Diabetic coma is a clinical syndrome characterized by disturbance of consciousness caused by diabetes. It includes two kinds of clinical types, namely, diabetic keto-acidosis and diabetic non-ketotic coma (hyperosmolar coma), they are the most common diabetes, the most dangerous complications, if timely treatment, often leading to death.
disease Overviewdiabetic coma caused by diabetes, a clinical syndrome characterized by disturbance of consciousness. It includes two kinds of clinical types, namely, diabetic keto-acidosis and diabetic non-ketotic coma (hyperosmolar coma), they are the most common diabetes, the most dangerous complications, if timely treatment, often leading to death.
signs and symptomsmedical attention dehydration extent, with or without breathing deep and speed, breath ketone flavor and peripheral circulatory failure.
1. history of mostly elderly, mostly occurs in 50 to 70-year-old, male and female prevalence is roughly the same. About half of known diabetes, approximately 30% had a history of heart disease; about 90% of people with kidney disease. Types of diabetes: more than for type 2 diabetes; minority for type 1 diabetes, more than coexist with DKA; can occur even in Cushing's syndrome, acromegaly patients with diabetes.
2. slower onset of the way. Patients before the onset of a few days to several weeks, often diabetes symptoms gradually worsened, clinical manifestations, including polydipsia polydipsia, polyuria, fatigue, dizziness, lack of appetite and vomiting.
3. dehydration and peripheral circulatory failure patients often have severe dehydration signs, visible skin dryness and decreased elasticity, sunken eyes, dry tongue, and may have longitudinal cracks. Patients with peripheral circulatory failure, rapid and weak pulse, incomplete filling of jugular vein in the supine, orthostatic hypotension, standing systolic blood pressure drop compared with the supine low-1.3kPa (10mmHg) above. The number of patient visits in a state of shock, severe dehydration, physical examination can be no sweat found. Although some patients with severe dehydration, but the permeability of plasma state to promote the intracellular fluid out, to add volume, may mask the extent of water loss, so that the blood pressure remained normal.
4. about half of the patients awareness of the signs and symptoms of the nervous system disturbances, 1/3 in a coma, some patients was misdiagnosed as cerebral vascular accident, even mistakenly entered the hypertonic glucose solution or a dehydrating agent, prompting exacerbations. HNDC patients with disturbance of consciousness or not and the extent of major decisions in the extent and speed of the increase in plasma osmolality and blood glucose level of a certain relationship, and has little to do with the degree of acidosis. Abroad, it was found that when the effective osmotic pressure of the plasma of patients with more than 320mmol/L, you can psychiatric symptoms such as apathy, lethargy; more than 350mmol/L when 40% of patients may have vague consciousness or coma. But some patients with effective plasma osmolality is slowly rising, visit Although more than 400 mmol/L, the patient is still in the waking state.
signs of nervous system: such as grand mal epilepsy, hemiplegia, muscle relaxation or involuntary contraction, aphasia, homonymous hemianopsia, visual disturbances, nystagmus, visual hallucination, the bust of sensory loss, Babin The Chomsky sign positive and central heating. These signs suggest that patients may be due to dehydration, hemoconcentration, or blockage of blood vessels caused by the cerebral cortex or subcortical damage. These changes can be reversed by effective treatment after the return to normal a few legacy can still be within a certain nervous and mental disorders in a period of time after HNDC correct the symptoms.
with the incidence of signs and symptoms in patients with high blood pressure, kidney disease, coronary heart disease and other original disease manifestations; pneumonia, urinary tract infections, pancreatitis-induced disease manifestations; and cerebral edema, thrombosis performance of the formation of vascular thrombosis and other complications. The body temperature of patients more than normal or mildly elevated, such as the temperature decreases, the prompt may be associated with acidosis and (or) sepsis, should be paid enough attention.
disease etiologyNote that the previous history of diabetes, recent treatment of the situation, with or without acute infection, diarrhea, eating disorders, sugar too much, not previously discovered diabetes misuse of too much sugar, severe mental stimulation, disable, or a significant reduction in insulin, large doses of biguanide hypoglycemic agents, and so on.
