Coma, diabetic

Insulin is necessary for controlling type 1 diabetes mellitus that is caused by a marked decrease in the amount of insulin produced by die pancreas. Insulin is also used to control the more severe and complicated forms of type 2 diabetes mellitus. However, many patients can control type 2 diabetes with diet and exercise alone or with diet, exercise, and an oral antidiabetic drug (see section Oral Antidiabetic Dmgp ). Insulin may also be used in the treatment of severe diabetic ketoacidosis (DKA) or diabetic coma. Insulin is also used in combination with glucose to treat hypokalemia by producing a shift of potassium from die blood and into die cells. 

The energy substrates are contraindicated in patients with hypersensitivity to any component of the solution. Dextrose solutions are contraindicated in patients with diabetic coma with excessively high blood sugar. Concentrated dextrose solutions are contraindicated in patients with increased intracranial pressure, delirium tremens (if patient is dehydrated), hepatic coma, or glucose-galactose malabsorption syndrome Alcohol dextrose solutions are contraindicated in patients with epilepsy, urinary tract infections, alcoholism, and diabetic coma... 

A second principle used widely for glucose analysis, is that of the oxidation of glucose enzymatically, mediated by the action of glucose oxidase with the formation of gluconic acid and hydrogen peroxide (22). In this procedure it is the hydrogen peroxide which is usually assayed for determination of glucose. This method suffers from the action of inhibitors which occur, particularly with patients in a diabetic coma and these need to be removed. 

Diabetic acidosis can develop in a matter of hours. Therefore, under certain circumstances, doctors may ask a diabetic patient to test for ketones at home using special test strips that can detect ketones in urine. For example, doctors recommend that diabetic patients test their urine every 4 to 6 hours if their blood sugar levels are very high. Patients should also test for ketones if they are sick with a cold or the flu, or if they experience any of the symptoms of acidosis. These symptoms include a very dry mouth, frequent urination, shortness of breath, and fruity smelling breath. Diabetic acidosis can be life-threatening, leading to a diabetic coma or death. It needs immediate medical care. Diabetic acidosis is also called ketoacidosis. 

The increased degradation of fat that occurs in insulin deficiency also has serious effects. Some of the fatty acids that accumulate in large quantities are taken up by the liver and used for lipoprotein synthesis (hyperlipidemia), and the rest are broken down into acetyl CoA. As the tricarboxylic acid cycle is not capable of taking up such large quantities of acetyl CoA, the excess is used to form ketone bodies (acetoacetate and p-hydroxy-butyrate see p. 312). As H"" ions are released in this process, diabetics not receiving adequate treatment can suffer severe metabolic acidosis (diabetic coma). The acetone that is also formed gives these patients breath a characteristic odor. In addition, large amounts of ketone body anions appear in the urine (ketonuria). 

Patients generally seek medical help because they want relief from disease. They have little interest in diagnosis—except in so far as it helps the doctor treat them more efficiently—and still less in the mechanism of their illness. Nevertheless, clinical chemistry traditionally has been more concerned with diagnosis and the elucidation of the mechanism of disease than with treatment. In only a few circumscribed areas, such as management of water and electrolyte imbalance, diabetic coma, and renal dialysis, has clinical biochemistry proved indispensable for treatment, the overall raison d etre of the health industry. 

Severe ketoacidosis/diabetic coma Insulin injection (regular insulin) may be given IV or IM for rapid effect in severe ketoacidosis or diabetic coma. 

Contraindications Diabetic complications, such as ketosis, acidosis, and diabetic coma, severe liver or renal impairment, sole therapy fortype 1 diabetes mellitus, or hypersensitivity to sulfonylureas... 

A specific complication of the use of large amounts of insulin during hyperosmolar diabetic coma is rhabdomyo-lysis (123). Low intramuscular phosphate and potassium concentrations, often masked by relatively high blood glucose concentrations, may be important contributory factors. 

