Hyperosmolar Nature of Diabetic Coma Milford Fulop, M.D., Andrew Rosenblatt, M.D., Stephen M. Kreitzer, M.D., and Brett Gerstenhaber, M.D., New York

SUMMARY Stupor in patients with nonketotic hyperglycemia has been ascribed to hyperosmolarity, but the cause of depressed consciousness in patients with ketoacidosis has been puzzling. In this study, blood pH, serum glucose and sodium concentrations, and serum osmolality were measured in eighty-five consecutive episodes of diabetic ketoacidosis and forty-seven of nonketotic hyperglycemia. In the acidotic patients, as in those with nonketotic hyperglycemia, stupor closely paralleled hyperosmolarity and not the severity of acidemia. Indeed, the mean elevations of serum osmolarity were almost the same in the ketotic and in the nonketotic patients who were deeply obtunded. It seems likely that depression of consciousness in patients with severely uncontrolled diabetes mellitus, if not due to a nonmetabolic disorder, such as acute stroke, is attributable to hyperosmolarity, whether or not ketoacidosis is present. DIABETES 24:594-99, June, 1975.

Patients with severely uncontrolled diabetes mellitus sometimes become stuporous because of an intercurrent illness. Often, however, the only explanation for their depression of consciousness seems to be the acute metabolic disturbance, and it was previously assumed that the ketosis or the acidemia might be responsible. In 1957, Sament and Schwartz suggested that stupor in patients without ketosis might be due to hyperosmolarity. 1 The factor responsible in patients with ketoacidosis remained uncertain 23 until our recent analysis of seventy consecutive episodes suggested that depression of consciousness in these cases also closely paralleled hyperosmolarity.4 In the present report, we compare the findings in eighty-five further episodes of diabetic ketoacidosis (DKA) with those in forty-seven of nonketotic hyperglycemia (NKH) treated during the same period. The data indicate that stupor in patients with severely uncontrolled diabetes mellitus closely parallels hyperosFrom the Department of Medicine, Albert Einstein College of Medicine, and Bronx Municipal Hospital Center, New York, New York 10461. Accepted for publication March 12, 1975.

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molarity, whether or not ketosis or acidemia is present. METHODS Patients. We report here the findings in the next eighty-five consecutive episodes of diabetic ketoacidosis treated on this medical service after our earlier report. 4 The present cases occurred in sixty-five patients hospitalized during a sixteen-month period. These thirty-three women and thirty-two men, average age 43.0 years ± 2.6 S.D., had uncontrolled diabetes mellitus, heavy glucosuria, and at least a moderately positive serum nitroprusside test (with Acetest tablets). The forty-seven episodes of nonketotic hyperglycemia occurred in the forty-five patients who were admitted with severely uncontrolled diabetes mellitus, serum glucose concentrations > 5 0 0 mg./dl., and negative or weakly positive serum nitroprusside tests during the same period as the foregoing eightyfive cases with DKA. The twenty-two women and twenty-three men with NKH were significantly older (average age 64.7 years ± 2.7 S.D.) than the ketoacidotic patients (P

Hyperosmolar nature of diabetic coma.

Hyperosmolar Nature of Diabetic Coma Milford Fulop, M.D., Andrew Rosenblatt, M.D., Stephen M. Kreitzer, M.D., and Brett Gerstenhaber, M.D., New York...
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