1. stress and infection, such as cerebrovascular accident, acute myocardial infarction, acute pancreatitis, gastrointestinal bleeding, trauma, surgery, heat stroke or cold stress. Infections, particularly upper respiratory tract infection, urinary tract infections, most commonly induced. Insufficient water intake elderly thirst center sensitivity decline in ambulatory patients, mental disorders, or coma suffering from the
who can not take the initiative to the water intake children.excessive
3. water loss and dehydration such as severe vomiting, diarrhea, severe burn patients, Neurology, Surgery dehydration therapy, dialysis treatment.
4. high intake of sugars and input such as a large intake of sugary drinks and foods high in sugar, the diagnosis is unknown or missed intravenous infusion of a large number of glucose solution, complete intravenous nutrition, and the use of sugar solution hemodialysis or peritoneal dialysis. In particular, in some patients with endocrine diseases with glucose metabolism disorders, such as hyperthyroidism, acromegaly, Cushing's syndrome, pheochromocytoma tumors who more likely to induce.
5. drugs Many drugs can be an incentive, such as extensive use of glucocorticoids, thiophene the triazine furosemide (furosemide), diuretics, propranolol, phenytoin, chlorpromazine , cimetidine, glycerol, azathioprine and other immunosuppressive agents and so on. Can cause or aggravate insulin resistance in the body make blood sugar, dehydration aggravated, some drugs such as thiazide diuretics also inhibit insulin secretion and reduce insulin sensitivity, which can induce HNDC.
6. other areas such as acute and chronic renal failure, diabetes, kidney disease, glomerular filtration rate, clearance of glucose has also decreased. Can also be an incentive.
diagnostic tests1 admission immediately to check blood glucose, ketone bodies, lactic acid, carbon dioxide combining power, urea nitrogen, blood pH, serum potassium, serum sodium, serum chloride, plasma penetration pressure [calculated using the formula: 2 (Na + + K +) mmol/L + (glucose mg/d1 ÷ 18) + (blood urea nitrogen mg/d1 ÷ 2.8)], urine sugar and ketone bodies, each subsequent 1 ~~ 4h retest 1, until the blood biochemical values returned to normal.
2. renal function tests, ECG. Check urine and ketone.
① The blood glucose was significantly higher, and increased blood ketone, blood carbon dioxide combining power and pH decreased, with positive urine ketone as diabetic ketoacidosis and coma.
② blood sugar very high (nearly 1000mg/d1 or higher), high sodium, plasma osmolality, no significant ketoacidosis, high permeability nonketotic coma; common in older patients.
③ The due to shock or taking a biguanide hypoglycemic agents, blood lactate increased acidosis generally hyperglycemia, ketosis by diabetes lactic acidosis.
treatment options1. implemented in accordance with coma care practices, and blood pressure hourly 1
2 diabetic ketoacidosis coma treatment
(1) injection of regular insulin
In order to prevent the course of treatment, blood sugar drop too fast, acidosis corrected too fast, leading to cerebral edema even fatal consequences, can be applied to small doses of insulin treatment plan: initial RI intravenous infusion (in saline middle), the dose at 5 ~ 10U/h, calculate the (0.1U/kg? h,), while intramuscular injection of 10 ~ 20U. close observation of blood glucose until the blood sugar to 13.9mmol/L (250mg/d1), insulin instead of every
2h subcutaneous injection once a dose urine + + + +16 U, + + +12 U, + +8 U, +4 U. With insulin and fluid therapy 2 to 3h after the blood sugar is still not decreased, you may have insulin resistance, hourly insulin dose should be doubled. Treatment with excessive insulin, act with undue haste while hypoglycemia, or blood sugar to drop too fast, leading to cerebral edema and hypokalemia should be avoided.
(2) to correct dehydration, electrolyte imbalance, acidosis
① fill saline: the beginning of 2 ~ 4h rehydration 2000ml, the first JCP 4000ml or so. Old age and heart and kidney dysfunction, rehydration should not be too much too fast. To blood glucose decreased to 13.9mmol/L (250mg/d1) following the switch to 5% glucose solution, or 5% glucose solution 4/5 and normal saline 1/5. When the patient can eat, to encourage the liquid food, semi-liquid food.