Insulin, a large polypeptide, is not suitable for oral administration. Even if the insulin molecule survived digestion by proteases in the stomach and small intestine, this compound is much too large to be absorbed through the gastrointestinal wall. Consequently, insulin is usually administered through subcutaneous injection. Insulin may also be administered by the intravenous route in emergency situations (e.g., diabetic coma). 

INS-RTK agonist [hypoG] overdose yields hypoglycaemia, diabetic coma death Claus von Bulow convicted thence acquitted through Alan Dershowitz of attempted murder by insulin of his wealthy wife Sunny left in a comatose state (1980s)... 

I was already rushing down the hallway. She s going into diabetic coma, we need ananitubncenow Tell them the police might still have one on standby ... 

Hyperosmolar diabetic coma occms chiefly in noninsulin-dependent diabetics who fail to compensate for their continuing, osmotic glucose diuresis. It is characterised by severe dehydration, a very high blood sugar (> 33 mmol/1 600 mg/100 ml) and lack of ketosis and acidosis. Treatment is with isotonic (0.9%) saline, at half the rate recommended for ketoacidotic coma, and with less potassium than in severe ketoacidosis. Insulin requirements are less than in ketoacidosis, where the acidosis causes resistance to the actions of insuhn, and should generally be half those shown in Table 35.2. Patients are more liable to thrombosis and prophylactic heparin is used. 

Sole therapy for type I diabetes mellitus, diabetic complications (ketosis, acidosis, diabetic coma), stress situations (severe infection, trauma, surgery), severe renal or hepatic impairment. 

Conventional insulin treatment with its fixed insulin dosage and food intake has dominated therapy of insulin-dependent diabetes mellitus for nearly 70 years. It has sharply reduced the mortality of diabetic coma. Nevertheless diabetic coma is still the largest single cause of death in diabetic patients under the age of 20 years with an episode rate of 7%, and diabetic coma accounts for 15% of deaths in diabetics under the age of 50 years. 

Blood pyruvate concentration is not altered in most cases of diabetes mellitus (A5, D14, S28). Previous results, obtained by use of the colorimetric technique of Friedemann and Haugen (F12) and showing an apparent high pyruvate level during diabetic coma, are erroneous and are due to the interference of acetoacetic acid on pyruvic add determination with that technique (Lll, L12, L13). 

The elimination of citric acid was shown by many workers to be decreased in diabetic patients (B24, K18, 08, 012) thus, Otto (08) found that the amount of citrate excreted in urine during diabetic coma is only 2-10 % of the normal values. It is not established whether this hypocitraturia is related to a metabolic abnormaUty, due to the disease itself, or to the acidosis, or even to a renal failure during coma (08) it appears, however, that the magnitude in the decrease of urinary citrate is not related to the severity of the acidosis (08). One must add that, if the results of Rechenberger and Benndorf (R4) concerning the decrease of blood citrate levels are confirmed, diabetic patients present a simultaneous decrease in blood and urine citrate analogous to that found by Nordmann et al. (N17) during acute renal insuflBciency. 

Tolazamide should not be used in patients with bums, acidosis, diabetic coma, severe infection, ketosis, or severe trauma, or in those who are undergoing major surgery, because such conditions of severe physiologic stress require insulin for adequate blood glucose control. 

Should complexed forms of insulin fe.g., NPH, lente, or ultralente) be used in emergency situations (e.g., the therapy of diabetic coma) ... 

The characteristic signs and symptoms of alcohol intoxication are well known. Nevertheless, an erroneous diagnosis of drunkenness may occur with patients who appear inebriated but who have not ingested ethanol. Diabetic coma, for example, may be mistaken for severe alcoholic intoxication. Drug intoxication, cardiovascular accidents, and skull fractures also may be confused with alcohol intoxication. The odor of the breath of a person who has consumed ethanol is due not to ethanol vapor but to impurities in alcoholic beverages. Breath odor in a case of suspected intoxication can be misleading because there can be other causes of breath odor similar to that after alcohol consumption. BALs are necessary to confirm the presence or absence of alcohol intoxication. 

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