by the patient. In addition, well-visible neurological symptoms.

For laboratory research blood is used, in which glucose concentration, osmolarity, and sodium concentration are evaluated. The glucose content is also studied in the urine, both biomaterials are evaluated for the presence of acidosis and.

Other indicators that could provoke a similar condition of the patient are also evaluated:

• hemoglobin and hematocrit levels;
• the level of leukocytes;
• the concentration of urea nitrogen in the blood.

If there are doubts or it is necessary to detect complications, other methods of examination may be prescribed:

• Ultrasound and X-ray of the pancreas;
• electrocardiogram and others.

Video about the diagnosis of coma in diabetes:

Treatment of pathology

Therapeutic measures can be divided into two levels: the provision of emergency care and further treatment in order to restore the state of the body.

Urgent care

With a hyperosmolar coma, the situation of a person is difficult and it worsens every minute, so it is important to properly provide him with first aid and get him out of this state. Only a resuscitation specialist can provide such assistance, where the patient must be delivered as soon as possible.

While the ambulance is on the way, the person should be laid on their side and covered with something to reduce heat loss. At the same time, it is necessary to monitor his breathing, and, if necessary, give artificial respiration or indirect massage hearts.

You can also measure the level of sugar in the blood with the help, and only if it is elevated (!) Inject insulin under the skin.

After entering the hospital, the patient is given rapid tests for an accurate diagnosis, after which drugs are prescribed to remove the patient from a serious condition. He is assigned intravenous administration liquid, usually a hypotonic solution, which is then replaced with an isotonic one. At the same time, electrolytes are added to correct the water-electrolyte metabolism, and a glucose solution is added to maintain its normal level.

At the same time, constant monitoring of indicators is established: the level of glucose, potassium and sodium in the blood, temperature, pressure and pulse, the level of ketone bodies and blood acidity.

The outflow of urine is necessarily controlled in order to avoid edema, which can lead to serious consequences, often a catheter is installed for this.

Further actions

In parallel with the restoration of water balance, the patient is prescribed insulin therapy, which involves intravenous or intramuscular injection hormone.

Initially, 50 units are administered, which are divided in half, introducing one part intravenously, and the second through the muscles. If the patient has hypotension, then insulin is administered only through the blood. Then the drip administration of the hormone continues until the level of glycemia reaches 14 mmol / l.

At the same time, the level of sugar in the blood is constantly monitored, and if it drops to 13.88 mmol / l, glucose is added to the solution.

A large amount of fluid entering the body can provoke cerebral edema in a patient; to prevent it, a solution of glutamic acid is administered intravenously to the patient, in a volume of 50 milliliters. To prevent thrombosis, heparin is prescribed and monitoring of blood coagulation parameters.

Video lecture:

Forecasts and prevention measures

The prognosis of the disease largely depends on the timeliness of assistance. The earlier it was provided, the less violations and complications had on other organs. The consequence of coma is a violation of the activity of organs that had previously had certain pathologies. First of all, the liver, pancreas, kidneys and blood vessels suffer.

With timely therapy, the disturbances are minimal, the patient regains consciousness within a few days, the sugar level normalizes, and the symptoms of coma disappear. He continues ordinary life without feeling the effects of a coma.

Neurological symptoms can last for several weeks or even months. With a severe lesion, it may not go away, and the patient remains paralyzed or speech impaired. Late care is fraught with serious complications up to the death of the patient, especially for those who have other pathologies.

Prevention of the condition is simple, but requires constant monitoring. It is about disease control. internal organs, especially of cardio-vascular system, kidneys and liver, since they are most actively involved in the development of this condition.

Sometimes hyperosmolar coma occurs in people who do not know they have diabetes. In this case, it is important to pay attention to the symptoms, especially constant thirst especially if there are relatives with diabetes in the family.

• constantly monitor blood glucose levels;
• adhere to the prescribed diet;
• do not violate the diet;
• do not change the dosage of insulin or other drugs on your own;
• do not take uncontrolled drugs;
• observe a dosed physical activity;
• control the state of the body.

All these are quite affordable processes that you just need to remember. After all, diabetes occurs due to improper lifestyle and because of it also leads to serious consequences.

The development of hyperosmolar coma in diabetes mellitus most often occurs in older people with a non-insulin-dependent type of disease. In the vast majority of cases, coma occurs against the background of kidney failure.

Pathologies of the kidneys and cerebral vessels, as well as the use of such groups of drugs as steroids and diuretics, can become additional provoking factors. Prolonged lack of treatment for hyperosmolar coma can cause death.