② timely potassium: If potassium is low or normal, full urine in the treatment of intravenous potassium chloride l ~ 1.5g/500ml, the first day of potassium 6 ~~ 9g. hyperkalemia by pre-treatment, after treatment, 3 ~ 4h Note potassium. The potassium appropriate electrocardiographic monitoring, or 2 ~ 3h measured serum potassium to prevent hyperkalemia. Termination of potassium when the potassium in 5mmol/L or more.
③ to correct acidosis: blood pH> 7.15 when no alkali agent, pH <7.0 with 5% sodium bicarbonate 150ml, pH 7.0 ~ 7.15, with half the amount.
3. hyperosmolar nonketotic coma treatment
(1) to correct the hypertonic dehydration, electrolyte loss: immediate intravenous infusion of normal saline, in the beginning 2h 2 ~ 3L, can also be injected from the tube in a considerable amount of warm water; blood recovery capacity, blood pressure rose to normal, and the osmotic pressure did not fall, especially hypernatremia lose hypotonic solution (0.45% or 0.6% sodium chloride) 500 ~ 1500ml/d; until the blood sugar decreased to 16.7mmol (300mg/d1)
below in favor of 5% glucose intravenous infusion. Serum potassium <5mmol namely potassium, potassium maintained at 4-5mmol/L.
(2) insulin: The dosage should be lower than ketoacidosis coma for a small (4 ~ 6U/h), the general can refer to the "small dose" program, intravenous regular insulin. But stressed that early diagnosis and treatment. Should not be in the 24 ~ 48h blood glucose less than 13.9mmol/L (250mg/d1).
(3) remove the incentive treatment, and attention to monitoring vital signs, blood, urine, electrolytes, BUN, etc..
4 lactic acid poisoning treatment
(1) active anti-shock, improve microcirculation perfusion, correction of tissue hypoxia.
(2) positive correction of acidosis, which may be intravenous infusion of 1.5% or 5% sodium bicarbonate, a larger amount, usually 5% sodium bicarbonate 200 ~ 1000ml strive to blood ph at 8h to normal, early 24h available 100mmol. Taken to avoid hypokalemia. Old age, heart and kidney dysfunction are required dialysis. Or tromethamine (The THAM), but disable sodium lactate.
(3) high blood sugar treatment; RI high blood sugar to be added glucose.
5. stop the application biguanide drugs
6. general treatment should control incentives
infected persons are speed controlled with antibiotics. shock active anti-shock measures, plasma or whole blood can be lost when the necessary hanged norepinephrine.
Safety Tips1, if the patient awareness is still awake, and able to swallow, then low blood sugar coma is the most effective way to enable patients to drink sweet water or eat candy, sweet pastry class
2, an effective method of high blood sugar coma drink salt tea or low-salt tomato sauce.
3, in patients with consciousness has been lost, the patient should be flat, unlock the collar to ensure airway patency.
nursing interventions1 diabetic patients with coma, if not rescued, it may be life-threatening, nursing staff and their families must always observe the patient's condition changes;
2, remember the patient's fluid intake and output, such as water or fluid volume, urine output, etc.;
3, when the patient out of danger, regained consciousness, aggressive treatment of diabetes, diet regulation, rational use of insulin in vivo metabolism of normal, to avoid the recurrence of diabetic coma;
4, diabetes is a chronic and long-term treatment of the disease, patients and their families should eliminate concerns about confidence, and learn knowledge about diabetes, a great benefit to patients;
5, for the prevention of the event, with diabetes should always carry carry marked with diabetes "card and the card can record some of the treatment methods and patient name, address, etc., so that a sudden awareness loss for others and for Physicians.
emergency measures1. First find out the causes of coma, the difference between high blood sugar coma or low blood sugar coma.
2. Hypoglycemia, the patients first felt the palpitation, dizziness, hunger, tremor, sweating
further development of irritability, convulsions, mental disorders, and finally into a diabetic coma . If the patients are still capable of swallowing, low blood sugar coma, is to enable patients to drink sugar water or eat candy, sweets.
3. High blood sugar coma, let the patient drink some salt in the tea, and at the same time sent to hospital.
4. Difficult to judge the reason of diabetic coma, do not blindly take measures, because of two reasons of hyperglycemia and hypoglycemia can cause coma treatment is exactly the opposite.
