Thoughts On Immediate Care: Coma in Diabetic Patients
Thoughts On Immediate Care: Coma in Diabetic Patients
Thoughts On Immediate Care: Coma in Diabetic Patients
Hypoglycaemia
The differential diagnosis of a diabetic patient in coma should not present any undue
difficulty as the clinical pictures of hypoglycaemia (insulin coma) and diabetic ketosis
(diabetic coma) are so dissimilar. The symptoms of hypoglycaemia are caused by a
combination of excess sympathetic activity (e.g. sweating, pallor, palpitations, tremor,
weakness, hunger, apprehension and circumoral numbness), together with a lack of
available glucose for the brain to metabolise (neuroglycopenia) as shown by abnormal
behaviour patterns (irritability, obstinacy, confusion, agitation, ‘drunken behaviour’)
and neurological abnormalities (e.g. diplopia, dysphasia, ataxia, fits and coma).
Hypoglycaemia may also produce severe headaches and it is important to accurately
time the onset of this symptom in relation to the patient’s normal diabetic control and
regime. Clinically the hypoglycaemic patient is not dehydrated, is often sweating with
a normal or slightly raised pulse rate and blood pressure and may exhibit variable
neurological signs (with extensor plantar responses). Urinalysis will usually show that
D. S . J. Maw, MB, BS, MRCP, Consultant Physician, Pembury Hospital &Kent and Sussex Hospital,
Tunbridge Wells, Kent.
520
Emergency management of diabetes mellitus 521
sugar is absent but occasionally the test may be positive due to the presence of pooled
urine present in the bladder for several hours from a time when the blood sugar was
higher than the renal threshold. Occasionally in patients on oral hypoglycaemic
compounds more chronic hypoglycaemia may be found producing a confusional state
at night (particularly in elderly patients on chlorpropamide).
Treatment. There is usually no problem in the treatment of hypoglycaemic states.
If the patient is sufficiently conscious to take nourishment by mouth, then 10-20
g glucose or equivalent orally will rapidly bring about an improvement in the patient’s
condition. If the patient is unconscious then the intravenous administration of 10-
25 g glucose (20-50 ml of a 50% solution) will be adequate to restore consciousness in
the vast majority of patients. It is, however, always a sensible precaution to take a
blood sugar for estimation before giving the intravenous injection so that the level
can be checked if there is any doubt about the patient’s subsequent condition; rarely
intravenous glucose administration may prove technically difficult in obese, restless
patients and intramuscular glucagon 1 mg may then be prescribed instead followed by
oral glucose when the patient recovers consciousness.
A few patients instead of regaining consciousness immediately remain in a con-
fused, disorientated condition for some minutes or even some hours afterwards. Some
patients who have had severe, prolonged hypoglycaemia may not recover conscious-
ness after glucose either because of the presence of cerebral oedema or irreversible
brain damage; in this small minority of patients who have failed to respond to glucose,
it is worthwhile giving treatment for cerebral oedema such as high dose of glucocorti-
coid therapy (intravenous dexamethasone) or intravenous mannitol (100 ml of 20%
solution). When the patient has regained consciousness, the precipitating factor lead-
ing to hypoglycaemic state should be sought and appropriate adjustments made to the
patient’s regimen.
Diabetic ketosis
The clinical picture of diabetic ketosis takes longer to develop, with a minimum
period of several hours and often several days.
The history is of a progressive illness with increasing malaise, thirst, polyuria and
weight loss. Other symptoms are more variable and may include abdominal pain,
vomiting, confusion leading to coma, etc. but the clinical findings are characteristic.
The patient looks ill, shows signs of dehydration and salt depletion (rapid, weak,
thready pulse, low blood pressure, lack of skin elasticity, dry mouth and sunken eyes).
Respiration is deeper than normal and the rate is usually slightly increased (the air-
hunger of Kussmaul respiration). There is a strong smell of acetone on the breath but
there is a wide variation in sensitivity to this smell in different observers. Urinalysis
shows the presence of heavy glycosuria and ketonuria.
