Coma in renal failure. Providing emergency care for uremic coma

Kidneys play in the body important role: they remove toxic substances, nitrogenous slags, hydrophilic metabolites, pump and purify the blood, also regulate the acid-base and water-electrolyte balance. In case of violation of the normal functioning of the paired organ harmful substances and residual waste products begin to accumulate in the blood, which leads to intoxication. The patient develops renal failure, gradually taking on a protracted form, the result of which is a uremic coma. According to ICD-10, she was assigned the code R39.2 - Extrarenal uremia, R40 - Somnolence, stupor, coma.

Uremic coma is an unconscious state caused by endogenous (internal) intoxication of the body due to severe kidney failure. Uremia in Latin means urination. According to the terminology adopted in medicine, it is not considered a disease, but a clinical syndrome that develops against the background of a complete failure of the functions of an organ.

Reasons for the dangerous condition

Uremic coma is the final stage of some protracted diseases. They develop against the background of kidney dysfunction, the causes of which are the following pathologies:

pyelonephritis;
glomerulonephritis;
bilateral urolithiasis;
prostate adenoma;
diabetes;
cystic formations in the kidneys.

Provoke the sudden onset of uremic coma factors that simultaneously lead to the development of acute renal failure and are characterized by a violation of the general and intrarenal circulation:

diseases caused by a viral or bacterial infection;
acute hemorrhage - vascular bleeding;
anaphylactic shock;
dehydration caused by vomiting or diarrhea;
poisoning with drugs, food, poisons;
abuse of alcohol, surrogate products, technical liquids.

Sometimes problems can be caused by congestive processes in the kidneys, which occur due to a violation of the outflow of urine. The membranes of the tubules of the paired organ are destroyed, and urine enters directly into the bloodstream. The condition is accompanied by unbearable sharp pains in inguinal region, an increase in temperature. Blockage of the excretory ducts may be due to the formation of stones or the development of a tumor.

Stages of development and symptoms

Pathogenesis serious illness does not depend on age, so both adults and children can suffer. Uremia develops imperceptibly against the background of long-term and sluggish diseases or congenital pathologies. The patient develops profuse diuresis (urination) mainly at night, violations of protein metabolism. In the first case, despite the withdrawal of a large volume biological fluid, the daily amount of excreted substances - creatinine, indican, urea, amino acids - is reduced and the level of residual nitrogen in the blood increases. In the second, there is a delay in acidic metabolic products and acidosis develops.

It's important to know! The intoxication process grows slowly, gradually, over several years. Against the background of the progression of renal failure, the daily amount of urine excreted gradually decreases, and later completely stops, that is, oliguria develops.

A patient with uremic coma may experience the following symptoms:

persistent headaches;
lethargy drowsiness;
nausea, often ending in episodes of vomiting;
the appearance of skin itching;
partial memory loss;
deterioration of vision and hearing;
deterioration in concentration;
Cheyne-Stokes breathing through the mouth;
decrease in performance.

Signs of neuromuscular irritability join the already existing ones - hiccups, convulsions, involuntary twitches individual groups muscles. Uremia in children is many times more severe than in adults. Often they have the following list of symptoms:

increased blood pressure;
hallucinations;
loss of consciousness;
change in heart tone;
increased bleeding;
ulcers and mucous epithelium.

The main criterion for classifying the severity of uremic coma is the level of impaired consciousness. In its course, the disease goes through several stages, each of which is characterized by a certain symptomatology.

During a coma, the scale of the disorder is assessed by criteria such as eye opening, motor and speech reactions. Doctors distinguish three types of it:

moderate coma (6-8 points);
deep (4-5 b.);
terminal (3 points).

The latter is called the transcendental and is considered the most difficult. Against the background of renal failure and the lung that joins it, cerebral edema occurs, the volume of circulating blood decreases, which often causes death.

Consequences of a coma

A serious complication of uremic coma is considered to be a problem associated with the defeat nervous system, - change in character, defects in thinking, consciousness, memory. Most clearly, the symptoms appear after the removal of the patient from an unconscious state. In uremic coma, the smell of ammonia comes from the whole body of the patient, and it is felt when air is exhaled. Doctors point to a number of other consequences:

osteoporosis;
increased bleeding;
disturbances of smell, vision and taste.

The most severe complications are cerebrovascular diseases, and the most terrible of all are deep coma and death of the patient.

Comprehensive examination

Confirmation of the diagnosis of uremic coma against the background of long-term renal failure is not difficult. It is much more difficult to identify the disease in the absence of an anamnesis, when the patient is unconscious, and the doctor can rely on clinical manifestations characteristic of uremic intoxication and information from close relatives. In the course of performing diagnostic manipulations, blood tests become the main ones.

Instrumental methods can be used by a doctor if necessary. They include a list of the following procedures:

ultrasound examination of the pelvic organs;
radiography of the kidneys;
electrocardiography;
MRI and CT;
analysis of cerebrospinal fluid (puncture);
conducting mental tests.

It's important to know! After obtaining data from laboratory tests and instrumental studies, differential diagnosis is carried out with diabetic, hepatic and cerebral coma, the latter, unlike the two previous ones, develops suddenly against the background of a stroke.

Helping the Patient

A patient with a rapidly growing acute renal failure, and especially a person who is in a pre- or coma state, is indicated urgent hospitalization. A difficult situation requires the use of emergency measures in order to prevent the death of the patient. Prior to the arrival of resuscitation doctors, he should be provided with emergency care, and in the future qualified treatment in a hospital.

Urgent measures awaiting doctors

With the development of a coma, the possibilities of providing first aid to loved ones are significantly limited. First of all, in case of inappropriate behavior of the patient, one should try to protect him from bodily harm; during bouts of vomiting, it is recommended to prevent aspiration of the secreted masses. While waiting for the ambulance team, it is advisable to call a nurse and carry out a number of activities:

The patient should be fed mineral water with alkali, put an ice compress on your head. At severe nausea and the urge to vomit should be offered to drink cold liquid in small sips.

Treatment in a hospital

The evacuation of a patient with acute uremia should be carried out on an ambulance in the supine position on a stretcher, accompanied by a doctor. He enters the intensive care unit, where emergency measures are taken for him: detoxification, restoration of water and electrolyte balance, normalization of blood pressure, symptomatic therapy. In uremic coma, emergency care has the following algorithm.

The degree of impairment of consciousness is assessed according to the Glasgow scale.
The work of the heart and lungs is restored, and in case of a repeated violation, mechanical ventilation, oxygenation, and myocardial massage are used.
Emergency diagnostic procedures are carried out.
Indicators such as blood pressure, pulse rate, and breathing are continuously monitored.
The gastrointestinal tract is washed with a 2% solution sodium bicarbonate and prescribe saline laxatives.

The most effective is the process of extrarenal blood purification - hemodialysis. From the moment of admission to the medical facility, the medical staff is advised to treat the patient as potentially serious.

Conservative therapy

Conservative treatment of uremic coma should begin at an earlier prehospital stage. acute form renal coma lends itself quickly and effective therapy, the fight against protracted pathology takes much more time.

The following tactic is considered optimal.

Correction of the drinking regime - an increase in the daily volume by 500 ml to compensate for the lack of fluid.
Salt-free diet - cooking with the addition of limited quantity table salt.
Reducing the formation of nitrogenous compounds - limiting protein intake to 40 g per day. Adequate calorie content of food should be maintained at the same time.
Prevention of the development of anuria or oliguria - reducing the amount of fluid consumed, the exclusion of salt from the diet, taking "Furosemide".
Antihypertensive therapy - taking diuretic drugs, primarily Corinfar.

Treatment of infectious complications, including pneumonia, diseases of the urogenital area, a course of antibiotic therapy with drugs of the penicillin group, macrolides is considered mandatory. Reception of means without nephrotoxic action is shown.

Surgery

In the case of the development of irreversible changes in the renal tissue, radical measures are resorted to - kidney transplantation. In modern medicine, its transplantation from a human donor is used. The main indication is total loss the functionality of the paired organ and the terminal stage of chronic renal failure, when the patient is at risk of death. In anticipation of transplantation (if indicated), the patient is on regular hemodialysis. The operation may not be for everyone. There is no clear list of contraindications, each clinic presents its own list. However, the following pathologies are considered absolute:

cross-immunological reaction with donor lymphocytes;
HIV infection;
chronic form of hepatitis B and C.