Reasons for development

The main factors provoking the development of this type of diabetic coma is a violation of the water and electrolyte balance (dehydration) of the body with the simultaneous occurrence of insulin deficiency. As a result, the patient's blood glucose level rises.

Dehydration of the body can provoke vomiting, diarrhea, taking diuretics, large blood loss and severe burns. In addition, insulin deficiency in diabetic patients often occurs for the following reasons:

• obesity;
• pathology of the pancreas (pancreatitis, cholecystitis);
• any surgical intervention;
• serious errors in nutrition;
• infectious processes localized in the urinary system;
• sharp hit a large number glucose into the blood when administered intravenously;
• pathology of the cardiovascular system (stroke, heart attack).

Studies have shown that pyelonephritis and impaired urinary outflow have a direct impact on both the development of hyperosmolar coma and its course. In some cases, a coma can form as a result of taking diuretics, immunosuppressants, with the introduction of saline and hypertonic solutions. And also during the procedure of hemodialysis.

Symptoms

Hyperosmolar coma usually develops gradually. First, the patient develops severe weakness, thirst and copious urination. Together, these manifestations of pathology contribute to the development of dehydration. Then there is dryness of the skin and a significant decrease in the tone of the eyeballs. In some cases, a strong weight loss is recorded.

Disturbance of consciousness also develops in 2-5 days. Begins with severe drowsiness and ends in a deep coma. A person's breathing becomes frequent and intermittent, but unlike ketoacidotic coma, there is no smell of acetone when exhaling. Disorders of the cardiovascular system are manifested in the form of tachycardia, rapid heart rate, arrhythmias and hypertension.

Gradually, abundant urination decreases, and over time it is completely replaced by anuria (urine stops flowing into the bladder).

From the side of the neurological system, the following disorders appear:

• incoherent speech;
• partial or complete paralysis;
• epileptic-like seizures;
• increased segmental reflexes or, conversely, their complete absence;
• the appearance of fever as a result of a failure of thermoregulation.

Dehydration causes the blood to thicken, causing blood clots to form in the veins. This situation is dangerous for the development of blood clotting disorders due to excessive release of thromboplastic substances from the tissues. Often, the death of a patient in a hyperosmolar coma causes a small volume of circulating blood. Due to dehydration, the blood volume is so small that the blood supply to vital organs can stop.

Diagnostic methods

The main difficulty of diagnostic measures when a diabetic coma develops is that they should be carried out as soon as possible. Otherwise, the patient may experience irreversible consequences and, as a result, death. Especially dangerous is the development of a coma, accompanied by an excessive decrease in blood pressure and sinus tachycardia.

Measuring blood glucose is a quick way to diagnose diabetic coma

Without fail, when making a diagnosis, the doctor takes into account the following factors:

• no smell of acetone in the exhaled air;
• high blood hyperosmolarity;
• neurological disorders characteristic of hyperosmolar coma;
• violation of the outflow of urine or its complete absence;

At the same time, other disorders identified in the analyzes cannot speak of the development of such a diabetic coma, since they are inherent in many pathologies. For example, elevated level hemoglobin, sodium, chloride or leukocytes.

Therapeutic measures

Almost always, any therapeutic measures are primarily aimed at providing emergency care to the patient. It includes the normalization of water and electrolyte balance and plasma osmolarity. For this purpose, infusion procedures are carried out. The choice of solution directly depends on the detected amount of sodium in the blood. If the concentration of the substance is high enough, a 2% glucose solution is used. In cases where the amount of sodium is within the normal range, choose a 0.45% solution. During the procedure, fluid enters the vessels, and the level of glucose in the blood gradually decreases.

The infusion procedure is carried out according to a certain scheme. In the first hour, the patient is injected with 1 to 1.5 liters of solution. In the next 2 hours, its amount is reduced to 0.5 liters. The procedure is carried out until dehydration is completely eliminated, constantly monitoring the volume of urine and venous pressure.

Separately carry out activities aimed at reducing hyperglycemia. For this purpose, insulin is administered intravenously to the patient, no more than 2 units per hour. Otherwise, a sharp decrease in glucose in hyperosmolar coma can provoke cerebral edema. Subcutaneous insulin can be administered only in cases where the blood sugar level has reached 11-13 mmol / l.

The development of hyperosmolar coma requires urgent hospitalization of the patient

Complication and prognosis

One of frequent complications with such a diabetic coma is thrombosis. To prevent it, the patient is administered heparin. During the procedure, doctors carefully monitor the level of blood clotting. The introduction of a plasma-substituting albumin drug helps to minimize the risk of developing cardiovascular pathologies.