Treatment. Diabetic ketosis is more difficult to treat than hypoglycaemia and,
despite improved biochemical control, there is still a significant morbidity and mor-
tality attached to this complication. Different physicians use various treatment
schedules and medical practitioners, who only occasionally meet the complication,
may find that the therapy is rather confusing in some details. In order to understand
the principles involved, it is necessary to consider the underlying metabolic derange-
ment. If a diabetic is out of control, the lack of insulin leads to hyperglycaemia and
glycosuria-an osmotic diuresis which becomes quantitatively more severe with
D. S. J. Maw
increasing hyperglycaemia, and also causes some loss of sodium and potassium salts,
The patient feels thirsty and partially corrects the water loss with oral fluids, unless
unable to do so due to vomiting. The lack of insulin means that energy substrates,
other than carbohydrate, have to be mobilised causing breakdown of fat (and protein).
Ketone body production occurs as the process continues. This initially leads to a
compensated metabolic acidosis as ketonuria increases but the ketonuria greatly
increases the osmotic stress and his condition soon deteriorates as a florid metabolic
acidosis develops.
It follows that the following abnormalities require treatment in a patient with
diabetic ketoacidosis, lack of insulin, dehydration, loss of salts (sodium and potas-
sium), metabolic acidosis and any precipitating factor which may be present.
Insulin therapy should begin as soon as the clinical diagnosis is established. It is
important to use only quick-acting soluble insulin, and to administer it by a route
which will make it readily available, i.e. intravenously and/or intramuscularly. It is
illogical to give it subcutaneously when the patient is in a hypotensive and collapsed
condition and the blood supply to subcutaneous tissues is reduced, for insulin so
administered will only be absorbed slowly and in an unpredictable fashion. In a severe
case of diabetic ketoacidosis it may be necessary to give 100 units of insulin initially
(60 units intravenously and 40 units intramuscularly; that is a dose in units approxi-
mately equivalent numerically to l/lOth of the blood sugar level in mg/100 ml or
approximately twice the blood sugar in mmol per litre). Subsequent intramuscular
insulin therapy may be given on a 2-hourly basis, depending on the patient’s clinical
and biochemical response.
Over recent years a great deal of attention has been paid to the action of insulin and
it has been realised that in viuo insulin has a short half life of 5 minutes. This means
that it would clearly be more logical to give small amounts of insulin very frequently
or preferably to give insulin by slow infusion. This last technique is not a practical
proposition for general use as slow infusion pumps are needed and other precautions
have to be taken to avoid absorption of insulin onto glassware and drip tubing. A
satisfactory, simple compromise which has been adopted is the frequent intramuscular
administration of small quantities of insulin (say 10 units hourly)’; this has the ad-
vantage from the practical point of view that it is easy to carry out and the dosage is
easily remembered. When the blood sugar falls below 250 mg/100 ml (13.9 mmol/
litre), or when the glycosuria falls below 2%, the hourly injections of insulin should be
stopped and the patient can then be placed on a sliding scale of insulin on a 6-hourly
basis (Table 1).
2% ++++ 20
1% +++ 16
+% + + 10
I% + 6
0 - 0
Emergency management of diabetes mellitus 523
Sliding scales of insulin administration have been rightly criticised on the grounds
that either too much or too little insulin is given. They are, however, useful for the
emergency in the first 24 hours while one is assessing the patient's insulin needs. When
an assessment has been made of the approximate overall daily dosage, the sliding scale
principle can still be used but can be tailor-made so as to control diabetes with only a
low amount of glycosuria; as an example a patient normally on 30 units of insulin
would be controlled on the thrice daily sliding scale insulin shown in Table 2, with a
level of 4% glycosurja, but would not show wild swings from 0 to 2% with the same
frequency as the patient treated with the more traditional sliding scale where no insulin
is given if the patient has no glycosuria.