Relative contraindications (that is, after their elimination, transplantation is considered possible) include:

oncological processes - 2 years after radical treatment;
tuberculosis - after a year of observation of the condition with adequate therapy .;
decompensated extrarenal pathologies;
mental disorders.

A refusal can be received by a patient who has no contraindications, but who at the same time does not observe discipline at the preparatory stage, does not follow the recommendations of the attending physician, and leads a hectic lifestyle.

Rehabilitation after uremic coma

Recovery from uremic coma should be aimed at eliminating the underlying cause of the disease and its prevention. As methods to help avoid the development of uremia, experts indicate:

regular medical examination;
prevention or timely treatment of infectious diseases;
exclusion of injuries and poisoning, as well as the occurrence of other provoking factors.

In the case of pregnancy planning, it is necessary to undergo a thorough diagnosis for a young couple, as well as family members of both partners to identify renal pathology.

Prognosis after treatment

Until recently, the prognosis for patients suffering from uremia was unfavorable, but in recent years, statistical indicators have improved significantly. Today, subject to timely treatment for qualified medical care, the chances of a full recovery and return to normal rhythm life appeared in 65-95% of patients. Exceptions are cases with particularly severe forms of damage to the urinary system and the inability to carry out extrarenal blood purification, which inevitably leads to death.

What is uremic coma?

Uremic coma (uremia) or urination develops as a result of endogenous (internal) intoxication of the body caused by severe acute or chronic kidney failure.

Causes of uremic coma

In most cases, uremic coma is the result of chronic forms glomerulonephritis or pyelonephritis. In the body, toxic metabolic products are formed in excess, which sharply reduces the amount of daily urine excreted and coma develops.

Extrarenal reasons for the development of uremic coma include: drug poisoning (sulfanilamide series, salicylates, antibiotics), industrial poisoning (methyl alcohol, dichloroethane, ethylene glycol), shock, intractable diarrhea and vomiting, transfusion of incompatible blood.

In pathological conditions of the body, a violation occurs in the circulatory system of the kidneys, as a result of which oliguria develops (the amount of urine excreted is about 500 ml per day), and then anuria (the amount of urine is up to 100 ml per day). Gradually increases the concentration of urea, creatinine and uric acid, which leads to symptoms of uremia. Due to an imbalance in the acid-base balance, metabolic acidosis develops (a condition in which the body contains too many acidic foods).

Symptoms of uremic coma

The clinical picture of uremic coma develops gradually, slowly. It is characterized by a pronounced asthenic syndrome: apathy, increasing general weakness, increased fatigue, headache, drowsiness during the day and sleep disturbance at night.

Dyspeptic syndrome is manifested by loss of appetite, often to anorexia (refusal to eat). The patient has dryness and a taste of bitterness in the mouth, smells of ammonia from the mouth, increased thirst. Stomatitis, gastritis, enterocolitis often join.

Patients with growing uremic coma have a characteristic appearance - the face looks puffy, the skin is pale, dry to the touch, traces of scratching are visible due to unbearable itching. Sometimes powder-like deposits of uric acid crystals can be observed on the skin. Hematomas and hemorrhages, pastosity (pallor and decreased elasticity of the skin of the face against a background of slight edema), edema in the lumbar region and the region of the lower extremities are visible.

Hemorrhagic syndrome is manifested by uterine, nasal, gastrointestinal bleeding. On the part of the respiratory system, his disorder is observed, the patient is worried about paroxysmal shortness of breath. Blood pressure falls, especially diastolic.

The increase in intoxication leads to severe pathology of the central nervous system. The patient's reaction decreases, he falls into a state of stupor, which ends in a coma. There may be periods of sudden psychomotor agitation accompanied by delusions and hallucinations. With an increase in a coma, involuntary twitches of individual muscle groups are acceptable, the pupils narrow, and tendon reflexes increase.

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The pathogenesis of uremic coma

The first important pathogenetic and diagnostic sign of the onset of uremic coma is azotemia. In this condition, residual nitrogen, urea and creatinine are always elevated, their indicators determine the severity of renal failure.

Azotemia causes such clinical manifestations as disorders digestive system, encephalopathy, pericarditis, anemia, skin symptoms.

The second most important pathogenetic sign is a shift in water and electrolyte balance. In the early stages, there is a violation of the ability of the kidneys to concentrate urine, which is manifested by polyuria. At terminal stage kidney failure develops oliguria, then anuria.

The progression of the disease leads to the fact that the kidneys lose the ability to retain sodium and this leads to salt depletion of the body - hyponatremia. Clinically, this is manifested by weakness, a decrease in blood pressure, skin turgor, increased heart rate, thickening of the blood.

In the early polyuric stages of the development of uremia, hypokalemia is observed, which is expressed by a decrease in muscle tone, shortness of breath, and often convulsions.

At the terminal stage, hyperkalemia develops, characterized by a decrease in blood pressure, heart rate, nausea, vomiting, pain in the oral cavity and abdomen. Hypocalcemia and hyperphosphatemia are the causes of paresthesia, seizures, vomiting, bone pain, and osteoporosis.

The third most important link in the development of uremia is a violation of the acid state of the blood and tissue fluid. At the same time, metabolic acidosis develops, accompanied by shortness of breath and hyperventilation.

This condition requires the use of emergency measures to prevent the death of the patient. Emergency care for uremic coma consists of the following therapeutic measures. The patient's condition is assessed according to the Glasgow scale. Then, first of all, they perform resuscitation of the heart and lungs, restoring their work, trying to maintain what has been achieved (using, if necessary, oxygenation and mechanical ventilation, heart massage). Regularly check vitals important indicators- pulse rate, breathing, blood pressure. They do a cardiogram, carry out emergency diagnostic procedures. Periodically in progress resuscitation assess the state of consciousness.

Carry out washing gastrointestinal tract Salt laxatives are prescribed with a 2% solution of sodium bicarbonate.

At salt deficiency intramuscular injections of isotonic saline solution of 0.25 liters are prescribed. Excess sodium is neutralized Spironolactone- a diuretic that does not remove potassium and magnesium ions, but increases the excretion of sodium and chlorine ions, as well as water. Shows selectively high blood pressure the ability to reduce it, reduces the acidity of urine. Contraindicated in anuria, liver failure, excess potassium and magnesium, sodium deficiency. May cause side effects on the part of the digestive system, central nervous system and metabolic processes. Assign a daily dose of 75 to 300 mg.

To lower blood pressure, antihypertensive drugs are prescribed, for example, Kapoten, which depresses enzymatic activity a catalyst for the synthesis of angiotensin II (a hormone produced by the kidneys). Helps relax blood vessels, reduces blood pressure in them and the load on the heart. Arteries expand under the influence of the drug to a greater extent than veins. Improves blood flow to the heart and kidneys. Provides a decrease in the concentration of sodium ions in the blood. Daily dose 50mg medication reduces the permeability of the vessels of the microvasculature and slows down the development of chronic renal dysfunction. Hypotensive action is not accompanied by a reflex increase in heart rate and reduces the need for oxygen in the heart muscle. Dosing is individual depending on the severity of hypertension. Side effects- an increase in the level of protein, urea and creatinine, as well as - potassium ions in the blood, acidification of the blood.

To eliminate acidosis, prescribe intravenous injections Trisamine, activating the functions of the blood system, maintaining its normal acid-base balance. The drug is administered slowly at a rate of 120 drops / min. The maximum daily volume of the injected substance should not be more than the calculated one - 50 ml per kilogram of the patient's body weight. Application can lead to oppression respiratory function, exceeding the dose - to alkalization, vomiting, lowering glucose levels, blood pressure. The drug in renal failure is used with caution.

Rehydration is stopped with infusion solutions: isotonic glucose in a volume of 0.3-0.5 l and sodium bicarbonate (4%) in a volume of 0.4 l. In this case, it is desirable to take into account both the individual sensitivity of the patient and the undesirable effect:

glucose solution - in cases of diabetes; sodium bicarbonate - with a deficiency of calcium and chlorine, anuria, oliguria, swelling and hypertension.

Normalization of protein metabolism is carried out using Retabolil. It is administered intramuscularly in 1 ml of a 5% solution. The drug effectively activates protein synthesis, eliminates exhaustion, compensates for nutritional deficiencies bone tissue, however, has a moderate androgenic effect. Caution is advised in renal and hepatic dysfunction.

Potassium deficiency compensated Panangin- it is believed that the active substances (potassium aspartate and magnesium aspartate), entering the cells due to asparginate, are poured into metabolic processes. Normalizes heart rhythm, compensates for potassium deficiency. If the patient complains of dizziness - reduce the dose of the drug. Assigned slow intravenous infusion solution: one or two Panangin ampoules - ¼ or ½ liter isotonic solution sodium chloride or glucose (5%).

