The disease of diabetes determines the entire life of those affected. Intensive education about how to manage the disease can help patients live their lives as normally as possible and prevent complications, such as hyperosmolar coma.
What is hyperosmolar coma?
Hyperosmolar coma is a life-threatening complication of type 2 diabetes and is a subtype of diabetic coma. Unconsciousness is caused by an extreme lack of insulin. If a hyperosmolar coma occurs, the affected person must be hospitalized immediately and treated as an inpatient. Most often, this involves elderly type 2 diabetes patients.
Causes
Hyperosmolar coma occurs when blood glucose levels rise extremely high due to insulin deficiency. The excess sugar is partially excreted by the kidneys. The sugary urine draws water with it, causing the body to suffer a severe loss of fluid that cannot be compensated for by drinking alone. Insulin deficiency can be caused by an inadequate supply of insulin or an increased need. An inadequate supply can occur when a diabetic patient does not inject himself or herself with enough insulin or not in the correct way, when he or she takes too few tablets that lower blood glucose levels, or when the prescribed dose is no longer sufficient. Older diabetics are often affected, whose pancreas still produces enough insulin to prevent excessive fat breakdown, but no longer enough to prevent excessive glucose formation in the liver. In about 25 percent of cases, this is a diabetic condition that was previously undiagnosed, and appropriate treatment was therefore completely lacking. Increased insulin deficiency is caused by an infection in 40 percent of cases, since blood glucose levels are elevated during an infection. Type 2 diabetics should definitely be aware of this when they are ill, for example if they have caught pneumonia or the flu. However, an unfavorable diet, hyperthyroidism, surgery or other illnesses can also lead to increased insulin requirements.
Symptoms, complaints, and signs
Severely elevated blood glucose levels and increased fluid excretion are typical of hyperosmolar coma. The glucose concentration in the urine is so high that it already exceeds the renal threshold. The body tries to get rid of the unused glucose and excretes it by means of increased urine volumes due to the increased osmolarity of the glucose. As a result, dehydration occurs, which can lead to unconsciousness. In addition, seizures may also occur. Furthermore, the pronounced glucosuria causes electrolyte disturbances. The low fluid volume can also cause volume deficiency shock. Finally, the kidneys are at risk of acute renal failure. The electrolyte disturbances have a negative effect on the nerve cells of the brain and are therefore also largely responsible for the disturbances of consciousness and seizures. Volume deficiency shock is manifested by a sharp drop in blood pressure, a strong feeling of thirst and also by signs of clouding of consciousness. In addition to the actual coma, other symptoms may also occur. These include dizziness, a strong feeling of thirst, weight loss, dry mouth, severe fatigue, visual disturbances, impaired concentration, fever, neck stiffness and circulatory disturbances up to circulatory shock. Fluid loss causes thickening of the blood, increasing the risk of thrombosis. Pneumonia is also observed. Mortality in hyperosmolar coma is very high. It ranges from three to 30 percent.
Diagnosis and course
Hyperosmolar coma can be diagnosed by measuring blood glucose. Usually, an extremely high value of more than 600 milligrams per deciliter is present. By comparison, in a non-diabetic, normal values in a fasting state are 80 to 120 milligrams per deciliter. Furthermore, the attending physician performs an examination of the blood. This tests whether the blood salts potassium and sodium are present in normal amounts. In addition, special parameters are used to determine whether there is a focus of inflammation in the body. In this way, it can be determined whether the hyperosmolar coma was triggered by an infection. Further examinations rule out the disease of other organs as a trigger.The first symptom to be observed is increased water excretion. As a result, affected persons develop extreme and persistent feelings of thirst, nausea and vomiting, parched mucous membranes, palpitations and low blood pressure. Later, dizziness and physical weakness are added, and the patient is barely responsive. Finally, a circulatory collapse occurs. If an infection is given as the trigger of hyperosmolar coma, symptoms of the corresponding inflammation also appear.
Complications
A number of different complaints occur with this condition, which can limit the daily life of the affected person and significantly reduce the quality of life. As a rule, there is increased thirst and thus increased urination in the patient. The mouth is dry and patients suffer from nausea and vomiting. It is not uncommon to also experience palpitations and low blood pressure. The low blood pressure can cause the affected person to lose consciousness or even fall into a coma. Various injuries may also occur. In general, a feeling of weakness occurs, combined with fatigue, so that the patient’s ability to cope with stress is also considerably reduced. Not infrequently, there are also temporary disturbances in thinking or speech, and those affected suffer from a lack of concentration. The treatment of this disease takes place with the help of infusions and does not lead to further complications. There is also no reduction in life expectancy. After the treatment, the medication of diabetes must be readjusted for the patient so that this condition does not occur again.
When should you go to the doctor?
