Diabetic (hyper glycemic) coma

Description:

Hyper glycemic (diabetic) coma - rather slowly developing state connected with increase in level of glucose in blood at a diabetes mellitus and accumulation of toxic transmutation products.

Reasons of a diabetic (hyper glycemic) coma:

Carry to the reasons of development of a hyper glycemic coma:

А). Inadequate treatment of a diabetes mellitus.

- insulin underdosage.
- uses of the delayed or frozen insulin.
- not observance of a diet.
Б). Injuries and other states causing increase in level of glucose in blood.

- the diseases (for example, a pancreatonecrosis) a pancreas leading to decrease in products of insulin.
- a serious inflammatory illness and injuries, especially at the persons suffering from a diabetes mellitus. The matter is that at data sostoyany insulin "consumption" is raised.

Pathogeny:

The key moment in development of a hyper glycemic coma is increase in level of glucose of a blood plasma and change of cellular metabolism. At the same time, if there is a sufficient synthesis of insulin cells of pozheludochny gland, then these changes can occur only when excessive concentration of glucose in blood, against the background of lack of its filtering by kidneys in blood is noted. The matter is that increase in level of glucose higher than 10 ¼¿½½¿¼«½ý/litre, leads to the fact that it gets into urine. As a result of it, amount of urine to become more. Respectively the amount of the removed sugar kidneys increases. It is a peculiar mechanism of decrease in a hyperglycemia - the increased glucose level in blood. Of course, it is not deprived of the side effects, such as, gradual destruction of a wall of tubules. But as, the mechanism of disposal of a short-term hyperglycemia, very much is even necessary.
Therefore, development of a hyper glycemic coma is possible only at a diabetes mellitus and similar sostoyany which are combined with some diseases of kidneys.
Now we will continue the mechanism of development of a coma.

The hyperglycemia, against the background of a lack of insulin, leads to the fact that despite excess of glucose in blood, cells lack for energy. Their metabolism, trying to prevent it, passes a way of energy production to bezglyukozna. As a result, proteins and fats begin to turn into glucose. And it leads to accumulation of a significant amount of products of their disintegration. One of the most significant in clinic, are ketonic bodies which have sufficient toxicity. As a result, the organism has double "blow". On the one hand - the hyperglycemia leads to dehydration ("dehydration" of cells), with another - ketonic bodies "poison" an organism as toxins. The hyperglycemia level more ketonic bodies is higher, the their influence on oppression of an organism and, first of all, a brain is considerable. And it is the key moment in development of the coma.

Symptoms of a diabetic (hyper glycemic) coma:

In development of a hyper glycemic coma, distinguish two periods, by analogy with a hypoglycemic coma: prekoma and hyper glycemic coma. But, time for their development is measured not by tens of minutes, and days.

At development of a hyper glycemic prekoma, the patient disturb:

- dryness in a mouth.
- thirst.
- frequent urination.
- skin itch.
- headache.
Then, in process of increase of ketonic bodies, nausea and vomiting joins. And, vomiting does not give relief. Abdominal pains are often noted. At the critical moment when the hyperglycemia and a ketosis (existence of ketonic bodies in blood) reach considerable figures, there is a confusion of consciousness, increase in a respiration rate which becomes noisy.

The coma has a number of special signs, except a loss of consciousness that distinguishes it from similar states:

- skin is dry, cold to the touch. Its raised peeling is noted.
- breath is frequent, superficial and noisy. At the same time, from the patient the acetone smell proceeds.
Speed of development of a coma depends on specific features, but, on average, the stage of a prekoma lasts 1-3 days. And the coma, without treatment, leads to death no more than per day. Though, also bigger term can be noted. Besides, a number of clinical physicians, allocate an intermediate stage - the beginning coma which time is estimated several hours.

Treatment of a diabetic (hyper glycemic) coma:

Prekomatoznoye and coma of patients with a diabetes mellitus demands their urgent hospitalization. Complex treatment of a coma includes recovery of deficit of insulin, fight against dehydration, acidosis, loss of electrolytes. It is necessary to enter insulin into an initial stage of a diabetic coma first of all. Enter only crystal (idle time) insulin and at all not drugs of the prolonged action. The dosage of insulin is calculated depending on coma depth. At easy degree of a coma enter 100 PIECES, at the expressed coma - 120-160 PIECES and at deep - 200 PIECES of insulin. Due to the disturbance of peripheric circulation at development of cardiovascular insufficiency in the period of a diabetic coma absorption of the administered drugs from hypodermic cellulose therefore a half of the first dose of insulin, it is necessary to enter intravenously struyno on 20 ml of isotonic solution of sodium chloride is slowed down. The patient elderly vozrasta.zhelatelno to enter no more than 50-100 PIECES of insulin because of threat of development in them of coronary insufficiency. In a prekoma enter a half of a full dose of insulin.

Further insulin is entered by each 2 h. The dose is selected depending on blood glucose level. If in 2 h the content of glucose in blood increased, then the dose of the entered insulin is doubled. The total quantity of insulin entered at a diabetic coma fluctuates from 400 to 1000 PIECES a day. Along with insulin it is necessary to enter glucose which has anti-ketogenic effect. It is recommended to begin administration of glucose after level it in blood under the influence of insulin begins to fall. Enter 5% glucose solution intravenously kapelno. For recovery of the lost liquid and electrolytes intravenously kapelno enter 1-2 l in an hour of isotonic solution of sodium chloride in combination with 15-20 ml of 10% of solution of the potassium chloride which is warmed up to body temperature. In total enter 5 - 6 l of liquid a day; the patient 60 years, and also with cardiovascular insufficiency - no more than 2-3 l are more senior. For fight against a metabolic acidosis enter intravenously kapelno 200-400 ml of 4-8% of solution of freshly cooked hydrosodium carbonate which cannot be mixed with other solutions. Intravenous administration of 100-200 mg of cocarboxylase, 3-5 ml of 5% of solution of ascorbic acid is shown. For recovery of hemodynamic frustration appoint cardiac glycosides (1 ml of 0,06% of solution of Korglykonum intravenously), subcutaneously or intravenously enter 1-2 ml of 20% of solution of caffeine or 2 ml of Cordiaminum.