The increased content of potassium in the blood is stopped: 0.7 l of sodium bicarbonate solution (3%) and glucose (20%).

Stubborn vomiting is stopped intramuscular injections Cerucala 2 ml, which has a normalizing effect on muscle tone upper divisions digestive tract. The antiemetic effect of the drug does not apply to vomiting of vestibular and psychogenic origin.

A mandatory procedure that allows you to cleanse the body of accumulated toxic metabolic products, excess water and salts is the use of the apparatus artificial kidney(extracorporeal hemodialysis). The essence of the method is that arterial blood passed through a system of filters (artificial semi-permeable membranes) and returned to the vein. In the opposite direction, bypassing the filter system, a solution flows, similar in composition to the blood in healthy body. The device controls the transition essential substances into the blood of the patient and harmful - into the dialysate. When normal composition blood is restored, the procedure is considered completed. This method has been used for a long time and has proven to be very effective in the treatment of acute or chronic uremia, caused both by impaired renal function in their insufficiency, and in cases of acute exogenous intoxication.

In the presence of an infectious process, individual antibiotic therapy is prescribed.

Since the development of uremic coma occurs with increasing intoxication, anemia and oxygen starvation tissues, the body needs vitamins. Ascorbic acid is usually prescribed, against which immunity increases, vitamin D, which prevents the development of osteoporosis, vitamins A and E, useful for overdried, itchy and losing skin elasticity, B vitamins, necessary for hematopoiesis. Of these, pyridoxine (vitamin B6) is especially useful. Its deficiency contributes to the rapid accumulation of urea in the blood. Its level decreases very quickly with a daily intake of 200 mg of this vitamin. Featured daily norms vitamins: B1 - at least 30 mg, E - 600 units, natural vitamin A - 25 thousand units.

In addition, it is advisable to take lecithin (from three to six tablespoons), as well as choline - four times a day: three before meals and once at bedtime, 250 mg (one gram per day).

Nutrition also plays a certain positive role. It is necessary to consume at least 40 g of protein daily, otherwise the accumulation of urea is rapid. Moreover, preference should be given vegetable proteins(beans, peas, lentils, bran). They do not contribute to the accumulation of sodium, as opposed to animals. For normalization intestinal microflora it is recommended to consume sour-milk drinks.

Physiotherapy treatment can be used in preventive purposes and during rehabilitation treatment. Magnetic, laser, microwave and ultrasonic therapy is used. Methods of treatment are selected individually, taking into account the anamnesis, tolerability, concomitant diseases. Physical procedures improve blood circulation, provide thermal, physical and chemical action on body tissues, stimulate immune function, contribute to the removal of pain, inflammation, slowing down dystrophic processes.

Alternative treatment

Alternative therapies used prophylactically can slow down the development of uremic coma and shorten the rehabilitation period.

With an exacerbation of uremia and the inability to immediately call an ambulance team at home, the following emergency procedures can be performed:

prepare a hot bath (42 ° C) and lower the patient there for 15 minutes; then make an enema with water with the addition of salt and vinegar (not essence); after the enema has worked, give a laxative, such as senna.

Providing assistance, it is necessary to periodically give the patient water or serum. Well helps in such cases alkaline mineral water. Put a cold compress or ice on your head. With nausea, as well as vomiting, you can give pieces of ice to swallow or drink cold tea.

Traditional medicine recommends wrapping the patient in a cold wet sheet, claiming that such an action helped save more than one life. If there really is no place to get medical help, then it is done like this: a warm blanket is spread on the bed, on top - a sheet soaked in cold water and well wrung out. The patient is laid on it, wrapped in a sheet, then a warm blanket. From above, they also cover with a warm blanket, they especially try to keep the patient's legs warm. The convulsions should pass, and, warmed up, the patient falls asleep for several hours. You don't need to wake him up. If, upon awakening, the patient's convulsions begin again, the wrapping is recommended to be repeated.

Prepare a mixture of crushed to a powder state of seven parts of pepper cumin, three parts of white pepper and two parts of saxifrage root. Take the powder with a decoction of wild rose, three or four times a day. Such a tool is considered a useful component complex treatment patients even on hemodialysis.

Prevention of the concentration in the blood of nitrogenous compounds and other toxins is considered daily use in the summer, parsley and dill, celery, lovage, lettuce and onions, as well as radishes and radishes, cucumbers and tomatoes. In raw form, it is good to use cabbage, carrots and beets, and also cook dishes from these vegetables. It is useful to eat dishes from potatoes, pumpkins and zucchini. Fresh berries have a cleansing effect:

forest - cranberries, strawberries, blueberries, lingonberries, blackberries; garden - strawberries, raspberries, gooseberries, plums, black and red mountain ash, grapes.

Watermelons and melons will be useful. In the spring, you can drink birch sap without restrictions. In the autumn-winter period, the already mentioned vegetables and apples, oranges, grapefruits are consumed.

A recipe for normalizing the water-salt balance: pour unpeeled oat grains with water, bring to a boil and simmer, without boiling, over a tiny fire for three to four hours. Then the still hot oats are rubbed through a colander. The resulting jelly should be eaten immediately, it is allowed to add a little honey.

With uremia, urolithiasis, herbal treatment is used. It is recommended to drink nettle infusion, which is prepared in the ratio: for 200 ml of boiling water - a tablespoon of crushed dry nettle leaves. First, a quarter of an hour is insisted on a water bath, then ¾ hours - with room temperature. Strain and drink a third of a glass before each meal (three or four times a day).

For chronic kidney problems, nephrolithiasis and uremia, it is recommended to pour two teaspoons of golden rod grass with a glass of cold boiled water, insist for four hours in closed jar. Then strain and squeeze the juice from the lemon to taste. Drink a quarter cup for a month four times a day before meals.

Grind and mix 15 g of bovine grass and parsley roots, rose hips and juniper, add to them 20 g of blackcurrant leaves and common heather flowers. Brew a dessert spoon of the vegetable mixture with boiling water (200 ml) for five minutes and strain. Drink three times a day for a month. Contraindicated in acute renal pathologies, ulcerative lesions of the gastrointestinal tract, pregnant women.

Grind and mix 30 g of herb herb smooth and horsetail, birch leaves and bearberry. A tablespoon of the plant mixture is poured into an enamel bowl and poured with a glass of water. With the lid closed, simmer over low heat for about three minutes. The broth is insisted for another five minutes. Strain, cool to warm state and take three times a day for a month. In acute cystitis, take with caution.

Summer recipe - an infusion of fresh lilac leaves: chop lilac leaves, take two tablespoons, brew with boiling water in a volume of 200 ml, bring to a boil and leave warm for two to three hours. Strain, squeeze lemon juice into the infusion to taste. Take one tablespoon before four main meals. The course of admission is two weeks, then after two weeks you can repeat. Such treatment is recommended to be carried out all summer, while there are fresh lilac leaves. In the autumn - to be examined.

Homeopathy

Homeopathic medicines can help prevent uremic coma, as well as promote rapid and quality recovery health and elimination of its consequences.

Ammonia (Ammonium causticum) is recommended as a powerful cardiac stimulant in uremia, when there are traces of blood, proteins and hyaline casts in the urine. A characteristic symptom of its use is bleeding from natural holes body, deep fainting.

Hydrocyanic acid (Acidum Hydrocyanicum) is also a first aid remedy for the agony of uremic coma. However, the problem is that usually these drugs are not at hand.

At inflammatory diseases kidneys, in particular, pyelonephritis or glomerulonephritis (which, when chronic, can lead to the development of eventually uremic coma), the drugs of choice are Snake Venom (Lachesis) and Gold (Aurum). However, if inflammation of the kidneys was preceded by tonsillitis, chronic tonsillitis developed, then Sulfuric liver (Hepar sulfuris) or Mercury preparations will be more effective. Therefore, in order to homeopathic treatment helped, you need to contact a qualified specialist.

As a preventive measure for chronic uremia, the complex homeopathic preparation Bereberis gommakord is recommended. It includes three plant component in various homeopathic dilutions.

Common barberry (Berberis vulgaris) - enhances the drainage function of the urinary organs, has an analgesic, anti-inflammatory effect, promotes the elimination of excess salts, the removal of calculous deposits and prevents their deposition.

