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PubMedDate not supplied

Uncontrolled diabetes mellitus in adults: experience in treating diabetic ketoacidosis and hyperosmolar nonketotic coma with low-dose insulin and a uniform treatment regimen.

A number of changes in therapy of uncontrolled diabetes have occurred in recent years. These include low-dose insulin regimens, often routine phosphate repletion, more cautious bicarbonate replacement, infusion of larger fluid volumes, the use of hypotonic solutions in hyperosmolar states, and recently magnesium repletion. These modalities (with the exception of routine magnesium repletion) have been employed at North Central Bronx Hospital since its opening in 1976. Through this retrospective analysis of 275 cases of uncontrolled diabetes we have tried to answer the following questions: What is the outcome of all episodes of uncontrolled diabetes in a municipal hospital population with a uniform treatment protocol? What are the results of treatment with new modalities in various age groups? Are the causes of death different from those tabulated in previous reports? Our results indicate a good outcome in those under the age of 50 yr regardless of the diagnosis of hyperosmolar nonketotic coma (HNC) or diabetic ketoacidosis (DKA). Mortality from DKA was 2% in those under age 50 yr and 26% in the older age group. Surprising was the low mortality in the hyperosmolar group with 0% mortality under age 50 yr and 14% in patients over this age. The major categories of causes of death in the series included sepsis, adult respiratory distress syndrome (ARDS), metabolic, cardiovascular, and shock. With the exception of ARDS, these categories were not different from other reported series. There were few thromboembolic events in this series.(ABSTRACT TRUNCATED AT 250 WORDS)

Bicarbonates↗
PubMedDate not supplied

A comparison of the Glasgow Coma Scale and the Swedish Reaction Level Scale.

The Glasgow Coma Scale (GCS) and the Swedish Reaction Level Scale (RLS85), two level-of-consciousness scales used in the assessment of patients with head injury, were compared in a prospective study of 239 patients admitted to a regional head injury unit over a 4-month period. Assessments were made by nine staff members ranging from house officer to registrar, after briefing about the two scales. Data were also collected on age, nature of injuries, surgical treatment, and condition at discharge or transfer using the Glasgow Outcome Scale. Both the GCS and the RLS85 reliably identified comatose patients and those with minor head injury, but were much less effective in defining the response level in patients considered to have a moderate head injury. Only 41% of the patients allocated to a moderate-head-injury category by the GCS and the RLS85 were common to both groups. Where a mismatch occurred, neither scale allocated patients to a 'better' or 'worse' category more frequently than the other. Assessment of patients' conscious levels using the GCS was difficult in only two cases. One patient had facial injuries, and the other was intubated. The RLS85 was reported by all users to be simpler to use than the GCS, but the latter is much more widespread in use. Both scales function well in cases of severe and minor head injury, but have weaknesses when defining moderate head injury. Level-of-consciousness scales are only an aid to assessment and the final choice between the two scales must remain a matter of personal or departmental preference.

Activities of Daily Living↗
PubMed1996

Naloxone-reversible coma unrelated to opiate drugs.

A role for endogenous opioids in central nervous system disorders has often been proposed. A case report is presented of a 47-year-old male, medicated only with carbamazepine and lithium, who developed a precipitous alteration of consciousness (Glascow coma scale = 4). An extensive medical workup did not reveal an underlying cause. He exhibited a graded awakening with two intravenous doses of naloxone, which gradually reversed as the last naloxone dose was eliminated. Immunoassay and thin-layer chromatography of two urine samples (to evaluate the possibility of a medication error, alcohol ingestion, or illicit drug use) revealed only the presence of carbamazepine. A dysregulation of the endogenous opioid system is believed to underlie this episode.

Atrophy↗
PubMed2004

Successful use of the new high-dose mannitol treatment in patients with Glasgow Coma Scale scores of 3 and bilateral abnormal pupillary widening: a randomized trial.

OBJECT: The authors evaluated long-term clinical outcomes in selected acutely comatose patients with severe diffuse brain swelling and recent clinical signs of impending brain death who received a novel high-dose mannitol treatment compared with those who received conventional-dose mannitol in the emergency room. METHODS: Forty-four adult patients with traumatic, nonmissile-inflicted, acute, severe diffuse brain swelling were prospectively and randomly evaluated. All patients were selected based on the presence of recent clinical signs of impending brain death on the first emergency room evaluation. These signs included bilateral abnormal pupillary widening and lack of motor responses to painful stimulation (Glasgow Coma Scale score of 3). The study group (23 patients) received ultra-early and fast intravenous high-dose mannitol treatment (approximately 1.4 g/kg), whereas the control group (21 patients) received half that dose (approximately 0.7 g/kg). Ultra-early improvement of bilateral abnormal pupillary widening was significantly more frequent in the high-dose mannitol group than in the conventional-dose group (p < 0.02). High-dose mannitol treatment in the emergency room was also associated with significantly better 6-month clinical outcomes (p < 0.02); the best rate of favorable outcomes was 43.5%, compared with only 9.5% in the conventional-dose mannitol group. The two groups of patients were well matched with respect to all emergency room and head computerized tomography findings, as well as the timing of initial mannitol treatment (approximately 80-90 minutes after the first evaluation at the scene of the injury). Comparative evaluation of bilateral pupillary widening between the scene of the injury and the emergency room showed no significant differences between groups, whereas mannitol dose dependence was statistically significant (p < 0.05), insofar as early pupillary improvement in the emergency room was concerned. CONCLUSIONS: Ultra-early high-dose mannitol administration in the emergency room is the first known treatment strategy significantly to reverse recent clinical signs of impending brain death, and also to contribute directly to improved long-term clinical outcomes for these patients who have previously been considered unsalvageable.