In cases of severe renal failure, hemodialysis is performed. If the coma provoked a purulent-inflammatory process, then the treatment is carried out with antibiotics.

The prognosis for hyperosmolar coma is disappointing. Even with timely medical care the statistics of lethal outcomes reaches 50%. The death of the patient can occur due to renal failure, increased thrombus formation or cerebral edema.

as such preventive measures does not exist in hyperosmolar coma. Patients with diabetes should measure their blood glucose levels in a timely manner. Also plays an important role proper nutrition and no bad habits.

Last update: April 18, 2018

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Hyperosmolar coma(GOK) is a rare acute complication of type 2 diabetes that develops as a result of severe dehydration and hyperglycemia in the absence of absolute insulin deficiency, accompanied by high mortality (Table 1).

Table 1

Hyperosmolar coma (GOC)

Etiology

GOK, as a rule, develops in elderly patients with type 2 diabetes. Such patients are most often lonely, live without care, neglect their condition and self-control, and do not take enough fluids. Infections often lead to decompensation (diabetic foot syndrome, pneumonia, acute pyelonephritis), violations cerebral circulation and other conditions that cause patients to move poorly, do not take hypoglycemic drugs and fluids.

Pathogenesis

Increasing hyperglycemia and osmotic diuresis cause severe dehydration, which, for the above reasons, is not replenished from the outside. The result of hyperglycemia and dehydration is plasma hyperosmolarity. An integral component of the pathogenesis of GOC is a relative deficiency of insulin and an excess of contra-insular hormones, however, the residual secretion of insulin remaining in DM-2 is sufficient to suppress lipolysis and ketogenesis, as a result of which the development of ketoacidosis does not occur.

In some cases, moderate acidosis can be determined as a result of hyperlactatemia against the background of tissue hypoperfusion. In severe hyperglycemia, to maintain the osmotic balance in the cerebrospinal fluid, the content of sodium from the brain cells, where potassium enters the exchange, increases. transmembrane potential is broken nerve cells. A progressive clouding of consciousness develops in combination with a convulsive syndrome (Fig. 1).

Rice. 1. Pathogenesis of hyperosmolar coma

Epidemiology

GOC accounts for 10-30% of acute hyperglycemic conditions in adult and elderly patients with type 2 diabetes. Approximately 2/3 of cases of GOK develop in individuals with previously undiagnosed diabetes.

Clinical manifestations

Features clinical picture hyperosmolar coma are:

• a complex of signs and complications of dehydration and hypoperfusion: thirst, dry mucous membranes, tachycardia, arterial hypotension, nausea, weakness, shock;
• focal and generalized seizures;
• fever, nausea and vomiting (40-65% of cases);
• of concomitant diseases and complications, deep vein thrombosis, pneumonia, cerebrovascular accidents, gastroparesis are common.

Diagnostics

It is based on the data of the clinical picture, the age of the patient and the anamnesis of CD-2, severe hyperglycemia in the absence of ketonuria and ketoacidosis.

Differential Diagnosis

Other acute conditions that develop in patients with DM, most often with concomitant pathology, which led to severe decompensation of DM.

Treatment

Treatment and monitoring in GOK, with the exception of some features, do not differ from those described for ketoacidotic diabetic coma:

• a larger volume of initial rehydration 1.5-2 liters in the 1st hour; 1 l - for the 2nd and 3rd hour, then 500 ml / h of isotonic sodium chloride solution;
• the need for the introduction of potassium-containing solutions, as a rule, is greater than with ketoacidotic coma;
• insulin therapy is similar to that for CC, but the need for insulin is less and the level of glycemia must be reduced no faster than 5 mmol / l per hour to avoid the development of cerebral edema; the introduction of a hypotonic solution (NaCl 0.45%) is best avoided (only with severe hypernatremia: > 155 mmol / l and / or effective osmolarity > 320 mOsm / l);
• there is no need to administer bicarbonate (only in specialized intensive care units for acidosis with pH< 7,1).

Forecast

Mortality in GOK is high and amounts to 15-60%. The worst prognosis is in elderly patients with severe comorbidity, which is often the cause of DM decompensation and the development of GOC.

Dedov I.I., Melnichenko G.A., Fadeev V.F.

One of the terrible and understudied complications of diabetes mellitus is hyperosmolar coma. There are still disputes about the mechanism of its origin and development.