Gourd bitter (Citrullus colocynthis) - activates the blood supply to the organs of the peritoneum, relieves spasms, has a neutralizing and diuretic effect, eliminates renal colic.

Hellebore white (Veratrum album) - has a tonic and antiseptic activity, has a beneficial effect on the functioning of the central nervous system, restores an exhausted body.

It is prescribed as a drainage agent, with pathologies urinary organs, joints, liver, digestive tract and dermatological diseases.

Drops are taken by patients over 12 years of age. Drop 10 drops into a container containing 5-15 ml of water and drink, trying to keep it in your mouth longer. The drug is taken three times a day for a quarter of an hour before a meal or an hour after.

The daily portion can be diluted in 200 ml of water and taken in small sips throughout the day.

For the relief of acute conditions, a single dose of 10 drops is taken every quarter of an hour, however, not more than two hours.

Side effects and interactions with other drugs have not been identified.

Complex homeopathic drops Galium-Heel act at the cellular level. This is one of the main drainage means of the parenchyma of the lungs, heart muscle, kidneys and liver. It is prescribed for detoxification of the body, with dyspeptic symptoms, impaired renal function, nephrolithiasis, as a diuretic, with bleeding, exhaustion, cerebral, cardiovascular and respiratory pathologies. Contains 15 components. Side effects have not been recorded. Contraindicated in case of individual sensitization.

Applicable at any age. For children 0-1 years old, the recommended dose is five drops; 2-6 years - eight drops; over six and adults - ten. For the relief of acute symptoms, a single dose is taken every quarter or half an hour for one or two days. The highest daily dosage is 150-200 drops. Duration of admission is one or two months.

The specificity of this homeopathic remedy involves its use at the initial stage of treatment as monotherapy (or in combination with Lymphomyosot - a drug for cleaning the lymphatic system). It is recommended to take the main drugs that affect the functioning of organs after a ten to fourteen-day time period from the start of drainage treatment. If it is impossible to postpone the intake of an organotropic drug, it is allowed to take Galium-Heel simultaneously with it. This drug is recommended to start taking in initial phase diseases, when there are still no pronounced clinical symptoms and complaints are minor, since by draining tissues, he is preparing for effective impact organotropic preparations, both homeopathic and allopathic. As a result, the effectiveness of treatment increases.

Lymphomyosot homeopathic preparation, contains 16 components. It enhances lymph flow, relieves intoxication, swelling and inflammation, reduces exudation, activating cellular and humoral immunity. Available in drops and solution for injection. Contraindicated in case of hypersensitivity to ingredients In pathologies thyroid gland exercise caution. In rare cases, allergic skin reactions may occur.

Drops are dissolved in water (10 ml) and kept in the mouth for absorption as long as possible, the reception is carried out three times a day before meals for half an hour or an hour after. Patients 12 years and older are given 10 drops, infants - one or two, from one to three years - three, from three to six - five, from six to 12 - seven.

For relief of acute conditions single dose taken every quarter of an hour, however, no more than 10 times. Then they switch to the usual reception.

At increased function thyroid gland take half the dosage corresponding to age, increasing it daily by one drop and bringing it up to the age norm.

In severe cases, an injection solution is prescribed. A single dosage is one ampoule and is used from the age of six. Injections are given two or three times a week intramuscularly, sub- and intradermally, intravenously and at acupuncture points.

Oral administration of a solution from an ampoule is also possible, for this its contents are diluted in ¼ glass of water and drunk throughout the day at regular intervals, holding the liquid in the mouth.

Echinacea compositum CH- a complex homeopathic medicine containing 24 components.

It is indicated for infectious and inflammatory processes of various origins, including pyelitis, cystitis, glomerulonephritis, immunity decline and intoxication. Contraindicated in active tuberculosis, blood cancer, HIV infection. Sensitization reactions (skin rashes and hypersalivation) are possible. It is administered intramuscularly in one ampoule from one to three injections per week. In rare cases, there may be an increase in body temperature as a result of stimulation of the immune system, which does not require discontinuation of the drug.

Ubiquinone compositum, a multicomponent homeopathic preparation that normalizes metabolic processes, is prescribed for hypoxia, enzymatic and vitamin-mineral deficiency, intoxication, exhaustion, tissue degeneration. The action is based on the activation of the immune defense and the restoration of the functioning of internal organs due to the components contained in the preparation. Available in ampoules for intramuscular injection similar to the previous tool.

Solidago compositum C prescribed for acute and chronic pathologies urinary organs (pyelonephritis, glomerulonephritis, prostatitis), as well as to stimulate the excretion of urine. It relieves inflammation and spasms, improves immunity, promotes recovery, and also has a diuretic and disinfectant effect, which is based on the activation of one's own immunity. It is produced in ampoules for intramuscular injection similarly to the previous remedy.

In violation of the absorption of vitamins, for the regulation of redox processes, detoxification and recovery normal exchange substances, Coenzyme compositum is used. Produced in ampoules for intramuscular injection, the principle of its action and application is similar to the previous means.

Surgery

With irreversible changes in the kidney tissue, in order to avoid death, there is only one way out - kidney transplantation. modern medicine practices an organ transplant from another person.

This is a rather complicated and expensive operation, however, it has already been performed repeatedly and successfully. The indication for transplantation of this organ is the terminal stage chronic disorder kidney function, when the work of the organ is simply impossible, and the patient is expected to die.

To save lives while waiting for transplantation, patients are on chronic hemodialysis.

There are no single contraindications for transplantation, their list may differ in different clinics. Absolute contraindication is a cross-immunological reaction with donor lymphocytes.

Almost all clinics will not undertake to operate on an HIV-infected patient.

The operation is not performed in the presence of cancerous tumors, however, after their radical treatment, in most cases, transplantation can be performed after two years, with some types of neoplasms - almost immediately, with others - this period is extended.

The presence of active infections is relative contraindication. After curing tuberculosis for a year, the patient is under the supervision of doctors, and if there is no recurrence, he will undergo an operation. Chronic inactive forms of hepatitis B and C are not considered a contraindication to surgery.

Decompensated extrarenal pathologies are relative contraindications.

The indiscipline of the patient at the preparatory stage may be the reason for his refusal to transplant an organ. Also mental illness, which will not allow you to comply with strict medical prescriptions, are contraindications for transplantation.

In diabetes mellitus, which leads to terminal kidney dysfunction, transplantation is carried out and is increasingly successful.

The optimal age for this operation is 15-45 years. In patients older than 45 years, the likelihood of complications increases, mainly vascular embolism and diabetes.

Uremic (azotemic) coma in the outcome of chronic renal failure is caused by poisoning of the body with end and intermediate products of protein metabolism (nitrogenous slags) due to their insufficient excretion by the affected kidneys. Uremic coma is the final stage of chronic diseases with diffuse damage to the kidney parenchyma - chronic glomerulonephritis, pyelonephritis, nephroangiosclerosis, polycystic kidney disease. Less commonly, it develops in acute renal failure. Let's look at what to do with uremic coma, and how it manifests itself.

Symptoms of uremic coma

A detailed picture of uremic coma for many months, and sometimes years, is preceded by symptoms indicating a developing and inexorably progressing insufficiency of kidney function. The patient develops abundant diuresis (urine with a monotonously low relative density), and a significant part of it occurs at night. Nocturia is associated with impaired ability to concentrate urine at night. Despite the large diuresis, the daily excretion of urea and other nitrogenous substances (creatinine, indican, amino acids) gradually decreases.

This leads to an increase in the level of residual nitrogen in the blood, the development of azotemia. At the same time, with the development of uremic coma in the blood and tissues, due to gross violations of protein metabolism, a significant amount of acidic products is retained, and acidosis develops. The accumulation of nitrogenous wastes and acidosis cause severe intoxication of the body with uremia. characteristic feature The course of uremic coma is usually a slow, gradual progression of all symptoms of the disease. With an increase in renal failure, the amount of urine excreted falls, oliguria develops. However, the specific gravity of urine remains low.

Clinical picture of uremic coma

The main manifestation of uremic coma is damage to the nervous system. Along with the increase in azotemia, patients develop general weakness, fatigue, inability to concentrate, headaches, and a persistent feeling of heaviness in the head. Often, vision deteriorates due to the development of severe changes in the retina, the contours of objects are perceived blurry, the field of view narrows. In the future, memory decreases, drowsiness and apathy join, the patient becomes indifferent to the environment. The depression of consciousness in uremic coma gradually increases. At times, drowsiness is replaced by agitation with abnormal behavior of the patient, confusion, hallucinations, which in such cases gives rise to erroneous diagnosis of mental illness.

