What Is a Hyperglycemic Hyperosmolar State?

Non-ketohypertonic diabetic coma is referred to as diabetic hyperosmolar coma, which is due to the relative lack of insulin in the stressful situation, and the increase of insulin antiregulatory hormones and the release of liver sugar lead to severe hyperglycemia, which is caused by hyperglycemic dehydration in the plasma. And clinical syndromes of progressive disturbance of consciousness. Seen in middle-aged and elderly patients, with or without a history of diabetes, the mortality rate is higher.

Basic Information

nickname: Hypertonic coma
Visiting department: Neurology
Multiple groups: Elderly people with mild diabetes or impaired glucose tolerance

Common causes: Severe stress states such as acute infection, acute myocardial infarction, cerebrovascular disease, acute pancreatitis, uremia, burns, craniocerebral surgery, etc.
Common symptoms: Thirst, polyuria, fatigue, increased appetite, etc.

Causes of non-ketohypertonic diabetic coma

This disease is more common in the elderly. People with mild diabetes or impaired glucose tolerance are susceptible to the following factors: severe stress states such as acute infection, acute myocardial infarction, cerebrovascular disease, acute pancreatitis, uremia, burns, Craniocerebral surgery, etc. Thiazines, mannitol, sorbitol, hypertonic sugar and sodium-containing fluids, and peritoneal dialysis may exacerbate hypertonic conditions. Glucocorticoids, beta-blockers, phenytoin, diazoxide, cimetidine, etc. may be induced by insulin resistance.

Clinical manifestations of non-ketohypertonic diabetic coma

Inducement

Various acute infections, severe vomiting and diarrhea, acute myocardial infarction, cerebrovascular disease, acute pancreatitis, traumatic brain injury, burns, craniocerebral surgery, and diuretics, peritoneal dialysis and excessive glucose infusion

2. Slow onset

In the early stages of thirst, polyuria, fatigue, and loss of appetite, obvious signs of thirst, polyuria, and dehydration gradually appeared.

3. Hypertonic dehydration symptoms

Thirst, dry lips, dry skin, poor elasticity, sunken eyes, less urine, closed urine. Insufficient blood volume: rapid heartbeat, low blood pressure or even shock, and no urine.

4. Neuropsychiatric symptoms

There are different degrees of conscious disturbance, such as slow response, indifferent expression, hallucinations, aphasia, blurred consciousness, lethargy, coma and other symptoms. May have large upper limb tremor, localized seizures, transient hemiplegia, hyperreflexia or disappearance of the knee, and the cone tract sign may be positive.

Non-ketohypertonic diabetes coma test

Blood sugar

Often> 33.6mmol / L (600mm / dl), strong urine glucose positive.

Blood ketone body

Normal or slightly elevated, negative or weakly positive for ketones.

3. Electrolyte

Blood sodium> 150mmol / L, blood potassium: normal or decreased.

4. Plasma osmotic pressure

> 330mOsm / L. The effective plasma osmotic pressure can be calculated by the formula: effective plasma osmotic pressure (mOsm / L) = 2 [blood sodium + blood potassium (mmol / L)] + blood glucose (mmol / L).

5. Blood pH or CO2 binding

Normal or low, acidosis was significantly reduced.

6. Blood urea nitrogen, creatinine

Increased by dehydration and shock.

7. White blood cell count

It can increase due to infection or dehydration, and the blood cell volume increases.

8. ECG

May have electrolyte disturbances (especially hypokalemia) and changes in myocardial ischemia or arrhythmia.

Diagnosis of non-ketohypertonic diabetic coma

Middle-aged and elderly patients, whether with or without a history of diabetes, such as the occurrence of unexplained progressive consciousness disorder and obvious dehydration, which cannot be explained by other diseases, the possibility of this disease should be considered, and blood glucose, urine glucose and ketones should be checked in time Body and blood electrolytes. For those who have been diagnosed with diabetes, especially middle-aged and elderly patients with type 2 diabetes, if they do not have diet control and regular treatment, they have the above-mentioned incentives for excessive drinking in the near future, sudden increase in polyuria symptoms, dementia, and sleepiness. In addition to ketoacidosis, the occurrence of this disease should also be watched. HHS laboratory diagnostic reference standards are: blood glucose 33.3mmol / L; effective plasma osmotic pressure 320mOsm / L; serum bicarbonate 15mmol / L, or arterial blood pH 7.30; urine glucose is strongly positive While urine ketone negative or weak positive. Clinical conscious disorder and significant dehydration manifestation with blood glucose exceeding 33.3mmol / L, strong urine glucose positive (those with changes in renal threshold may not coincide with blood glucose), effective plasma osmotic pressure exceeding 330mOsm / L, if urine ketone body test is negative or weakly positive The diagnosis is established.

Treatment of non-ketohypertonic diabetic coma

1. Send to the ICU immediately

Open the vein, check blood glucose, electrolytes, blood gas analysis, hematuria routine, urinary ketone, electrocardiogram, chest radiograph and brain CT.

2. Rehydration

The infusion volume is estimated at 12% of body weight: if there is no heart or kidney dysfunction, 1000 ~ 2000ml of normal saline can be quickly replenished in the first 1 ~ 2 hours, followed by intravenous drip at a rate of 500 ~ 1000ml in 2 ~ 4 hours until blood pressure rises and urine The amount increases. However, the elderly, those with heart and kidney dysfunction, need to use central venous pressure monitoring to prevent heart failure and pulmonary edema caused by too fast infusion, and those who cannot tolerate can rehydration from the gastric tube. When blood glucose dropped to 13.9mmol / L (250mg / dl) and plasma osmotic pressure dropped below 320mOsm / L, 5% glucose solution i was used instead.

3. Insulin treatment

Methods The treatment is the same as that of diabetic ketoacidosis. Continuous intravenous drip of 0.1-0.15U / kg / h with a small dose of insulin reduces blood sugar to 13.9mmol / L, and changes to 5% glucose or 5% glucose saline. Blood sugar should be maintained at 11.1mmol / L to prevent cerebral edema caused by too rapid decrease in osmotic pressure.

4. Supplement potassium

The principle is the same as that of toxins in ketoacids.

5. Other

Alkali supplementation is generally not needed, and the blood sugar should not drop too quickly. It is advisable to drop 5.6mmol / L (100mg / dl) per hour. After the condition is stable, insulin can be changed to subcutaneous injection.

Other treatments: Remove incentives: Infected patients should use antibiotics. Shock correction: Shock has not been corrected after fluid replacement, and plasma can be transfused. Due to hypertonicity and increased blood viscosity, arteriovenous thrombosis and disseminated intravascular coagulation (DIC) should be prevented and treated with appropriate anticoagulation. Prevent brain edema during treatment.