The disease is not acute, the condition of a diabetic may worsen for two weeks before the first impairment of consciousness. Most often, coma occurs in people over 50 years of age. Doctors are not always able to immediately make a correct diagnosis in the absence of information that the patient has diabetes.

Due to late admission to the hospital, diagnostic difficulties, severe deterioration of the body, hyperosmolar coma has a high mortality rate - up to 50%.

What is a hyperosmolar coma

Hyperosmolar coma is a condition with loss of consciousness and disturbance in all systems: reflexes, cardiac activity and thermoregulation fade, urine stops being excreted. A person at this time literally balances on the border of life and death. The reason for all these disorders is the hyperosmolarity of the blood, that is, a strong increase in its density (more than 330 mosmol / l at a rate of 275-295).

This type of coma is characterized by high blood glucose, above 33.3 mmol/l, and severe dehydration. at the same time, it is absent - ketone bodies are not detected in the urine by tests, the breath of a diabetic patient does not smell of acetone.

Hyperosmolar coma international classification refer to violations of water-salt metabolism, ICD-10 code - E87.0.

The hyperosmolar state leads to coma quite rarely, in medical practice there is 1 case per 3300 patients per year. According to statistics average age The patient is 54 years old, he has non-insulin-dependent type 2 diabetes, but does not control his disease, therefore he has a number of complications, including kidney failure. In a third of patients in a coma, diabetes is long-term, but was not diagnosed and, accordingly, was not treated all this time.

Compared with ketoacidotic coma, hyperosmolar coma occurs 10 times less frequently. Most often, its manifestations are still on mild stage diabetics themselves stop without even noticing it - they normalize blood glucose, start drinking more, turn to a nephrologist because of problems with the kidneys.

Reasons for development

Hyperosmolar coma develops in diabetes mellitus under the influence of the following factors:

1. Severe dehydration due to extensive burns, overdose or long-term use of diuretics, poisoning, and intestinal infections accompanied by vomiting and diarrhea.
2. Lack of insulin due to poor diet, frequent skipping of glucose-lowering medications, severe infections, or physical activity, treatment hormonal means inhibiting the production of their own insulin.
3. undiagnosed diabetes.
4. Long-term infection of the kidneys without proper treatment.
5. Hemodialysis, or intravenous glucose, when doctors are unaware of the patient's diabetes.

Pathogenesis

The onset of a hyperosmolar coma is always accompanied by a pronounced one. Glucose enters the blood from food and is simultaneously produced by the liver, its entry into tissues is complicated due to. Ketoacidosis does not occur, and the reason for this absence has not yet been precisely established. Some researchers believe that the hyperosmolar type of coma develops when there is enough insulin to prevent the breakdown of fats and the formation of ketone bodies, but too little to suppress the breakdown of glycogen in the liver with the formation of glucose. According to another version, the exit fatty acids from adipose tissue is suppressed due to a lack of hormones at the beginning of hyperosmolar disorders - somatropin, cortisol and glucagon.

Further pathological changes resulting in hyperosmolar coma are well known. With the progression of hyperglycemia, the volume of urine increases. If the kidneys are working normally, then when the limit of 10 mmol / l is exceeded, glucose begins to be excreted in the urine. With impaired kidney function, this process does not always occur, then sugar accumulates in the blood, and the amount of urine increases due to a violation of reabsorption in the kidneys, dehydration begins. Fluid comes out of the cells and the space between them, the volume of circulating blood decreases.

Due to dehydration of brain cells, neurological symptoms occur; increased blood clotting provokes thrombosis, leads to insufficient blood supply to organs. In response to dehydration, the production of the hormone aldosterone increases, which prevents sodium from the blood from getting into the urine, hypernatremia develops. It, in turn, provokes hemorrhages and swelling in the brain - a coma occurs.

In the absence of resuscitation measures to eliminate the hyperosmolar state, a lethal outcome is inevitable.

Signs and symptoms

The development of hyperosmolar coma takes one to two weeks. The onset of changes is associated with a deterioration in diabetes compensation, then signs of dehydration join. Last of all, neurological symptoms and consequences of high blood osmolarity occur.

Due to the fact that the functions of all organs are impaired in hyperosmolar coma, this condition can be masked by a heart attack or signs similar to the development of a severe infection. Complex encephalopathy may be suspected due to cerebral edema. In order to quickly make the correct diagnosis, the doctor must know about the patient's history of diabetes or identify it in time according to the analysis.

Necessary diagnostics

Diagnosis is based on symptoms given laboratory diagnostics and the presence of diabetes. Although this condition is more common in older people with type 2 disease, hyperosmolar coma can develop in type 1 regardless of age.

