tailieunhanh - Diabetes in Old Age - part 3

Theo DKA, các đặc điểm lâm sàng của tình trạng hôn mê tiếng còi bao gồm các triệu chứng thẩm thấu, sự suy giảm chung, nhưng đặc biệt có thể bao gồm các triệu chứng thần kinh như ® ts và thần kinh đầu mối de | 56 DIABETES IN OLD AGE As per DKA the clinical features of HONK coma include osmotic symptoms general deterioration etc. but in particular can include neurological symptoms such as fits and focal neurological deficits Lorber 1995 . Again the first step in management is to recognize that a problem exists and to perform the tests to look for HONK coma establish baseline biochemical variables and look for an underlying cause. The main difference from DKA is in the type of fluid replacement. Use half-normal mM saline if serum sodium is 150 mM or more but if the patient is hypotensive use normal saline or colloid in similar rates to DKA until the hypotension is corrected when the hypernatraemia needs attention. The insulin infusion used is the same as for DKA but these patients may be quite insulin-sensitive. Otherwise the management is very similar to that for DKA. After the illness the patient may or may not be controlled on diet alone. Anticoagulation in Hyperglycaemic Coma There is a major threat of acute thrombotic events in HONK coma and full anticoagulation has been employed. However unless the indications are strong pulmonary embolism large deep vein thrombosis unstable angina the author would not fully anticoagulate the subject since many with HONK have haemorrhagic gastritis the vascular event may already have happened prior to medical attention and there are no studies to guide US on this decision. Other authors Krentz and Nattrass 1997 Alberti 1989 Small et al 1988 also do not support the need for full anticoagulation. Given the subject s immobility always consider deep venous thrombosis prophylaxis in subjects with hyperglycaemic coma. Traps for the Unwary in Subjects with Hyperglycaemic Coma Ketone bodies can interfere with the creatinine assay so that an elevated creatinine may be due to ketosis rather than to impaired renal function Page and Hall 1999 Kitabchi and Murphy 1988 . Ketosis can also cause a falsely elevated amylase level Page and Hall .