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Abstract: Overdose of insulin can lead to hypoglycemia and even coma, as in the case of the patient in this case, a 73-year-old grandfather, who suddenly developed coma with vomiting due to overdose of insulin, and whose head CT showed normal.
Basic information】Male, 73 years old
Disease Type】Low blood sugar
Hospital】Beijing Hospital
Date of Consultation】October 2020
Treatment plan】Medication (glucose injection) + hyperbaric oxygen therapy
Treatment Period】6 days in hospital
Effectiveness】The hypoglycemia was corrected, and the patient was discharged in good condition.
I. Initial consultation
The patient was found to be unconscious for 2 hours at our hospital. The family described that the patient was found at home at 4:20 a.m. on the same day, with deep breathing, salivation and vomiting twice, no vomit and vomiting blood, no jet vomiting, no urinary or fecal incontinence, and no slanting of the corners of the mouth or convulsions. The emergency CT scan of the head did not show any hemorrhage or infarct foci, and the emergency blood gas analysis revealed a blood glucose of 1.8 mmol/L (see the figure below). He was admitted to the hospital as “cause of impaired consciousness to be investigated, hypoglycemia”. Physical examination: body temperature: 36.5℃, pulse: 72 beats/min, respiration: 18 breaths/min, blood pressure: 128/70mmHg, BMI: 25.95kg/m2. The patient was drowsy, could respond to calls, bilateral pupils were 3.0mm in diameter, light reflex was sensitive; lips were not cyanotic, neck was soft, no resistance; respiratory sounds of both lungs were clear; heart rhythm was uniform, no murmur was heard in the auscultation area of each valve; abdomen was soft, no pressure pain. The abdomen was soft, no pressure pain, and the liver and spleen were not palpable; both lower limbs were not swollen. The neurological examination did not show any abnormality. The patient had been diabetic for 15 years, and was taking acarbose tablets, glargine tablets and arginine biosynthetic human insulin injection subcutaneously at bedtime on a regular basis, with satisfactory glycemic control.
II. Treatment history
After admission, the patient’s electrocardiogram, blood routine, coagulation function, nail function, stool routine, urine routine, glycosylated hemoglobin, liver function, kidney function, brain natriuretic peptide and myocardial necrosis markers were normal. Cardiac ultrasound showed hypo-diastolic left ventricular function, and carotid vascular ultrasound showed bilateral carotid intima-media thickening. The patient was drowsy on admission. After asking for medical history, the family members counted the medications and found that the patient might have over-injected insulin before bedtime yesterday, combined with the admission blood gas analysis of blood glucose 1.8 mmol/L. After the emergency intravenous continuous glucose infusion, the consciousness improved, and the emergency cranial CT scan did not show any obvious abnormality. After admission, he was given 50% glucose injection + 10% glucose injection by continuous sedation, and 50% glucose injection was intermittently pushed intravenously according to the blood glucose level to maintain blood glucose around 10mmol/L. On the second day of hospitalization, hyperbaric oxygen therapy was started, and on the third day of hospitalization, the high glucose infusion was stopped. After resuming normal diet, the patient requested to continue the previous hypoglycemic drug therapy, and the drug treatment plan was adjusted according to the monitored fasting glucose and postprandial glucose.
III. Treatment effect
On the morning of the second day, the patient returned to consciousness, answered fluently and moved freely. On day 3, the glucose infusion was stopped and the diabetic diet was gradually resumed, and the terminal random blood glucose fluctuated from 7 to 10 mmol/L. On day 5, the C-peptide release test showed that the peak of insulin secretion was delayed. On the 6th day of hospitalization, the patient requested to be discharged from the hospital, and the fasting blood glucose fluctuated from 5-7mmol/L and the postprandial blood glucose fluctuated from 9-10mmol/L. The results of the blood biochemical examination before discharge were as follows, and the indexes gradually returned to normal, and the patient was discharged from the hospital.
IV. Notes
We are glad that the patient’s condition has improved after treatment. After discharge, we suggest the patient to adopt a relatively lenient target value of glucose reduction to avoid applying a larger dose of insulin, and to control fasting glucose below 8mmol/L and postprandial 2h glucose below 10mmol/L. Moreover, due to the patient’s age, it is better to have a family member to assist in the injection in order to avoid miscalculation of insulin dose and other operational errors. In addition, it is recommended that family members pay attention to the patient’s psychological status to avoid some suicidal behaviors due to personal emotions and other factors. During the subsequent long-term glucose-lowering treatment, it is important to regularize three meals a day and closely monitor blood glucose levels. On the basis of good blood glucose control, reduction of diabetes-related complications and improvement of prognosis, the patient’s medication safety should be maximized to prevent the recurrence of such events.
V. Personal insight
Hypoglycemic reaction is a common complication of diabetes mellitus, with a higher incidence especially in people treated with insulin. The average age of patients with acute toxic reactions due to insulin overdose is 44. 7 years, of which 89.4% are suicides. The reason for this patient’s self-injection of large amounts of insulin is unknown, and how to avoid the recurrence of similar events in the subsequent treatment becomes the focus and difficulty in choosing a treatment plan. Studies have confirmed that insulin therapy is associated with diabetes-related psychological distress and that relatively lenient glucose-lowering target values imply the use of relatively small doses of insulin. In addition, a comprehensive assessment including psychological and family support, including the Diabetes Problem Scale, Diabetes Distress Scale, Anxiety and Depression Scale, and Family Support Scale, is conducted when acceptable to the patient. Since most diabetic patients need lifelong medication and require strict abstinence from food, which affects their quality of life, they should be provided with long-term standardized health education, counseling and follow-up, including many aspects of psychological adaptation, self-monitoring of blood glucose, hypoglycemia recognition, prevention and self-help.