There are 2 types: Diabetic ketoacidosis and Nonketotic hyperosmolar coma.
Diagnosis of Diabetic ketoacidosis (DKA):
D → dehydration
K → ketosis
A → acidosis
Dehydration: Sweeting or dry skin - woody tongue - hypotension - shock.
Ketosis: Epigastric pain - acetone odour in breathing - nausea & vomiting.
Acidosis: deep rapid breathing.
Clinically → random glucose more than 200.
Hyperosmolar nonketotic coma differs from Diabetic ketoacidosis in:
* very very severe dehydration.
* very high blood sodium so when you give saline give 0.45% not 0.9%.
Treatment:
Insulin - Fluids - Electrolytes - Heparin - Treatment of precipitating factors - Symptomatic
treatment.
1- Fluids to treat and prevent dehydration to prevent renal failure.
Give saline 0.9% (in Diabetic ketoacidosis) in the following way:
* 2 liters in first 2 hours
- 500 ml in first 15 minutes.
- 500 ml in second 15 minutes.
- 500 ml in next 30 minutes.
- 500 ml in the remaining 1 hour.
- after that 500 ml every 2 hours.
* The patient takes about 5 & 1/2 to 7 & 1/2 liters of saline a day.
2- Insulin:
R/ Actrapid insulin using 100 unit syringes by one of the following methods.
A- IM method.
- Calculating the dose according to blood sugar:
* (150 Mg/dl - 200 Mg/dl → 5 units) - (200 Mg/dl - 250 Mg/dl → 10 units) - (250 Mg/dl - 300 Mg/dl → 15 units) - (300 Mg/dl - 350 Mg/dl → 20 units) and so on.......
e.g. If blood sugar of the patient is 400 Mg/dl give him 30 units insulin IM and so on.
Then:
- Give the patient 10 insulin units IM every hour and urinary acetone follow up every 1/2 hour till glucose
reaches 250 Mg/dl then give the patient 10 units subcutaneous and then the patient may go home.
- But the best is:
Through 48 hours → measure blood sugar every 6 hours, calculate the dose according to blood sugar and
give it to the patient then calculate the average dose of insulin per day.
e.g. If the patient received 150 units during 48 hour so the average dose per day is 75 units then give the patient:
R/ Insulin Mixtard 75 units
→ 2/3 the dose in the morning.
→ 1/3 the dose in the evening.
B- Infusion method:
500 ml saline + 50 insulin units in the saline solution + 3 ml of the patient blood.
* The advantage of patient blood in the solution is to prevent precipitation or deposition of insulin on the wall of the bag of the solution.
* Infusion rate: 15 - 20 drops per minute.
If faster → may lead to hypoglycemia.
C- IV method:
Start with 10 - 20 units IV actrapid insulin then continue as in IM or infusion method.
NB: If blood sugar reaches 250 mg/dl and still there is acetone in urine, stop saline and give only 100 ml
glucose 25% instead while insulin is in the other hand as before.
3- Electrolytes:
Take blood sample as soon as the patient comes and measure blood Na & K (normal K level = 3.5 -5.5).
* If normal K, give K ampoule in the solution every 2 hours.
* If low K, give K ampoule in the solution every 2 hours.
* If K is below 2.5, give 2 K ampoules in the solution every 2 hours.
4- Heparin:
If old patient, give heparin subcutaneous.
R/ heparin ampoule SC (5000 units) as dehydration may cause cerebral thrombosis.
Treatment of Hyperosmolar coma: as treatment of diabetic ketoacidosis but there is no acetone in urine.
Diagnosis of Diabetic ketoacidosis (DKA):
D → dehydration
K → ketosis
A → acidosis
Dehydration: Sweeting or dry skin - woody tongue - hypotension - shock.
Ketosis: Epigastric pain - acetone odour in breathing - nausea & vomiting.
Acidosis: deep rapid breathing.
Clinically → random glucose more than 200.
Hyperosmolar nonketotic coma differs from Diabetic ketoacidosis in:
* very very severe dehydration.
* very high blood sodium so when you give saline give 0.45% not 0.9%.
Treatment:
Insulin - Fluids - Electrolytes - Heparin - Treatment of precipitating factors - Symptomatic
treatment.
1- Fluids to treat and prevent dehydration to prevent renal failure.
Give saline 0.9% (in Diabetic ketoacidosis) in the following way:
* 2 liters in first 2 hours
- 500 ml in first 15 minutes.
- 500 ml in second 15 minutes.
- 500 ml in next 30 minutes.
- 500 ml in the remaining 1 hour.
- after that 500 ml every 2 hours.
* The patient takes about 5 & 1/2 to 7 & 1/2 liters of saline a day.
2- Insulin:
R/ Actrapid insulin using 100 unit syringes by one of the following methods.
A- IM method.
- Calculating the dose according to blood sugar:
* (150 Mg/dl - 200 Mg/dl → 5 units) - (200 Mg/dl - 250 Mg/dl → 10 units) - (250 Mg/dl - 300 Mg/dl → 15 units) - (300 Mg/dl - 350 Mg/dl → 20 units) and so on.......
e.g. If blood sugar of the patient is 400 Mg/dl give him 30 units insulin IM and so on.
Then:
- Give the patient 10 insulin units IM every hour and urinary acetone follow up every 1/2 hour till glucose
reaches 250 Mg/dl then give the patient 10 units subcutaneous and then the patient may go home.
- But the best is:
Through 48 hours → measure blood sugar every 6 hours, calculate the dose according to blood sugar and
give it to the patient then calculate the average dose of insulin per day.
e.g. If the patient received 150 units during 48 hour so the average dose per day is 75 units then give the patient:
R/ Insulin Mixtard 75 units
→ 2/3 the dose in the morning.
→ 1/3 the dose in the evening.
B- Infusion method:
500 ml saline + 50 insulin units in the saline solution + 3 ml of the patient blood.
* The advantage of patient blood in the solution is to prevent precipitation or deposition of insulin on the wall of the bag of the solution.
* Infusion rate: 15 - 20 drops per minute.
If faster → may lead to hypoglycemia.
C- IV method:
Start with 10 - 20 units IV actrapid insulin then continue as in IM or infusion method.
NB: If blood sugar reaches 250 mg/dl and still there is acetone in urine, stop saline and give only 100 ml
glucose 25% instead while insulin is in the other hand as before.
3- Electrolytes:
Take blood sample as soon as the patient comes and measure blood Na & K (normal K level = 3.5 -5.5).
* If normal K, give K ampoule in the solution every 2 hours.
* If low K, give K ampoule in the solution every 2 hours.
* If K is below 2.5, give 2 K ampoules in the solution every 2 hours.
4- Heparin:
If old patient, give heparin subcutaneous.
R/ heparin ampoule SC (5000 units) as dehydration may cause cerebral thrombosis.
Treatment of Hyperosmolar coma: as treatment of diabetic ketoacidosis but there is no acetone in urine.
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