Consultation with a doctor is necessary when the affected person suffers from various symptoms over a long period of time. A persistent urge to urinate, which recurs shortly after the last visit to the toilet, is a warning sign from the body of inconsistencies. If there is an increased feeling of thirst, dry mucous membranes in the mouth and throat or a general feeling of internal dryness, a visit to the doctor is necessary. This is especially true if there is no physical exertion or if intense heat is prevalent. An apparently causeless intense feeling of thirst should be clarified by a doctor. If symptoms such as vomiting, nausea, dizziness or general weakness occur, a doctor should be consulted. If further abnormalities occur or the existing symptoms increase, a visit to the doctor is necessary. An unusually weak blood pressure, a strong need for sleep, permanent fatigue or a pale complexion are indications of diseases that should be checked and treated. If the affected person suffers from palpitations, sweating or a feeling of illness, he or she should consult a doctor to have the complaints clarified. If there is reduced performance, everyday duties can no longer be fully performed, or if digestive complaints arise, a doctor should be consulted.
Treatment and therapy
Hyperosmolar coma is treated in the hospital, often in the intensive care unit. First, salt and fluid loss must be restored as quickly as possible. By infusion, patients are given about five to six liters of a saline solution within the first eight hours. The infusion of fluids is usually started by the paramedics on the way to the hospital. In addition, intravenous insulin is administered. If necessary, a triggering infection is treated. Metabolism is slowly restored to normal under close observation of kidney, blood glucose and pH levels, and electrolyte balance. Subsequently, type 2 diabetes medication is readjusted. If circulatory collapse is not appropriately treated, the affected person will slowly become unconscious and fall into a deep coma, which in the worst case can end in death.
Outlook and prognosis
The prognosis of hyperosmolar coma is described as unfavorable. In severe cases, the patient does not awaken from the coma and premature death occurs. If the affected person regains consciousness, he or she must expect considerable health losses. The acute condition develops in diabetes patients. This is a chronic disease with a potentially progressive course. Severe impairment of lifestyle is already present in patients before the comatose state.According to current scientific and medical possibilities, there is no cure for diabetes. The coma further worsens the patient’s already existing state of health. Therefore, a further decrease in the quality of life and an increase in already existing complaints are to be expected. In addition, further disorders develop in most of those affected. Once the coma is overcome, the patient’s medication regimen is readjusted. This is to prevent recurrence of hyperosmolar coma and to have a preventive effect. In addition, current symptoms are reassessed and an optimization of the treatment plan occurs. If the patient cooperates and follows the physician’s instructions, significant improvements can be observed. Although there is no prospect of cure, an adequate lifestyle can still be established.
Prevention
The most important preventive measure for diabetes patients is to become adequately informed about their disease. To prevent hyperosmolar coma, they must measure their blood glucose levels regularly and be able to quickly detect rising levels, for example, during an infection. If blood glucose levels are elevated, the insulin dose must be adjusted accordingly. Special training courses for diabetes patients provide information about complications and give tips on how to deal with the disease on a day-to-day basis. Furthermore, it is important to always drink enough; at least two liters per day are recommended.
Aftercare
The risk of hyperosmolar coma can be detected during follow-up by careful monitoring. To this end, it is important that diabetics are aware of the risks and monitor their blood glucose closely. Among other things, this includes adjusting the daily dose of insulin to match daily activities and meals. Increased awareness helps identify any changes as warning signs. If diabetic coma is suspected, quick countermeasures are needed. A visit to the doctor or a call to the emergency service will initiate further steps. Following initial treatment with insulin and plenty of fluids, longer-term observation takes place. This focuses on the adjustment of blood glucose levels and on the stability of the patient. Comprehensive education of those at risk is an important contribution in the context of safe follow-up. To prepare for an acute emergency, individuals need the appropriate medications. Involving family members is also useful. These can take the necessary measures in an emergency, should the patient become unresponsive. Regular follow-up appointments also include nephrological, ophthalmological and GP check-ups. These are to ensure that diabetes does not lead to serious sequelae such as kidney problems, blindness or a diabetic foot.
What you can do yourself
Relatives of a diagnosed diabetic and also the sufferer himself usually recognize the signs of a disturbed blood sugar level quite early. However, if the metabolism degenerates too quickly or goes unnoticed, there is often no time left for prophylactic measures. If the patient falls into a hyperosmolar coma, he is in a life-threatening emergency situation. This is a state of deep unconsciousness. This means that the heartbeat and breathing are still present, but conscious existence is switched off. Likewise, the affected person no longer has vital protective reflexes. For this reason, no attempts to ingest food should now be made. The affected person has neither swallowing nor coughing reflexes. There is a risk of aspiration and thus a likelihood of choking. The only self-help option is to act quickly and measure the blood glucose level. The patient must be placed in the recovery position as quickly as possible and the ambulance service called. While waiting, it is important to check the patient’s breathing regularly and, if necessary, perform mouth-to-nose resuscitation. If the victim’s spontaneous breathing appears to be insufficient or if his skin turns bluish, cardiopulmonary resuscitation must be performed. If more than one rescuer is on the scene, CPR should be performed in rotation, alternating without pause. This is necessary until the rescue service arrives at the emergency scene.