Intravenous fluids should be given at the same time as insulin therapy is started in
patients with diabetic ketoacidosis. There is often a considerable fluid deficit (possibly
about 7 litres) and it is consequently necessary to give large quantities of intravenous
fluid in the early stages and when the extra-cellular fluid has been replenished to a
significant extent, the pulse rate will begin to decrease and the blood pressure rise and
the renal perfusion will improve.
Physiological saline (0.9% sodium chloride) is the best solution to use in the early
stages; it has the advantage of being readily available on all wards and of being a
solution which does not provide an osmotic distorting stress and hence one which
can be given rapidly intravenously. An average adult will need approximately 1-2
litres of normal saline in the first hour and 1 litre in the second hour. The rate of
infusion should be less in older patients, or in any patients where there may be some
doubt as to myocardial state.
The clinician may need to consider administration of base at the end of the first
2 hours. This is, however, a matter of some controversy, since intravenous fluids
enable the kidneys to excrete more of the ketone load and insulin administration slows
down the rate of production of ketone bodies, both of which lessen the acidosis. The
administration of one-sixth molar sodium lactate has little to recommend it as this is
not active as base until lactate has been metabolised and there is in any case a block
in metabolism of lactate in diabetic ketosis. If on clinical and biochemical criteria the
patient is extremely acidotic (e.g. plasma bicarbonate below 8 mEq/litre or pH below
7.1) the administration of small quantities of sodium bicarbonate may be justified
524 D . S.J. Maw
mEq/litre give 0.45% saline if it is available. If the blood sugar level is not falling, give
a double dose of insulin.
(6) Change the intravenous infusion to 4.0% dextrose and 0.18% saline giving
1 litre every 4-6 hours plus additional potassium chloride as indicated by the results of
blood analysis. Measure the blood sugar every 2 hours.
(7) When the blood sugar is below 250 mg/100 ml (13.9 mmolllitre) change to a
sliding scale of insulin administration.
Anaesthesia
Diabetic patients should be adequately stabilised before undergoing any form of
elective operative treatment. If the procedure is going to be performed under local
anaesthesia there is obviously no particular problem regarding diabetic management.
Traditionally the anaesthetist normally supervises the control of the diabetic patient
over the operation and in the immediate postoperative period, handing control back
to his medical and surgical colleagues on the first postoperative day, although this
may vary in different centres.
The anaesthetist’s most important brief is to ensure that the patient does not suffer
either from hypoglycaemia or diabetic ketosis as a result of the stress of operation or
the illness leading to operation.
526 D.S. J. Maw
Pre-operative routines for all diabetics
A pre-operative blood sugar should be obtained in all diabetic patients to confirm that
diabetic control is adequate and to act as a base line in the event of there being any
problem in the postoperative period. All diabetic patients should be placed on diabetic
urine charts and regular checks carried out for sugar and ketone bodies (e.g. 4-hourly).
significant risk that vomiting may be produced. Many different schedules for insulin
administration have been described but their suitability depends on the severity of the
diabetes and nature of the operative procedure. The following procedures may be
used :
Soluble insulin in divided doses and intravenous dextrose. This scheme is the most
flexible and generally applicable of the schedules as it can be used on all insulin
dependent diabetics (whether mild or brittle) irrespective of the severity of the surgical
procedure and length of anaesthesia. It combines the advantage of flexibility with the
knowledge that the diabetes will be adequately controlled during the operative period.
It does require pre-operative stabilisation of the patient on twice daily soluble insulin,
however.
The timing of operation is important and it is preferable that the diabetic patient
should be operated on early in the morning list unless there is some cogent reason why
this should not be so.
