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Query: UMLS:C0011849 (diabetes)
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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.
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PMID:Hyperosmolar nonketotic diabetic coma: diagnosis and management. 331 90

Aorto-coronary (A-C) bypass operations were performed in 20 patients aged 68 to 78 years, and the indications for this operation were discussed retrospectively. The subjects consisted of 14 patients successfully operated and six patients unsuccessfully operated (death 3, graft occlusion 2, perioperative infarction 1). The results were as follows: Average age: There was no difference between the successful group (71.1 +/- 3.3 years; mean +/- SD) and the unsuccessful group (70.3 +/- 2.9 years). Coronary arteriographic findings: The average number of narrowed branches (greater than or equal to 75% stenosis) was 4.3 +/- 3.0 in the successful group (triple vessel disease in 12 cases and double vessel disease in four) and 2.7 +/- 0.5 in the unsuccessful group (triple vessel disease in four and double vessel disease in two), showing no significant difference between the two groups. Nine patients (64.3%) in the former group and one (16.7%) in the latter group had significant left main coronary artery disease (greater than or equal to 50% stenosis). Hemodynamic findings: Ejection fractions of less than 40% existed in three patients (50%) solely in the unsuccessful group; two of whom died. Left ventricular end-diastolic pressures of 30 mmHg or more existed in two cases (33.3%) only in the latter group. Other cardiac findings: Left ventricular end-diastolic dimension of 55 mm or more was found in one (7.1%) successful case and four (66.7%) unsuccessful cases. 201Tl-scintigrams showed a dilated left ventricular cavity in one case (7.1%) in the former group and two (33.3%) in the latter. Functions of other organs: Forced expiratory volume 1.0% or % vital capacity less than 70% was recognized in two cases (33.3%) only in the latter group. A level of serum creatinine more than 1.5 mg/dl was seen in only one case in the latter group. A case with advanced diabetes mellitus was present in the unsuccessful group, and this patient died of diabetic coma. A-C bypass operations are indicated for elderly patients when they have good cardiac function and have no complications of the kidneys, lungs and other organs. It is presumed that grafting the main coronary branches, thereby shortening the time of cardiopulmonary arrest prevents postoperative complications.
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PMID:[Indications for aortocoronary bypass operation in elderly patients: medical point of view]. 349 11

Hyperosmolar hyperglycemic nonketotic diabetic coma after cardiac operations was reviewed in a total of 12 patients from the literature and from my experience in an attempt to determine the clinical features of this condition. Among the unique features of this disease were the following: The mortality is high (42%). The morbidity and mortality are higher in patients with no previous history of diabetes mellitus (67% and 50%) than in those with such a history (33% and 25%). Polyuria is usually a heralding symptom. There is an average time lag of 6 days between the onset of polyuria and the established diagnosis of hyperosmolar hyperglycemic nonketotic diabetic coma. The time lag in patients who died was 7.5 +/- 0.8 days (mean +/- standard error of the mean), significantly longer than in survivors (4.5 +/- 0.8 days). Polyuria usually emerges after the stormy immediate postoperative days have passed (on postoperative day 5.3 on the average). Polyuria is generally regarded as a favorable sign not suggestive of complicating hyperosmolar hyperglycemic nonketotic diabetic coma. Therapies known to precipitate this disorder are continued even after development of polyuria. Gastrointestinal bleeding can be a precipitating factor. Hyperalimentation or elemental diet may cause dehydration and trigger hyperosmolar hyperglycemic nonketotic diabetic coma. A high or rising serum sodium concentration and/or blood urea nitrogen level with polyuria may be a warning sign of this complication. Too hasty correction of the hyperosmolar state can be dangerous. Pulmonary dysfunction may be involved in the symptoms of hyperosmolar hyperglycemic nonketotic diabetic coma.
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PMID:Clinical features of hyperosmolar hyperglycemic nonketotic diabetic coma associated with cardiac operations. 352 Jan 59

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.
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PMID:[Nonketotic hyperosmolar coma. Clinical aspects and treatment in 12 cases]. 352 2

