To the Editor.—
The editorial (227:317, 1974) rightly stated that ketoacidosis is not the only factor in the production of diabetic coma. Dehydration and consequent hyperosmolarity are important considerations. As coauthor of the article of reference,1 I would like to add further observations.In my own experience with the different types of diabetic coma, I have found that the ketotic type of coma is the more severe, requires more insulin, and often has a worse prognosis than that of the nonketotic type. I think there is a direct correlation between the bedside evaluation of the severity of the ketosis ("acidotic breathing," ketones in urine and blood) and the severity of coma. Ketosis does, in fact, directly produce coma, and of a greater severity than that due to hyperglycemia and dehydration.The poor correlation between the blood pH and severity of coma that you mention is supported by the observation
Sament S. Hyperosmolar Diabetic Coma— Ketotic and Nonketotic. JAMA. 1974;228(4):461. doi:10.1001/jama.1974.03230290017009
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