In parallel with changes in consciousness, signs of neuromuscular irritability appear and grow - hiccups, convulsions, involuntary contractions and twitches various groups muscles. Increasing intoxication of the nervous system leads to the development of a deep coma.

Kidney dysfunction in uremic coma is accompanied by a compensatory release of toxic nitrogenous substances through the gastrointestinal tract, often with the development of severe uremic gastritis and colitis. Already at an early stage of uremia, the patient's appetite decreases sharply, dry mouth, thirst, nausea and vomiting appear, especially in the morning. In the future, diarrhea joins, often with an admixture of blood, which can serve as a reason for erroneous diagnosis of dysentery - in the later stages of the disease, ulcers and gastrointestinal bleeding often develop

Ulcers form on the oral mucosa in uremic coma; often there is bleeding from the gums, nosebleeds. At a distance, there is a smell of ammonia in the exhaled air (appears as a result of the splitting of urea contained in saliva). The skin is dry, earthy-gray in color, with traces of scratching (often disturbed by severe itching); sometimes slight jaundice. In the final period of uremia, a thin layer of white powder can sometimes be seen on the skin of the face, which is a plaque of small urea crystals (“uremic frost”).

Consequences of uremic coma

Lack of erythropoietin secreted by healthy kidneys and uremic intoxication bone marrow lead to the development of anemia, so characteristic of patients with uremia. Pulse tense, frequent. Blood pressure is usually elevated due to excess fluid in the body. In the terminal stage of uremia, fibrinous toxic pericarditis often develops. In these cases, a pericardial friction rub is heard over the heart, which is a poor prognostic sign ("death knell"). The widespread use of hemodialysis has led to the fact that uremic pericarditis has become much less common. Sometimes in chronic kidney disease, uremia is combined with heart failure, edema, congestion in the lungs. Circulatory disorders and left ventricular heart failure are often accompanied by pulmonary edema, the origin of which, in addition, may be associated with uremic intoxication with damage to the bronchial mucosa and increased permeability of the vascular wall. For a detailed clinical picture of uremia, a violation of the rhythm of breathing by the type of Cheyne-Stokes or Kussmaul breathing is characteristic.

Diagnosis of uremic coma

The diagnosis of uremic coma in the presence of a long-term renal history is simple. However, it should be borne in mind that often kidney disease, even in the stage of developing functional insufficiency, can proceed unnoticed by the patient and not give symptoms of intoxication for a long time. In cases where the patient is admitted in a coma unaccompanied and the anamnesis cannot be clarified, the diagnosis is made on the basis of the characteristic clinical picture of uremic intoxication (coma with respiratory rhythm disorder, ammonia smell of exhaled air, dry, earthy-gray skin with scratching and often hemorrhages, raids urea crystals on the face, nausea, vomiting, diarrhea, anemia, hypertension and pericarditis). Laboratory findings of high levels of residual nitrogen and low relative density of urine with low daily diuresis support the diagnosis of uremic coma.

Cerebral coma in stroke, unlike uremic, begins suddenly - in patients with a previous vascular history. Examination reveals focal neurological symptoms (paralysis, paresis).

Considering the question of what to do with uremic coma, one cannot but draw your attention to the fact that a patient with increasing renal failure, and even more so in a pre-coma or coma, is subject to mandatory hospitalization!

With the development of a coma, the possibilities of providing assistance are limited. In order to remove nitrogenous wastes released through the mucous membrane of the stomach and intestines, the stomach is washed abundantly with a 4% solution of sodium bicarbonate, and high siphon-type enemas are put. At the same time, 40 ml of a 40% solution and 250-500 ml of a 5% glucose solution, sodium bicarbonate (200 ml of a 4% solution) are injected parenterally. Most effective method treatment for coma - hemodialysis.

What to do with uremic coma: treatment methods

Treatment should begin in a preuremic state. Conservative treatment of uremic coma includes:

1. Adequate fluid intake - in most cases equal to daily diuresis plus 500 ml (to replenish hidden water losses). A diet without added salt is shown. With the appearance of heart failure or persistent arterial hypertension, the intake of water and table salt is sharply limited. With the development of oliguria or anuria, enter large doses furosemide (up to 4 g per day).

2. Reducing the formation of nitrogenous slags - limiting protein in the diet to 40 g per day while maintaining adequate caloric content of food.

3. Antihypertensive therapy for uremic coma - primarily diuretics; effective use of calcium antagonists (Corinfar).

4. Correction of anemia - recombinant human erythropoietin.

5. Treatment of infectious complications (pneumonia, urinary tract infections) - penicillins, macrolides, levomycetin (antibiotics without nephrotoxic action).

In chronic renal failure, periodic hemodialysis and kidney transplantation are successfully used. Indications: no effect from conservative therapy and progression of renal failure; oliguria, hyperkalemia, encephalopathy, increased urea above 40 mmol/l and creatinine above 900 µmol/l.

Acute renal failure in uremic coma develops most often as a result of prolonged renal ischemia (with severe bleeding, a significant decrease in circulating blood volume, intraoperative hypotension, shock). Less commonly, acute renal failure occurs with toxic kidney damage that occurs with damage to the parenchyma of the organ, the appearance of dystrophic and necrotic changes in the epithelium of the tubules, which can occur with salt poisoning heavy metals(mercury, bismuth), ethylene glycol, arsenic hydrogen, acids, as well as when taking antibiotics from the group of aminoglycosides and radiopaque substances. Acute renal failure due to damage to the tubules can also develop with transfusion of incompatible blood (transfusion shock), septic abortion with massive hemolysis, burns and severe traumatic shock with crushing of soft tissues.

How does uremic coma develop?

The clinic of the initial period of acute renal failure depends mainly on the nature of the underlying disease that caused kidney damage; with mercury poisoning, symptoms from the oral cavity and gastrointestinal tract are detected, with sepsis - high fever, chills, anemia, jaundice, etc. However, already during this period, the duration of which is usually 24-36 hours, almost always decreases the amount of urine produced (oliguria). In the initial period with uremic coma, oliguria is different. Sometimes diuresis reaches 500 - 600 ml per day, in some cases from the first days it does not exceed 100 - 200 ml.

In the future, regardless of the cause that caused acute renal failure, there is a rapid decrease in diuresis up to the development in some cases of complete anuria. In this stage of the disease, called oliguric, a sharp decline the amount of urine excreted is the most striking and easily detectable symptom of an impending catastrophe. The exact volume of diuresis can vary from several hundred milliliters per day to complete anuria, but more often it is 50-100 ml. Urine contains a large amount of protein, cylinders, despite low diuresis, the relative density of urine does not exceed 1.005 - 1.010. In acute renal failure due to transfusion shock on the first day, dark urine is released, which is due to the admixture of hemoglobin (hemoglobinuria). Patients during this period usually complain of a lack of appetite, sometimes vomiting, upset stools, dull constant pain in the lower back. Palpation of the kidney area on both sides is usually painful. Blood pressure in the phase of anuria is lowered, however, in some cases, impaired blood circulation in the kidneys may be accompanied by the appearance of arterial hypertension. Sometimes there are signs of cardiac, mainly left ventricular, insufficiency up to pulmonary edema. At the same time, large confluent areas of blackout around the roots of the lungs are determined radiologically (like a "butterfly wing").

Blood changes in the oliguric stage of acute renal failure are very characteristic: usually leukocytosis up to 20,000 - 30,000 leukocytes with a shift of the formula to the left, combined with anemia. The content of residual nitrogen is rapidly increasing, the figures of which reach 214.2 - 357 mmol / l. High azotemia is associated not only with a violation of the excretion of nitrogenous substances by the kidneys, but also with increased tissue breakdown in extensive injuries, hemolysis, and poisoning. At the same time, the content of potassium in the blood increases. In an electrocardiographic study, hyperkalemia is manifested by an increase in the amplitude of peaked T waves, a decrease in the amplitude of the P wave, a prolongation of the P-Q interval, a widening of the QRS complex, a shortening of the Q-T interval. Bradycardia, arrhythmias, and possible cardiac arrest.

The oliguric stage of acute renal failure lasts 1 to 2 weeks (if oliguria persists for more than 4 weeks, the diagnosis of acute renal failure should be questioned). Usually, between the 9th and 15th days of illness, diuresis is restored with a gradual increase, polyuria develops, which is dangerous due to significant dehydration and loss of salts.