Acute Disease↗
PubMed1992

Early prediction of outcome from coma.

It is increasingly important to be able to predict early in the course of illness a patient's outcome from coma. Potential indicators include clinical scales, electrophysiologic responses, and cerebral blood flow and metabolism. Our current knowledge provides some understanding of the ultimate impact of the illness, but is of limited assistance in decisions regarding initiation or withdrawal of therapy.

Brain↗
PubMed1990

[Psychic life and awakening from coma in neurosurgical intensive care].

What is knowable concerning the lived experience and the psychopathology of patients during the border state between coma and waking? The waking up period appears divided in two parts: "apparent incommunicability" and "waking in strangeness". A pluridisciplinary follow-up seems necessary for patients beginning with the neurosurgical reanimation process.

Coma↗
PubMed1990

[Clinical evaluation of coma states].

Coma is difficult to define and the different gradings and scales (Glasgow, Liège) are practically used and usefull. The development of pre-hospital management and patient imaging make clinical evaluation in the acute phase of lesser importance. Brain death pose a problem for diagnostic, features (permanent loss of cerebral functions) and legal aspects. Loss of integrated neuronal functions with persistent brain stem activity will define persistent vegetative state.

Age Factors↗
PubMed1990

[A case report of hyperosmolar hyperglycemic non-ketotic coma after aortic valve replacement].

A 56-year-old man without a past history of diabetes mellitus underwent aortic valve replacement. On the 8th postoperative day, the patient became confused with a peak blood glucose level of 600 mg/dl and peak serum osmolarity level of 411 mOsm/l, without ketotic urine. The diagnosis of hyperosmolar hyperglycemic non-ketotic coma (HHNKC) was made, and the patient was immediately treated with massive infusion of 0.45% saline water and continuous insulin administration, and the patient could completely recover. It is important to prevent and keep in mind the complication of HHNKC for the postoperative care after open heart surgery.

Aortic Valve↗
PubMed1990

[Hyperosmolar hyperglycemic coma in a 10-year-old patient].

A ten-year-old patient referred to a child ambulatory for preoperative examination suddenly falls unconscious. The physical finding and laboratory results suggest hyperosmolar hyperglycaemic coma. The authors describe the clinical course and therapeutic procedure. They draw attention to adequate fluid and ion repletion, to the importance of their balancing and to possible complications of treatment.

Child↗
PubMed1990

[Non-ketotic hyperosmolar diabetic coma in neurosurgical cases; review of 7 cases].

Neurosurgical patients with non-ketotic hyperosmolar diabetic coma (NHC) in our institution were analysed retrospectively. Seven cases were diagnosed as NHC being 0.47% of the number of inpatients in the last 5 years. The age ranged from 60 to 72 years old (mean 65) and there were 6 males and 1 female. Only 2 patients (29%) had a clear past history of diabetes mellitus. Prior to the NHC, systemic infection was present in 2 cases. Intravenous hyperalimentation (IVH) was performed in 5 cases, glycerol osmotherapy in 3 cases, diphenylhydantion therapy in 3 cases and tube feeding in 2 cases. The overall mortality rate in our series was 71% (5 cases), of which 2 cases died within 2 days due to cardiopulmonary failure, and 3 cases in the chronic stage died due to disseminated intravascular coagulopathy (DIC), or due to renal failure. The prognosis of NHC in neurosurgical patients is generally bad because of the presence of consciousness disturbance prior to the onset of NHC, which may mask the symptoms occurring from the NHC. Other predisposing factors could be systemic infection, IVH or tube feeding, and osmotic agents which are frequently used in neurosurgical patients. There was a tendency for NHC to occur predominantly in the chronic stage after the blood sugar had returned to normal range from the hyperglycemic state in the acute stage.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1987

Hyperosmolar, hyperglycemic, nonketotic coma in a patient receiving home total parenteral nutrient therapy.