This study was performed to examine the relationship between postmortem biochemical values and cause of death. The follow samples were taken from 399 corpses: cerebrospinal fluid (CSF; n = 376, suboccipital), blood (n = 158, femoral vein), and urine (n = 101, at autopsy). (See Table 1 for causes of death) All samples were stored at -80 degrees C. A further 100 samples of blood were later taken and stored at +4 degrees C before testing. Biochemical determinations made were: glucose in CSF, blood, and urine (hexokinase method); lactate (LDH/GPT) and free acetone (HS-gas chromatography) in CSF; hemoglobin A1 in blood (microcolumn technique). In 34 cases fatal diabetic coma was considered verified by morphological and chemical findings. One hundred cases of sudden cardiac death were chosen as the main control group. In 32 of the 34 cases defined above, the value of the formula of Traub (glucose + lactate in CSF) exceeded 415 mg/dl. It is not influenced significantly by hyperglycemia or hyperlactatemia due to factors other than diabetes (i.e., carbon monoxide, asphyxia). After death the value rose till the 30th hpm, then remained stable for at least 1 week. Fatal coma was defined as the ketoacidotic form if free acetone in CSF ranged above 21 mg/l. In these cases, CSF glucose and free acetone correlated positively. Hemoglobin A1 remained stable after death. Its amount was independent from postmortem blood glucose, postmortem interval and total hemoglobin. Furthermore, the manner of storage (-80 degrees or +4 degrees C) had no significant influence on its values. In 29 of 34 cases of fatal coma, Hb A1 exceeded 12.1%. Analysis of urine glucose showed elevated levels (over 500 mg/dl) in diabetic comas. On conclusion, fatal diabetic coma seems indicated as the cause of death if measured values of postmortem biochemistry exceed the following limits: CSF-Traub 415 mg/dl, free acetone (CSF) 21 mg/l; Hb A1 12.1%; urine glucose 500 mg/dl. Most important are the Traub formula and hemoglobin A1. Usually, in fatal coma both values are elevated. If both of them are normal, diabetic coma can nearly be excluded. Combined evaluation of all values is absolutely necessary. Morphology must also always be taken into account. Consequently, a diagnosis of fatal coma can be obtained by a process of elimination.
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PMID:[Biochemical measurements of glucose metabolism in relation to cause of death and postmortem effects]. 376 99

The descriptive epidemiology of diabetic coma at onset was investigated in a nationwide survey of insulin-dependent diabetic (IDDM) children (age at onset less than 18 yr) throughout Japan for the years 1970-81. Of the 1172 cases, 148 (12.6%) were unconscious at onset. Diabetic coma was highly associated with abnormalities in the biochemical variables. There was no sex difference in the frequency of coma; however, there was an inverse association with age wherein children under 5 yr of age were approximately two times more likely to present in coma than older children. There was a strong association with reported infections wherein patients with coma were more than twice as likely to report infection than patients without coma. It seemed that the frequency of coma did not decline during the study period. The risk of dying at onset was very high; diabetic children in coma (4.7%) were 12 times more likely to die than patients without coma.
Diabetes 1985 Dec
PMID:Coma at the onset of young insulin-dependent diabetes in Japan. The results of a nationwide survey. Japan and Pittsburgh Childhood Diabetes Research Groups. 386 5

Diabetes mellitus affects almost 5.5 million Americans each year. An estimated additional 5 million individuals may have diabetes, but remain undetected. Individuals with diabetes are at high risk for the development of micro- and macrovascular disease, diabetic coma and adverse outcome of pregnancy. The rate at which these complications develop are now partially identifiable for the United States. For 5 potentially preventable complications (retinopathy, adverse outcome of pregnancy, vascular disease, nephropathy and diabetic coma) the morbidity and mortality rates can now be calculated. There exist 50,000 cases of blindness due to diabetes with an additional 5800 new cases each year. Adverse outcome of diabetic pregnancy occurs in over 18,000 births each year, with as many as 4500 related perinatal deaths. Each year 40,000 diabetics are required to have a lower extremity amputation. Of the already 70,000 diabetics who have had an amputation, 25,000 will die this year. End stage renal disease affects 4000 diabetics each year. During the same time period, of the 7500 existing cases of end stage renal disease, 2000 will result in mortality cases. Diabetic coma (DKA and HHNK) accounts for 67,400 hospitalizations and results in 3600 deaths each year. Together these complications and those associated with cardiovascular disease account for 323,000 deaths with diabetes as the underlying or contributing cause in the United States.
Diabetes Res Clin Pract 1985 Oct
PMID:An epidemiological model for diabetes mellitus in the United States: five major complications. 393 16

Two West Indian men with no previous history of diabetes mellitus developed hyperosmolar non-ketotic diabetic coma. Intra-abdominal catastrophes secondary to mesenteric thrombosis played a major part in the death of these patients, in both of whom control of the hyperosmolar state had been achieved. Both patients had evidence of infarction of intestine at necropsy. Vascular thromboses are a major complication of this form of coma and must be considered when such patients develop signs of an acute abdomen.
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PMID:Hyperosmolar non-ketotic diabetic coma: with particular reference to vascular complications. 531 81

Adrenal cortical response in acute medical illness has been studied by measuring the plasma 11-hydroxycorticosteroid (11-OHCS) concentration in 178 patients. Those with unbalanced diabetes, acute infections, and severe myocardial infarction had high levels. The results obtained suggest that in a patient with a severe infection and hypotension a plasma 11-OHCS level of less than 15 mug./100 ml. indicates an inadequate adrenal cortical response, and one patient with septicaemia and temporary adrenal cortical insufficiency is described. Growth hormone levels were increased in patients with severe diabetic ketosis but not in those with hyperosmolar non-ketotic diabetic coma.
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PMID:Plasma 11-hydroxycorticosteroid and growth hormone levels in acute medical illnesses. 579 69

The physiopathology and clinical picture of hyperosmolar diabetic coma are described, and four personal cases are presented. This form of coma is a rare, but particularly serious complication of diabetes mellitus. Since its prognosis is poor, even when suitable treatment is provided, the greatest possible care should be devoted to preventing its main cause, namely dehydration.
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PMID:[Hyperosmolar diabetic coma. Case reports and review of the literature]. 633 18


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