What to do in acute renal failure to prevent uremic coma

Treatment of acute renal failure should begin as early as possible, before the development of irreversible changes in the kidneys and other organs and tissues.

In case of sublimate poisoning, leading to acute renal failure, it is necessary first of all to remove and neutralize the poison. To do this, the patient's stomach is washed again, activated charcoal is administered orally, and early hemodialysis is performed. At the same time, 10 ml of a 5% unithiol solution should be injected intramuscularly. On the first day, the introduction of unithiol should be repeated every 4-6 hours.

Critical in initial period diseases are measures aimed at combating shock: intravenous drip of polyglucin, if necessary, intravenous drip of dopamine at a rate of 1-10 mg / kg per 1 min (at this rate of administration, the drug increases renal blood flow). Assign potent diuretics (furosemide up to 200 mg per dose) or mannitol, which increases the flow of urine.

After eliminating hypovolemia, during the period of oliguria, fluid intake should not exceed daily diuresis, taking into account imperceptible losses (daily urine output plus 500 ml), since urine output is reduced or stops and excess fluid in the body can lead to pulmonary edema. In case of anuria without signs of dehydration and hyperhydration, no more than 500 ml of fluid per day should be administered under the control of body weight. With indomitable vomiting, diarrhea, symptoms of dehydration of the body, the amount of fluid administered should be increased.

To neutralize the toxic effect of hyperkalemia, in addition to the appointment of saluretics, in order to stimulate the transition of potassium ions from the extracellular fluid into the cells, an urgent intravenous infusion of sodium bicarbonate (up to 200 ml of a 5% solution by drip) and / or glucose (200 - 300 ml of a 20% solution) together with 10 - 20 units of insulin. In addition, calcium is recommended, which has the opposite effect on cardiac conduction as potassium (10 ml of a 10% calcium gluconate solution intravenously in a stream).

A patient with acute renal failure should be treated from the first hours of the disease as potentially severe, subject to immediate hospitalization. It should be transported by ambulance, accompanied by a doctor. In a hospital with great success, hemodialysis is used to prevent uremic coma, the indications for it are pronounced clinical manifestations of uremia, life-threatening humoral changes (hyperkalemia more than 7 mmol / l, acidosis, hyperhydration), uremic encephalopathy.

30.06.2018 Doctor Evgenia Aleksandrovna Miroshnikova 0

Danger of uremic coma

Uremic coma is the final stage of chronic damage to both kidneys. At this stage, the kidney tissue is reduced so much that it is no longer enough for the full removal of toxins. As a result, unnecessary products accumulate in the body, leading to its poisoning.

There may be hemorrhages in the brain, epidermis and mucous tissues of internal organs. Then the person falls into a state of stupor. Everything ends in a coma.

Long term kidney disease chronic, often accompanied serious complications. One of the most severe pathological conditions requiring urgent medical care, is an azotemic coma. As a rule, it occurs as a result of permanently occurring glomerulonephritis, pyelonephritis, amyloidosis, polycystic kidney disease and other diseases.

Diagnosed to whom, as a rule, on the basis of characteristic features prolonged kidney damage and the dynamics of the disease. Both are fixed in medical card patient. The coma of the patient suggests emergency measures to avoid death. First of all, it is necessary to bring a person out of a coma. Urgent measures include resuscitation important organs(heart and lungs), control of breathing, blood pressure, pulse.

Scientists and doctors are still studying the mechanism of the onset of uremia, since its pathogenesis has not been fully tracked. It is well known that this condition occurs due to:

blood concentration a large number protein breakdown products, namely: nitrogenous slags, urea, creatinine, uric acid;
deterioration in kidney function;
changes in the acid-base balance and mineral structure of the human body.

Under the influence of the above changes in the body, there is a violation normal operation vital internal organs and systems, therefore, azotemic coma is accompanied by severe liver damage and metabolic dysfunction.

The process of developing kidney failure is usually divided into two stages:

initial or hidden - it can be detected only during a deliberate special examination of the kidneys. It consists in determining the daily indicators of the main characteristics that reflect the activity of the paired organ, its quantitative and speed parameters. These include glomerular filtration, urea clearance, electrolytes, ammonia excretion, and others;
the second phase is a specific clinical picture pathological condition. With the help of a clearance test, a disorder in the filtration and reabsorption of the kidneys is established. Even a slight excess of the standard indicator signals a violation of the nitrogen excretion capacity of the organ.

It should be noted that the increase in this indicator in conditions of prolonged course of renal diseases occurs at a slow pace.

Chronic renal failure is systematized depending on the indicators of azotemia and the state of the initial process of urine formation (glomerular filtration). There are three types:

Initial - there is a small amount of preserved nitrogen in the blood, namely, the content of the substance does not exceed 60 mg; nitrogen-containing carboxylic acid (creatine) - the norm is not more than 3.0 mg; moderate decrease in glomerular filtration.
(A and B) severe, in which the level of nitrogen and creatinine significantly exceeds the norm and electrolyte imbalance.
Terminal - an obvious clinical picture of uremia.

Signs of chronic renal failure are manifested in:

violations of the normal activity of all vital organs (dyspeptic disorders). Characteristic indicators: loss of appetite, thirst, a feeling of dry mouth, bouts of nausea and vomiting, the smell of ammonia from the oral cavity. There is stomatitis, gingivitis and others;
formation of pathological processes ( neurological disorders). This is a state of anxiety or stupor, seizures, extreme agitation, muscle cramps, damage to the motor neurons of the motor nuclei of the cranial nerves and anterior horns spinal cord, respiratory function is disturbed;
damage to the nervous system (trophic disorders), as a result of which the process of cellular nutrition is disrupted, which ensures the preservation of the structure and functioning of an organ (or its tissue) of neurogenic origin. There is a slowdown in the reactions of the patient, as well as a soporous state, when the patient has a deep sleep, from which it is quite difficult to get him out.

In the process of developing uremia in a patient, the risk of developing pneumonia and bronchitis increases, and a sudden decrease in vision and hearing is also noted. Excruciating itching of the skin, bleeding, deposition of nitrogenous slags (urea sweat) on the forehead and wings of the nose are additional indicators of a progressive disease. Last stage uremia ends with the development of terminal endocarditis, which is a harbinger of death.

Features of the course of the disease in adults and children

The occurrence of uremic coma does not depend on age. It occurs in the process of intoxication of the body, kidney dysfunction, destabilization of hormonal metabolism, excessive concentration of poisons resulting from protein metabolism.

This condition is seen in adults and children. The etiology of the disease in both is based on renal failure and its symptoms. First of all, it is an indicator of the volume of urine formed per day (diuresis). Despite the fact that a large amount of fluid is excreted from the body, waste products are not completely eliminated and gradually accumulate. Kidney failure leads to the development of acidosis, that is, a shift in the acid-base balance of the body towards an increase in acidity (a decrease in pH). Both factors, acidosis and azotemia, cause severe poisoning.

Uremic coma is characterized by a gradual increase in all the signs of this condition:

general weakness;
decreased efficiency and ability to concentrate;
headache;
loss of vision and hearing;
memory loss;
drowsiness;
apathy;
smell of ammonia, etc.

In mature people, uremic coma is caused by:

in men, most often prostate adenoma;
in women, it may be the result of pyelonephritis, hormonal metabolism disorders, or other pathologies of the urinary system.

Children endure this condition more severely than adults. They often have:

hallucinations and loss of consciousness;
ulcers and necrosis on the mucous membranes;
increased bleeding;
change in heart tone;
increased blood pressure;
leukocytosis.

The state of coma occurs gradually. During this period, the child is lethargic, irritable.

Grounds for the formation of a coma

Azotemic uremia is caused by:

prolonged pyelonephritis;
glomerulonephritis;
intoxication of the body with medicines (antibiotics, painkillers, antimicrobials);
concentration in the body of toxic substances (methyl alcohol, ethylene glycol);
incompatibility of donor blood during transfusion;
persistent bouts of vomiting and diarrhea.

continuous pathological process, which develops in the kidneys, leads to an increase in oliguria and a decrease in the outflow of urine. Thus, there is: accumulation of urea, uric acids and creatinine, imbalance of acids and alkali in the body, development of metabolic acidosis.

Complications and consequences

With the onset of uremic coma, doctors do not give the most favorable prognosis for the patient. It is best to prevent this condition, to identify the disease at an early stage. Then the methods of treatment will be more effective. Complications worsen the situation, for example, pneumonia. Of particular danger are internal bleeding in the brain, gastrointestinal tract.

