Hyperglycemic coma
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Hyperglycemic Coma: Definition and Types
Hyperglycemic coma is a severe and potentially life-threatening complication of diabetes mellitus. It most commonly presents as either diabetic ketoacidosis (DKA) in type 1 diabetes or as hyperosmolar hyperglycemic state (HHS) in type 2 diabetes. True unconsciousness occurs in about 10% of cases, but the risk of death can be as high as 2% in general and up to 20% in HHS, which is significantly higher than in DKA 1510.
Pathophysiology and Risk Factors
Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS)
DKA is characterized by absolute insulin deficiency, leading to high blood sugar, acidosis, and ketone production, and is more common in type 1 diabetes. HHS, on the other hand, is seen mostly in type 2 diabetes and is marked by extremely high blood sugar, severe dehydration, and increased plasma osmolality, but without significant ketone production or acidosis 1510.
Precipitating Factors
Several factors can trigger hyperglycemic coma, including infections, dehydration, high-carbohydrate diets, beta cell failure, and certain medications. In patients with burns, high carbohydrate intake and increased water loss from burn treatments can precipitate HHS . Cardiac surgery, gastrointestinal bleeding, and hyperalimentation can also increase the risk, especially in those without a prior history of diabetes . Rarely, intentional ingestion of large amounts of sugar can lead to hyperglycemic coma, as seen in some suicide cases .
Special Populations
Hyperglycemic coma can also occur in infants with neonatal diabetes mellitus due to genetic mutations affecting insulin production, which requires different management compared to typical type 1 diabetes . Additionally, cancer patients treated with PD-1 inhibitors may rapidly develop type 1 diabetes and progress to hyperosmolar hyperglycemic coma, highlighting the need for close glucose monitoring in these patients .
Clinical Features and Diagnosis
The main features of hyperglycemic coma include extreme hyperglycemia, dehydration, and altered mental status, ranging from confusion to coma. Polyuria (excessive urination) is often an early warning sign, and a delay in recognizing these symptoms can worsen outcomes 69. Laboratory findings typically show very high blood glucose (often >600 mg/dL in HHS), increased plasma osmolality (>320 mOsm/kg), and, in DKA, the presence of ketones and acidosis 1510.
Management and Prognosis
Treatment Principles
Early diagnosis and prompt treatment are critical to improving outcomes. The mainstays of therapy include aggressive rehydration, insulin administration, correction of electrolyte imbalances, and identification and management of underlying causes 1510. In HHS, careful correction of the hyperosmolar state is important to avoid complications .
Prognosis
The prognosis depends on several factors, including age, degree of dehydration, and the presence of other illnesses. Mortality is higher in older patients, those with severe dehydration, and those with additional health problems 510. Early recognition and intervention are essential to reduce the risk of death and long-term complications.
Conclusion
Hyperglycemic coma is a serious emergency in diabetes care, most often resulting from DKA or HHS. It can be triggered by various factors, including illness, dehydration, and certain treatments. Early recognition, rapid intervention, and addressing underlying causes are key to improving survival and reducing complications in affected patients 125910.
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