5. If the patient awareness has been lost, patients should be flat, unlock the collar to ensure airway patency, and immediately sent to the hospital.
four of the prevention and treatment of diabetic comain the course of treatment of diabetes, due to the improper loss rule wrong treatment or conditioning of life of diabetic ketoacidosis coma, hyperosmolar nonketotic diabetic coma, lactic acidosis, coma, diabetic hypoglycemia coma four Intensive, if not rescued, there will be fear for their lives.
diabetic ketoacidosis coma due to severe lack of insulin, the fat accelerate the decomposition of a significant increase in fatty acid oxidation of ketone bodies in the liver, leading to ketone bodies accumulate, and ketoacidosis. On this basis, coma called diabetic ketoacidosis coma. Prevalent in the sudden interruption of the insulin-treated diabetic patients without any treatment of newly diagnosed diabetes. Zheng Jian polydipsia, polyuria, Shenpi, fatigue, poor appetite, Oue, breathing deeply and fast and then slow shallow breath can be a rotten apple, dizziness, headaches, and even shock, lethargy, coma. Treatment to rehydration, the use of insulin, to correct electrolyte imbalance and acid-base balance mainly.
nonketotic hyperosmolar diabetic coma refers to diabetic patients in severe infection, trauma, blood or peritoneal dialysis, the use of diuretics or adrenal corticosteroids, severe high blood sugar, blood hypertonic state, dehydration, coma for the clinical features of disease. Zheng Jian fever polydipsia, polydipsia and polyuria, Shenpi fatigue, the Oue anorexia, dry skin, reduce flexibility, chapped lips and tongue, eyes sunken, blood pressure, dehydration performance and even shock, rapid shallow breathing, rapid heart rate minds dazed, limbs, convulsions, trance, disorientation, irritability or apathy and even coma, epileptic seizures, hemiplegia aphasia, hemianopia, or nystagmus, pathological reflex was positive. Treatment to use insulin, a rapid and massive rehydration, maintenance of water and electrolyte and acid-base balance, prevention of infection was the main patients with errors
diabetes lactic acidosis, comadiabetic patients with lactic acidosis is common in combined heart, lung, liver, kidney and serious illness The use biguanide phenformin cases. Phenformin, increase the sugar of anaerobic glycolysis, lactate production increases when the number of lactic acid increase more than intake of liver and muscle and kidney excretion limit occurs when lactic acidosis. Zheng Jian, nausea, vomiting, abdominal pain, bloating, fatigue, weakness, breathing deeply and fast, and gradually fell into a coma. Treatment to disable Jiangtangling can cause lactic acidosis, drugs, the use of insulin, 5% sodium bicarbonate injection, infection control, to correct dehydration and shock, diuretic row Acid, to correct water and electrolyte disturbance, oxygen, potassium and, if necessary when blood or peritoneal dialysis-based dialysis solution without lactic acid root.
diabetes low blood sugar coma found in patients with diabetes go on a diet over-injection of insulin overdose, oral hypoglycemic agents improper use of such circumstances. Zheng Jian hunger, fatigue, dizziness, headache, cold sweat dripping, palpitation and shortness of breath, tachycardia, nausea, vomiting, blurred vision, the whole body tremble, and even mental confusion, abnormal behavior, lethargy, coma, limbs, convulsions and even death. hypoglycemia can occur in the daytime, but also occur in the night. Hypoglycaemic episodes cause a patient in a sleep state at night, awakened from a dream, accompanied by cold sweat dripping, irritability, tachycardia. Hypoglycemia, if any, should be timely monitoring of blood glucose, into the syrup, candy, fruit, biscuits, snacks, bread and sugary foods as soon as possible, and promptly to the hospital for infusion of glucose, oxygen, glucose, blood pressure, heart rate, respiration, body temperature monitoring to observe the mind changes, and appropriate treatment, to avoid accidents.the main cause of diabetic coma, and first aid
nonketotic hyperosmolar coma This coma more common in elderly diabetic patients over the age of 60. Severe dehydration, hyperglycemia, high plasma osmolality and neuropsychiatric symptoms as the main clinical manifestations.
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