The nervous system is subject to serious changes during the period of uremia. After suffering a uremic coma, a change in character is observed in a person, memory suffers, his cognitive activity is lost. This is a deadly pathology that has an unfavorable prognosis for the patient, therefore, if there is characteristic symptoms you should consult a doctor.

Diagnostics

To determine the condition and identify the specific factor that provoked renal coma First of all, a general clinical blood test is performed. It shows the quantitative content of urea and creatine. Based on these indicators, the direction of treatment is selected.

Ultrasound and radiography pelvic floor are the methods used to determine the source of the disease. These diagnostic methods allow you to identify the presence of stones in genitourinary system and determine changes in the structure of kidney tissues. In some cases, carry out computed tomography. Additionally, an indicator of electrolytes in the blood is determined, with the help of which the administration of medicinal solutions is controlled in order to normalize the electrolyte, acid-base balance of the body.

Treatment and emergency care

A patient in a state of uremic coma is admitted to the intensive care unit. Doctors carry out medical and hardware therapy. Medications, diuretics, saline, and glucose are given intravenously. In especially severe cases, hormonal drugs are used. By using special devices carry out blood purification procedures (hemodialysis and plasmapheresis).
Hemodialysis

First Aid Receptions:

neutralization of intoxication;
restoration of water and electrolyte balance;
normalization of blood pressure;
with the help of symptomatic therapy, certain especially dangerous signs of coma, for example, convulsions, are eliminated;
hemodialysis.

The main direction of treatment of the patient's condition after suffering a coma is to prevent the sources of kidney pathologies that provoke uremia. For example:

surgery to remove stones from the kidneys and bladder;
changing the diet and avoiding foods that contribute to the production of ammonia;
limiting close contact with toxic substances.

Prevention

As preventive methods to help avoid the development of uremic coma, doctors recommend:

systematically undergo a medical examination;
heal everything inflammatory processes occurring inside the body, especially in the organs of the genitourinary system;
carefully undergo a course of therapy for the pathology that led to the formation of renal failure (prolonged glomerulonephritis, pyelonephritis, polycystic disease, diabetes, and others).

If there is already kidney failure, then the patient needs to register as early as possible in medical institution, methodically and systematically treat the disease, following all the recommendations of a specialist. In addition, complications, surgical operations, bleeding should be avoided. Normalization of blood circulation in case of its insufficiency will significantly reduce the risk of renal coma.

In conclusion, it should be said that self-administration of medications without the approval of a doctor can also provoke kidney failure. Therefore, antibiotic drugs, such as Streptomycin, Tetracycline, should be taken only as prescribed by a specialist and under his control. The same rule applies to the application antimicrobial agents(sulfonamides), drugs that have a depressing effect on the central nervous system (barbiturates), analgesics and other medicines.

Alternative treatment

Alternative medicine, which includes homeopathy and traditional medicine, is quite capable of slowing down the formation of uremia and limiting the rehabilitation period.

Folk recipes:

the use of alkaline mineral waters and a large amount of liquid;
Nausea is relieved by cold green tea and ice cubes (they should be swallowed, after crushing not small pieces);
useful kefir and whey;
convulsions are relieved by wrapping the patient in a damp cloth, wetting it in cold water. Then the person needs to be wrapped in a blanket.
enter the days when the patient eats only fruit. This is an effective prophylactic of the disease;
decoctions of juniper, wild rose, elderberry, horsetail, St. John's wort.

Homeopathy

Homeopathic remedies help stop the course of uremic coma and help restore health, relieving a person from the consequences of the disease:

ammonia is used to stimulate the work of the heart, especially if there is blood, protein, hyaline cylinders in the urine;
hydrocyanic acid - effective in case of agony during coma;
common barberry has analgesic and anti-inflammatory properties, and is also used for a more intensive process of removing fluid from the body. Barberry helps to remove excess salts, eliminate deposits and prevent their re-formation;
hellebore white and bitter gourd activate the blood circulation of the organs located in the peritoneum;
drug Galium-Heel - its action is aimed at reducing the activity of toxins, stabilizing the structure of organs and restoring their functions, and stimulates the immune system. The tool has a positive effect on the tissues of vital organs: heart, liver, kidneys, lungs.

Life expectancy and possible end of coma

Uremic coma does not have any significant effect on the continuation of life. Modern methods resuscitation allows you to bring a person out of this state. However, a fatal outcome is not excluded, but this does not occur often. Subsequently, how long a person will live depends on the fulfillment of all the doctor's instructions aimed at preventing factors that provoke uremia.

It is worth emphasizing that the transferred uremia can reduce the patient's quality of life due to a significant effect on his nervous system. The deterioration of memory and cognitive activity of a person negatively affects its existence in the future.

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GBOU VPO OrGMA of the Ministry of Health of Russia

Department of Propaedeutics of Internal Diseases

on the topic: Uremic coma

Completed:

Barinov D.A.

Checked:

Bashaeva Z.R.

Orenburg 2014

Introduction

1. Etiology of uremic coma

2. Pathogenesis of uremic coma

3. Clinical manifestations

5. Treatment of uremic coma

Conclusion

Introduction

Chronic damage to both kidneys, no matter what it was caused, sooner or later may end in such a decrease in renal tissue, which will no longer be sufficient to remove accumulated waste products (toxins) from the body; then there are symptoms of self-poisoning of the body by these non-excreted metabolic products, up to uremic coma.

Uremic coma is a condition caused by endogenous intoxications due to severe, rarely acute or even chronic insufficiency kidney functionality. coma kidney uremia intoxication

1. Etiology of uremic coma

The development of kidney failure is various diseases kidney: most often inflammatory, infectious nature(rarely infectious-allergic) - glomerulonephritis, pyelonephritis; as well as poisoning with certain medicinal or industrial poisons; prolonged arterial hypertension; sepsis; defeat renal vessels various genesis (including systemic vasculitis); mechanical obstruction to the outflow of urine through the ureters (bilateral kidney stones, congenital deformities both kidneys) acute hemolytic crisis (including transfusion of incompatible blood); malignant course hypertension; sharp dehydration of the body, followed by oliguria and anuria, etc. Violation of the excretory function of the kidneys is accompanied by a delay in the body, primarily of products nitrogen metabolism, which essentially cannot be excreted by the extrarenal route. Urea, creatinine, uric acid, guanidine, phosphates, sulfates and various other compounds accumulate in the blood. Along with this, the water-electrolyte balance changes dramatically; the concentration of sodium and calcium in the blood decreases, the content of potassium and magnesium is subject to large fluctuations. Sodium deficiency causes an increased release of aldosterone by the adrenal cortex, which in turn leads to fluid retention in the body and arterial hypertension; the emergence of the latter is also facilitated by increased formation of renin. Under these conditions, the excretion of hydrogen ions and organic acids by the kidneys is sharply reduced; as a result, a pronounced metabolic (uremic) acidosis develops.

2. Pathogenesis of uremic coma

The totality of humoral disorders with increasing renal failure determines the violation of normal dynamics internal environment organism with concomitant damage to almost all organs and systems. The adaptive reactions of the body, aimed at excreting the products of nitrogen metabolism by the sweat and salivary glands, stomach and intestines, are not able to compensate for the insufficient function of the kidneys and often cause severe stomatitis, gastritis, enteritis and colitis (sometimes erosive and ulcerative). The accumulation of urates and ammonia salts in the blood is accompanied by aseptic inflammation of the serous and mucous membranes with the formation of pericarditis, pleurisy, arthritis, tendo-vaginitis, vasculitis - as a rule, it will develop gradually.

As renal failure progresses, glomerular filtration and also tubular reabsorption are sharply disturbed, oliguria occurs, then anuria.

3. Clinical manifestations

Uremic coma usually develops gradually. Patients have pronounced asthenic syndrome - apathy, general weakness, fatigue, headache, sleep disturbance (drowsiness during the day and insomnia at night). All these phenomena are associated with the toxic effect of urea on the central nervous system. Dyspeptic syndrome is manifested by a decrease in appetite up to anorexia (complete refusal to eat), dryness and bitterness in the mouth, smell of urine from the mouth, thirst. Stomatitis, gastritis, enterocolitis develop. All this is due to the presence of extrarenal pathways for the excretion of toxic metabolic products: through the mucous membrane of the gastrointestinal tract, skin and sweat glands.

