APPROACH TO DIABETIC COMA

Dr RUKMAN MECCA

HYPOGYCAEMIA DIABETIC KETOACIDOSIS HYPEROSMOLAR HYPERGLYCEMIC COMA

Hypoglycaemia Diabetic ketoacidosis History Type 1 & 2 On insulin/OHA + missing meals Diabetic nephropathy Faulty dose of insulin/OHA Type 1 & 2 H/o missing insulin Poor control of diabetes Infections, IHD, stroke, surgery, anaesthesia, and other stressful states Symptoms of uncontrolled diabetes Nausea, vomiting, air hunger

Hyperosmolar coma Type 2 H/o missing insulin Infections, IHD, stroke, surgery, anaesthesia, mannitol, phenytoin

Symptoms

Sweating, palpitation, anxiety and hunger followed by dizziness Convulsions

Symptoms of uncontrolled diabetes

Hypoglycaemi a General examination Coma resembles natural sleep, profuse sweating, No signs of dehydration

Diabetic ketoacidosis Coma doesnt resemble natural sleep, cold extremities, Signs of dehydration, Abdominal tenderness Low volume / tachycardia

Hyperosmolar coma Coma doesnt resemble natural sleep, cold extremities, Signs of dehydration

Pulse

Normal/high volume

Low volume / tachycardia

BP

Normal/wide pulse pressure

Hypotension

Hypotension

Respiration

Normal

Deep and rapid(KUSSUMA UL)

Normal

Hypoglycaemi a Features of infection Not present

Diabetic ketoacidosis Often present.

Hyperosmolar coma May be present

Neurological deficit

Altered sensorium which recovers after IV dextrose Seizure disorder

Altered sensorium Focal deficits Visual defects

Altered sensorium

INVESTIGATIONS
Hypoglycaemi a Blood sugar pH Very low Normal Diabetic ketoacidosis Around 300600mg% Decreased Hyperosmolar coma Often>6001000mg% May be decreased due to lactic acidosis and pre-renal azotaemia Absent Marked elevation prerenal azotaemia due to extreme

Ketone bodies Urea

Nil Normal or high(diabetic nephropathy)

Present May be high if there is prolonged hypotension

MANAGEMENT

Hypoglycaemia : 50ml 25% Dextrose followed by infusion of 5%dextrose till hypoglycaemia is corrected. Stop insulin/OHA temporarily. Find out the cause for hypoglycaemia.

MANAGEMENT OF DKA

Introduce IV cannula, take blood sample for urea , SE ,CBC(infection). Plain 0.1-0.2U/kg/hr iv bolus folld. by 0.1U/hr infusion till blood sugars fall below 300mg/dl. then 2-3U/hr infusion Monitor blood glucose before each insulin dose.

Correct dehydration: Give NS sufficient to correct hypotension(6 Lin 24 hrs). Initially @ 1L/hr then 0.5L/4hr After attaining 300mg/dl 5% dextrose in NS is ideal(to restore depleted hepatic glycogen)

When RBS falls below 200mg% , start 8th Hrly s/c plain insulin. If the patient is not able to take oral feeds, start 5%dextrose infusion with 8 units of insulin added to it. Continue this till oral feeds start. Adjust the dose of insulin based on RBS.

Anticipate hypokalemia (enthusiastic correction is dangerous) Insulin resistance is common in DKA due to infections, surgery. Antibiotics should be instilled. Lung, urinary tract, meninges are common sites of infections. If pH is <7.1,50mEq of sodium bicarbonate is added to iv fluids.

End point of energetic Mx of DKA is RBS below 200mg%, normal pH A proper chart should be maintained dose and timing of insulin, IV fluids and records of vital signs, urine volume.

MANAGEMENT OF HYPEROSMOLAR NONKETOTIC DIABETIC COMA

Rapid administration of large amount of IV fluids to correct severe dehydration. 2-3 litres of NS in first 2hrs. Subsequently half NS can be used. Insulin 10units Hrly with frequent monitoring. As blood glucose approaches normal, 5% dextrose with 8 units of insulin can be given.

K+ replacement Treatment of precipitating factors(stroke or M.I.) Prophylactic heparin therapy (more prone for thrombosis)- recommended.

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