A patient who developed hyperosmolar, hyperglycemic, nonketotic coma (HHNC) while receiving home total parenteral nutrient (TPN) therapy is described, and the etiology, clinical features, and treatment of HHNC are reviewed. A 51-year-old black man diagnosed as having Dukes' stage D signet-cell carcinoma of the rectum was discharged on home TPN therapy after a prolonged hospital course and the persistence of a gastrointestinal fistula. Seventeen days after discharge, the patient developed polyuria, became febrile, and lost mental acuity. Upon hospitalization, the patient's physical condition and laboratory values were consistent with the diagnosis of HHNC. The patient was treated with intravenous fluids and small quantities of insulin. The patient's home records indicated that he had lost large volumes of fluid through his fistula, resulting in a net negative fluid balance. The patient's records also indicated that he had had mild glycosuria with a normal urine output at home. This normal urine output despite a body-fluid deficit could be explained by osmotic diuresis related to either glucose or urea. Hypotonic fluid loss resulting from fistula output and osmotic diuresis may have led to this patient's hypertonic state and critical illness. The patient died on hospital day 11 as a result of widely disseminated cancer. HHNC arises most often as a complication of non-insulin-dependent diabetes. It is also a major complication resulting from hypertonicity related to glucose intolerance or other conditions that can occur in patients receiving TPN therapy. The underlying cause of the hyperosmolar state appears to be dehydration.(ABSTRACT TRUNCATED AT 250 WORDS)

Diabetic Coma↗
PubMed1988

[Hyperosmolar coma in a premature newborn infant: iatrogenic complication of parenteral feeding].

The authors report the case of a 34-week preterm newborn weighing 1,545 g receiving a parenteral mixture by a central venous catheter. A mistake in the flow-rate program led to the infusion of 200 ml within 2 h. Coma occurred quickly and the patient showed intracellular dehydration, polyuria, metabolic acidosis, hyperglycemia and hyponatremia. The therapeutic aim was the correction of dehydration and acidosis, as well as the prevention of secondary hypoglycemia. Clinic and biologic symptoms disappeared 6 h later Volumetric infusion pumps need permanent safe and accurate control of volume flow-rate.

Diabetic Coma↗
PubMed1987

Hyperosmolar nonketotic diabetic coma: diagnosis and management.

Hyperosmolar nonketotic diabetic coma (HHNC) is a syndrome of acute decompensation of diabetes mellitus, occurring mainly in the elderly and characterized by marked hyperglycemia, hyperosmolarity, severe dehydration, occasional neurological signs, obtunded sensorium, and absence of ketonemia or acidosis. The mortality is high. Early aggressive therapy with large amounts of normal or half normal saline, insulin, and potassium is of prime importance. Since associated diseases cause most fatalities the importance of managing these problems effectively cannot be overemphasized. Complications of therapy can be congestive heart failure secondary to excessive fluid administration, hypoglycemia if too much insulin is given, and hypokalemia if potassium is inadequately replaced.

Aged↗
PubMed1986

[Nonketotic hyperosmolar coma. Clinical aspects and treatment in 12 cases].

Non-ketotic hyperosmolar diabetic coma is a complication of diabetes characterised by extreme dehydration, plasmatic hyperosmolarity and the absence of ketosis. The mortality rate is very high, especially in elderly subjects with type II diabetes. A personal series of 12 cases is reported with an assessment of general features, triggering factors, biochemical parameters at onset and treatment given. The data confirm reports in the literature and the results show the therapeutic superiority of continuous endovenous infusions of insulin at 3-10 mu/hour over other treatment protocols.

Aged↗
PubMed1986

Hyperosmolar coma treated with intravenous sterile water. A study of three cases.

Three patients with hyperosmolar coma were treated with intravenous isotonic saline, dextrose, and hypotonic saline solutions. The development of pulmonary edema and increasing hypernatremia precluded the further use of sodium solutions, and the presence of severe hyperglycemia made the further use of dextrose solutions undesirable. To provide further solute-free fluid, intravenous sterile water was administered through a central venous catheter. The hyperosmolar state improved, and all patients survived without biochemical evidence of hemolysis or clinical evidence of cerebral edema.

Aged↗
PubMed1985

Hyperosmolar nonketotic diabetic coma.

Hyperosmolar nonketotic coma occurs most frequently in the elderly patient with underlying renal impairment. It often has an insidious onset, and may be precipitated by an identifiable illness, medication or procedure. Various neurologic manifestations may occur and obscure the diagnosis. Rapid recognition and appropriate treatment can greatly reduce the high mortality rate.

Aged↗
PubMed1984

[Nontraumatic rhabdomyolysis with reversible acute kidney failure following hyperosmolar diabetic coma in a child].

A 9 10/12 year year old girl developed severe hyperosmolar diabetic coma, and 5 days later acute renal failure. Extremely elevated levels of myoglobin were measured in serum and urine with a radioimmunoassay kit leading to the diagnosis of atraumatic rhabdomyolysis. Intermittent hemodialysis was performed for 2 weeks. Subsequently myoglobin and creatinine values in serum returned to normal. Psychological disturbances and paresis of the lower extremities subsided 4 resp. 12 weeks after the onset of acute illness.

Acute Kidney Injury↗
PubMedDate not supplied

Optimal insulin delivery in diabetic ketoacidosis (DKA) and hyperglycemic, hyperosmolar nonketotic coma (HHNC).

Both diabetic ketoacidosis (DKA) and hyperglycemic, hyperosmolar nonketotic coma (HHNC) are stressful metabolic occurrences brought about by the orchestration of numerous events. Adequate hydration and replacement of electrolytes, along with physiologic doses of insulin, are treatment objectives for both of these conditions. Additionally, the physician must search for the factors precipitating these events and frequently evaluate the patient's overall condition.

Biological Availability↗