The appearance of patients is characteristic - the face is puffy, the skin is pale, dry, with traces of scratching due to excruciating itching, sometimes deposition of uric acid crystals in the form of powdered sugar on the skin. Bruises and hemorrhages, pastosity of the face, swelling of the lower extremities and lower back are characteristic. Hemorrhagic syndrome in uremia is clinically manifested by nasal, uterine and gastrointestinal bleeding, which is associated with damage to the vascular wall and thrombocytopenia (a decrease in platelet count in the blood).

Changes are taking place in cardiovascular system. High hypertension appears (diastolic, lower pressure is especially increased).

Disorders in the respiratory system are manifested by a disorder in the frequency and depth of breathing, paroxysmal dyspnea, which may be a precursor of uremic pulmonary edema due to salt and fluid retention and the development of acute left ventricular failure. An increase in intoxication leads to toxic damage to the central nervous system and the transition of lethargy and a soporous state into a proper coma. Consciousness is lost, however, there may be periods of sharp psychomotor agitation with delusions and hallucinations. Oppression respiratory center leads to Kussmaul breathing. With an increase in a coma, fibrillar twitches of individual muscle groups are possible, miosis, tendon reflexes are increased. Anemia, thrombocytopenia, leukocytosis (an increase in the number of leukocytes), accelerated ESR are noted in the blood. The level of residual nitrogen and urea, the concentration of creatinine increase. In acute renal failure, the specific gravity of urine is high, marked albuminuria, macrohematuria, cylindruria is determined.

4. Diagnosis of uremic coma

The diagnosis of uremic coma is based on clinical data: ammonia breath, general form patient (yellowish-pale color of open areas of the skin, dry skin and mucous membranes, hemorrhagic manifestations, scratching, etc.), arterial hypertension, pathological rhythms breathing (such as Kussmaul or Cheyne - Stokes), fibrillar muscle twitching, typical neurological symptoms and relevant laboratory parameters.

The dimensions of the heart are enlarged mainly due to the left ventricle, over the apex and at the Botkin point, characteristic systolic murmurs, on the aorta - accent II tone; tachycardia, sometimes up to the gallop rhythm; in the terminal stage, a rough pericardial friction rub is determined, occasionally perceived even by palpation. ECG changes largely reflect electrolyte disturbances (hypocalcemia and hyperkalemia); the interval Q -- T is extended (due to the segment S -- T), the T wave is high, equilateral with a pointed apex or, less commonly, low.

Above the lungs, in the posterior and lower all sections chest, percussion sound is greatly shortened, and breathing is weakened in places, hard in places, wet and scattered dry rales are heard, sometimes pleural friction noise. Pneumonia often develops.

X-ray signs of interstitial, acinar-lobular, infiltrative-like or even massive pulmonary edema are determined; and in some cases there is a darkening of the lung fields according to the type of "butterfly wings".

A clinical blood test reveals severe anemia with a decrease in the number of erythrocytes to 2,000,000 and hemoglobin to 50 g / l, thrombocytopenia and a sharp leukocytosis (up to 15,000 - 30,000). The content in the blood of residual nitrogen, unabsorbed urea, creatinine, indican, phosphates and sulfates increases; there is sub- or decompensated metabolic acidosis, hyponatremia, hypocalcemia, and most often hyperkalemia.

In chronic renal failure, urine will be low specific gravity, colorless; characterized by microproteinuria, microhematuria with a predominance of leached erythrocytes, single cylinders in the urinary sediment. In acute renal failure, urine density is high; urine contains a lot of protein and erythrocytes, often free hemoglobin, blood detritus, myoglobin, pigment cylinders, sometimes crystals of substances that caused kidney failure (for example, sulfonamides).

Previous medical documentation and history support the diagnosis.

5. Treatment of uremic coma

Emergency care includes the following activities. The stomach and intestines are washed with 2% sodium bicarbonate solution, laxatives are prescribed. With hyponatremia (dry flabby skin, low blood pressure and central venous pressure, no edema), 250 ml of isotonic sodium chloride solution is injected intramuscularly. With hypernatremia (pronounced swelling of the extremities, high blood pressure and central venous pressure), spironolactone is prescribed (0.075 - 0.3 g per day), with arterial hypertension - capoten, caposide, vasocardin, atenolol. Trisamine is administered intravenously to eliminate acidosis. During rehydration, 300 - 500 ml of 5% glucose solution and 400 ml of 4% sodium bicarbonate solution are injected. To correct violations of protein metabolism, anabolic hormones are prescribed (retabolil - 1 ml of a 5% solution). With gynokalemia, it is necessary to introduce potassium chloride or panangin; with hyperkalemia - 700 ml of 3% sodium bicarbonate solution, 20% glucose solution. Antibiotics are prescribed for an infectious process. With persistent vomiting, raglan or cerucal (2 ml intramuscularly) is prescribed. Perform extracorporeal hemodialysis. In case of severe irreversible changes in the kidney parenchyma, transplantation of this organ is indicated.

Conclusion

Important in the prevention of the development of uremia is the issue of prevention of renal dysplasia - the creation of conditions for the course of pregnancy, protecting the embryo and fetus from teratogenic effects.

It is essential to search for markers of heterozygous carriage of pathology, as well as antenatal diagnosis of malformations of the organs of the urinary system in cases of increased risk.

If it is impossible to carry out replacement therapy or transplantation in uremic coma, then the prognosis is lethal.

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Symptoms

General weakness precedes. Lack of appetite, nausea, vomiting, diarrhea, thirst, skin itching, lethargy, drowsiness. The skin is pale, dry, with fine peeling and traces of scratching. Urinous odor from the mouth. Sometimes agitation, delirium, hallucinations; pupils are constricted. Breathing speeded up, may be of the Kussmaul type. Blood pressure is usually elevated. In the final stage, a pericardial friction rub is heard. Anemia, leukocytosis, a sharp increase in the level of creatinine, residual nitrogen in the blood, hyperkalemia, metabolic acidosis. Low relative gravity of urine, proteinuria, changes in urine sediment.

First aid

In case of inappropriate behavior and unconsciousness, protect the patient from bodily harm. When vomiting - prevention of aspiration of vomit.

First aid

With increased blood pressure intramuscularly 2 ml of 1% dibazol solution; when excited - 1 ml of a 1% solution of diphenhydramine. Gastric lavage and siphon enemas with 2-3% sodium bicarbonate solution, ingestion activated carbon, sodium bicarbonate 3 g per 0.5 glass of water 3 times a day.

Medical emergency

Medical Center

Intravenously 400 ml of 5% glucose solution (with sharp rise AD in combination with 2 ml of 1% dibazol solution), intramuscularly 2 ml of cordiamine, oxygen inhalation. With persistent vomiting, subcutaneously 0.5 ml of a 0.1% solution of atropine, with a sharp excitation - 1 ml of a 1% solution of diphenhydramine intramuscularly. Evacuation to the hospital on an ambulance, lying on a stretcher, accompanied by a doctor.

Omedb, hospital

With preserved diuresis, additionally intravenously inject 40 mg of furosemide (lasix) in 400 ml of 5% glucose solution or 400 ml of 0.9% sodium chloride solution; 5-10 ml of a 2.4% solution of aminophylline intravenously; with acidosis - 150-200 ml of 4% sodium bicarbonate solution intravenously; with hyperkalemia intravenously drip 400 ml of 20% glucose solution with 16-20 IU of insulin, 20 ml of 10% calcium gluconate solution. With high blood pressure - intramuscularly 1 ml of a 2.5% solution of benzohexonium or 1 ml of a 5% solution of pentamine; intramuscularly or intravenously 1 ml of 0.01% clonidine solution. With infectious complications, antibiotics that do not have a nephrotoxic effect (penicillin, semi-synthetic penicillins, carbenicillin, erythromycin). In the absence of the effect of ongoing conservative therapy and the absence of contraindications - hemodialysis, hemosorption, peritoneal dialysis.

Coma in renal failure. Providing emergency care for uremic coma

Reasons for the dangerous condition

Stages of development and symptoms

Consequences of a coma

Comprehensive examination

Helping the Patient

Urgent measures awaiting doctors

Treatment in a hospital

Conservative therapy

Surgery

Rehabilitation after uremic coma

Prognosis after treatment

What is uremic coma?

Causes of uremic coma

Symptoms of uremic coma

The pathogenesis of uremic coma

Alternative treatment

Homeopathy

Surgery

Danger of uremic coma

Features of the course of the disease in adults and children

Grounds for the formation of a coma

Complications and consequences

Diagnostics

Treatment and emergency care

Prevention

Alternative treatment

Homeopathy

Life expectancy and possible end of coma

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