Usually, a comprehensive examination of blood and urine is needed to make a diagnosis:

To find out how much the heart has suffered, and whether it is able to endure resuscitation, an ECG is done.

Emergency Algorithm

If a diabetic patient has lost consciousness or is in an inadequate condition, the first thing to do is call an ambulance. Emergency care for hyperosmolar coma can be provided only in the intensive care unit. The faster the patient is brought there, the higher his chance of survival, the less damage to the organs, and the faster he will be able to recover.

While waiting for an ambulance:

1. Lay the patient on his side.
2. Wrap it up if possible to reduce heat loss.
3. Monitor breathing and heartbeat, if necessary, start artificial respiration and chest compressions.
4. Measure blood sugar. In case of a strong excess of the norm, make an injection. You cannot administer insulin if there is no glucometer and glucose data is not available, this action can provoke the death of the patient if he has hypoglycemia.
5. If there is an opportunity and skills, put a dropper with saline. The rate of administration is a drop per second.

When a diabetic enters the intensive care unit, he is given express tests to establish a diagnosis, if necessary, he is connected to a ventilator, urine outflow is restored, and a catheter is placed in a vein for long-term administration of drugs.

The patient's condition is constantly monitored:

• glucose is measured hourly;
• every 6 hours - potassium and sodium levels;
• to prevent ketoacidosis, ketone bodies and blood acidity are controlled;
• the amount of urine excreted is counted for the entire time when droppers are installed;
• often check pulse, pressure and temperature.

The main directions of treatment are the restoration of the water-salt balance, the elimination of hyperglycemia, the treatment of concomitant diseases and disorders.

Correction of dehydration and replenishment of electrolytes

To restore fluid in the body, volumetric intravenous infusions are carried out - up to 10 liters per day, the first hour - up to 1.5 liters, then the volume of the solution administered per hour is gradually reduced to 0.3-0.5 liters.

Choose a drug depending on the sodium indicators obtained in the course of laboratory tests:

When dehydration is corrected, in addition to restoring water reserves in the cells, the volume of blood also increases, while the hyperosmolar state is eliminated and the level of sugar in the blood decreases. Rehydration is carried out with the obligatory control of glucose, since its sharp decrease can lead to a rapid drop in pressure or cerebral edema.

When urine appears, the replenishment of potassium reserves in the body begins. Usually it is potassium chloride, in the absence of renal failure - phosphate. The concentration and volume of administration is selected based on the results of frequent blood tests for potassium.

Fighting hyperglycemia

Blood glucose is corrected with the help of short-acting insulin, in minimal doses, ideally with continuous infusion. With very high hyperglycemia, an intravenous injection of the hormone is preliminarily made in an amount of up to 20 units.

With severe dehydration, insulin may not be used until the water balance is restored, glucose at this time and so rapidly decreases. If diabetes and hyperosmolar coma are complicated by comorbidities, more insulin may be needed.

The introduction of insulin at this stage of treatment does not mean that the patient will have to switch to his lifelong intake. Most often, after stabilization of the condition, type 2 diabetes can be compensated by dieting () and taking hypoglycemic agents.

Treatment of comorbid disorders

Simultaneously with the restoration of osmolarity, correction of already existing or suspected violations is carried out:

1. Hypercoagulation is eliminated and thrombosis is prevented by the introduction of heparin.
2. If renal failure worsens, hemodialysis is performed.
3. If hyperosmolar coma is provoked by infections of the kidneys or other organs, antibiotics are prescribed.
4. Glucocorticoids are used as antishock therapy.
5. At the end of treatment, vitamins and microelements are prescribed to replenish their losses.

What to expect - forecast

The prognosis of hyperosmolar coma largely depends on the time of initiation of medical care. At timely treatment disturbances of consciousness can be prevented or restored in time. Due to delayed therapy, 10% of patients with this type of coma die. The cause of the remaining deaths is considered to be old age, long-term uncompensated diabetes, a “bouquet” of diseases accumulated during this time - heart and kidney failure,.

Death in hyperosmolar coma occurs most often due to hypovolemia - a decrease in blood volume. In the body, it causes insufficiency of internal organs, primarily organs with already existing pathological changes. Cerebral edema and massive thrombosis not detected in time can also end fatally.

If the therapy turned out to be timely and effective, the patient with diabetes regains consciousness, the symptoms of coma disappear, glucose and blood osmolarity normalize. Neurological pathologies when leaving a coma can last from a couple of days to several months. Sometimes full recovery of functions does not occur, paralysis, speech problems, and mental disorders may persist.