Two-thirds of the predetermined morning dose of soluble insulin should be ad-
ministered at the usual time and an intravenous drip should be set up with 5%
dextrose to run in at the approximate rate of 500 ml every 6 hours during the period
that the patient is unable to take fluid by mouth. Additional intravenous injections of
glucose should also be given in order to ensure that the patient’s normal carbohydrate
intake is covered. This can be done by giving intravenous injections of 10 g glucose
(20 ml of 50% dextrose solution followed by 20 ml of 0.9% saline to prevent thrombo-
phlebitis).
The pre-operative blood sugar should be checked on the morning of operation and
it is useful to carry out a Dextrostix estimation at the same time as this method may be
used to keep a check on the blood sugar level during anaesthesia and in the immediate
postoperative period. It is, however, sensible to carry out a formal blood sugar
estimation in the Laboratory as well, as very occasionally discrepancies may occur,
usually due to incorrect technique.
The blood sugar should again be checked when the patient has returned to the
ward after operation, and the remaining third of the morning dose of insulin should be
then administered at lunchtime, unless the blood sugar level is on the low side of
normal, say below 110 mg/100 ml(6.1 mmol/litre) in which case it should be withheld.
The predetermined dose of insulin can then be given at the normal time in the
evening, together with oral fluids if the patient is able to take them, depending on the
nature of the surgical procedure. If this is not possible then the patient should con-
tinue with intravenous dextrose (or 4.0% dextrose in 0.18% saline). If the patient is
known to be a very brittle diabetic and very prone to ketosis it is advisable to divide
the insulin into four doFes, with a slightly reduced amount at midnight.
Pregnancy
Special precautions need to be taken in pregnant diabetics who are having a caesarean
section. The insulin demand drops within a couple of hours of delivery to the pre-
pregnancy level; if a caesarean section is being undertaken in the morning, the normal
pre-pregnancy dose of insulin should be administered rather than the dose that the
patient has been requiring over the previous few days. If operation is being deferred
until lunchtime or early afternoon, the current dose of soluble insulin may be ad-
ministered (but not isophane) and a close watch should be kept for postoperative
hypoglycaemia.
Emergency management of diabetes mellitus 529
Summary
Some of the acute metabolic derangements of unstable diabetes have been discussed.
The management of patients undergoing surgical operations has also been considered.
No problems are usually encountered in diabetic patients treated with diet alone or
with oral hypoglycaemic compounds, although chlorpropamide may need to be
stopped sometime before operation. Patients receiving insulin therapy should be
stabilised pre-operatively on a regimen which will allow more flexible management
during operation and in the postoperative period; this can be readily performed by
placing the patient on soluble insulin and giving spaced dosages. Other routines may
be used for minor procedures.
Adequate supplies of carbohydrate should be given in the form of intravenous
dextrose and under no circumstances should oral glucose be given in the 6 hours
before operation.
Acknowledgments
The author wishes to thank Dr R. C. King and Dr M. S. Everest for their helpful
criticism and Mrs L. J. Gosling for secretarial assistance.
References
1. FLETCHER, J., LANGMAN, M.J.S. & KELLOCK, T.D. (1965) Effects of surgery on blood sugar levels
in diabetes mellitus. Lancet, 2, 52.
2. OAKLEY, W.G., PYKE,D.A. & TAYLOR, K.W. (1968) Clinical diabetes and its biochemical basis.
Blackwell Scientific Publications, Oxford.
3 . MARRLE, A., WHITE,P., BRADLEY, R.F. & KRALL, L.P. (1971) Joslin’s diabetes mellitus, 11th edn.
Lea and Febiger, Philadelphia.
4. BLACK,K.O. & KING,R.C. (1971) Anaesthesia in diabetes mellitus. In: General Anaesthesia,
(Ed. by T. C. Gray and J. F. Nunn), 3rd edn, Vol. 2, p. 54. Butterworths, London.
5. ALBERTI, K.G.M., HOCKADAY, T.D.R. & TURNER,R.C. (1973) Small doses of intramuscular
insulin in the treatment of diabetic ‘coma’. Lancet, 2, 515.