Hypoglycemia And Hypoglycemic Coma – Clinical Froms, Incidence, Symptoms, Diagnosis And Prognosis

Hypoglycemic coma represents the extreme manifestation of hypoglycemia, it is announced by loss of consciousness or, in other words, the patient’s inability to act appropriately to manage hypoglycemia without the intervention of others. Coma is characterized by a total inability to regain consciousness.

Hypoglycemia is a syndrome caused by decreased plasma glucose concentration below the level for which the human body is adapted . Biochemical criteria of hypoglycemia for adults are: from breakfast (on an empty stomach) <3.3 mmol / l in plasma or serum, and <2.8 mmol / l in capillary blood (glucose in the blood plasma and serum is 15% higher than in capillary blood) and the postprandial hypoglycemia (over 3-4 hours after glucose load) – in plasma and serum <2.8 mmol / l and  in capillary blood <2.2 mmol / l.

Hypoglycemia without clinical manifestations can be seen in healthy individuals or in the case of reactive hypoglycemia. Hypoglycemia is dangerous on short term periods and evolves worse than hyperglycemia, as glucose is the primary energy substrate for brain tissues.

Clinical Forms Of Hypoglycemia

Hypoglycemia signs and symptoms may occur on an empty stomach or  3-4 hours after eating (postprandial).

• Fasting hypoglycemia (starvation)

• Postprandial hypoglycemia (reactive or functional)

In the first case plasmatic hypoglycemia occurs only when hungry for over 5 hours. In the second case hypoglycemia occurs only in response to meals, and usually occurs within 5 hours after. Hunger hypoglycemia means that a pathological process is associated with decreased plasma glucose, while symptoms suggestive of postprandial hypoglycemia are often found in the absence of diseases that could be recognized.

Affected organs and systems: the central nervous system suffers mainly  from hypoglycemia, the cardiovascular system, other – depending on the underlying cause, which induced hypoglycemia.

Hypoglycemia Incidence And Prevalence

Hypoglycemia found in 1.5 -3: 1000 newborns, in the major risk groups the prevalence is much higher. The transient hypoglycemia occurs in 2 of 3 new born babies and also in 80-90% of babies born from mothers who suffer from insulin-dependent diabetes or have suffered from gestational diabetes. Approximately 10-20% of children from the high risk groups, develop stable severe hypoglycemia.

Prevalence

Hypoglycemia prevalence in adults is not known because many patients solve this problem alone, without resorting to medical help. Age and sex predominance is also unknown.

Hypoglycemia

Hypoglycemia Signs And Symptoms

Neurological symptoms – slow decrease in glucose levels : marked fatigue, extreme hunger sensation, vertigo, headaches, confusion, visual disturbances (diplopia), paraesthesia, convulsions, coma, which is installed quickly. Adrenenergic symptoms – predominantly caused by sudden decrease of glucose levels: sweating, irritability, restlessness, tremors in the extremities, tachycardia, irregularity of heart contractions, hypertension, hyperreflexia, muscle hypertonia.

Complications – cerebral edema.

Hypoglycemia Causes

The postprandial hypoglycemia causes are:

• Hyperinsulinism (exaggerated insulin secretion response)
• Hereditary fructose intolerance
• Galactosemia
• Sensitivity to leucine
• Idiopathic hypoglycemia (hypoglycemia with unknown cause)

The main causes of fasting hypoglycemia installation may be either due to low production of glucose or excessive use of glucose.

The causes of  fasting hypoglycemia are:

• Hormonal deficits: hypopituitarism, glucagon deficiency, adrenal insufficiency, catecholamine deficiency
• Enizimatic defects: glucose-6-phosphatase, liver phosphorylase ,pyruvate – carboxylase, glycogen synthase; deficit of substrates: ketosis hypoglycemia in children, malnutrition, muscle atrophy, advanced pregnancy.
• Liver disease: acute fulminant hepatitis, hepatic congestion, severe forms of liver cirrhosis
• Uremia
• Hypothermia
• Some drugs, alcohol, propranolol, salicylates
• Sulfonylureas
• Autimmune diseases with insulin or insulin receptor antibodies
• Insulinoma (insulin secreting tumor of the pancreas)

Hypoglycemic coma causes

In diabetes type 1

• Insulin overdose
• Inadequate food intake, too long interval between injection and meal
• Intense and prolonged exercise
• Suppression of  certain medications
• Alcohol abuse.

In diabetes type 2

• Sulfonamides overdose, especially with generation 2 sulfonamides (which determine a long and severe hypoglycemia), and insulin overdose;
• Additional drugs (coumarin, phenylbutazone, sulfonamides, b-blockers)
• Travelling and diminished food intake.

Hypoglycemia Risk factors

Older age, renal disease, cardiovascular failure, gastroenteritis, alcoholism, poor nutrition, mental disorders (intentional overdose of insulin with suicidal purpose).

Hypoglycemia Diagnosis

Hypoglycemia diagnosis is not difficult to establish. The difficult part to achieve is to identify the cause of hypoglycemia. Diagnosis of severe hypoglycemia in diabetes mellitus is established on the patient history, collected from the patient or family diary data from and on the clinical signs: sudden onset of symptoms, irritability, sweating, hunger, headache. Hypoglycemic coma occurs frequently during the night, during sleep, with signs that should alert the family members: noisy breathing, convulsions and sweating. With rapid determination of blood glucose using a  home glucometer, the diagnosis of hypoglycemia is specified in minutes.

Laboratory investigations

• Hypoglycemia <2.8 mmol / 1.
• High levels of insulin
• Increasing levels of peptide C
• Alkaline reserve and normal pH.
• Cetonuria and glycosuria do not refute the diagnosis of hypoglycemic coma

Hypoglycemia Prognosis

Diagnosed early and treated properly severe hypoglycemia can have a good prognosis. Possible cerebral functional disorders can be detected only by fine psychological tests. If hypoglycemia lasts more than 5-10 hours, and the blood sugar levels are very low (lower than 25 mg / dl) total recovery may be possible only after a prolonged period of treatment (several hours).

Serious two complications can occur: stroke or myocardial infarction, leading to increased mortality and post-hypoglycemia encephalopathy, massive retinal hemorrhage or loss of vision, which severely affects the patient’s quality of life.

Hypoglycemic coma mortality varies according to age, 5% in young adults and reaching up to 25% in the elderly persons with multiple complications