Case Scenario

A 68 yrs old male presented in emergency with progressive drowsiness for past 48 hrs. He is known diabetic for 10 yrs and taking metformin.  Before deterioration he was suffering from high grade fever, burning micturition, polyuria and increased thirst for 3 weeks.


Examination
He is drowsy, dehydrated and have reduced skin turgor. o Pulse = 112/min (Feeble, Regular) o Temp = 102 F o BP = 100/60 mm Hg o RR = 22 / min o BSL = 650 mg / dl

Hyperglycaemic Hyperosmolar Non-Ketotic Comma (HONK) Diabetic Ketoacidosis (DKA)

Investigations
Hb = 8 gm /dl TLC = 18 x 103 / ul DLC = Neutrophils 80% Platelets = 2000 x 103 / ul ESR = 30 LFTs = Normal Urea = 65 mg/dl Creatinine = 1.9 ml/dl Na = 151 mmol/l K = 3 mmol/l Cl = 110 mmol/l CUE = Pus cells 10 ~ 12, Glucose +++, Proteins + Ketones = -ive

Pathophysiology
DM
Acute Illness Dehydration

Decreased insulin Increased Glucagon, catecholamine's, cortisol, Hyperglycemia, Hyperosmolarity Osmotic diuresis, Dehydration, Electrolyte Loss

No Significant Ketosis seen



Factors

Relative Insulin availability Decreased Lipolysis Relatively low Counter regulatory hormones

A preceding or inter current infection (pneumonia, UTIs). Unknown concomitant illness

History
Known Case of type 2 DM 30 ~ 40 % HONK is initial presentation Duration of days to weeks Preceding Illness + increasing dehydration Decreased oral hydration (vomiting,dementia, immobility)

Polydipsia Polyuria Weight loss Weakness

Vital signs
Tachycardia Hypotension Tachypnea Temperature (Increase or decrease)
(Hypothermia is a poor prognostic factor)

kin examination
Decrease turgor Sunken eyes, Dry mouth Cranial neuropathies Visual field losses

Diagnostic Considerations
The differential diagnosis includes any cause of altered mental status Central nervous system infection Hypoglycemia Hyponatremia Severe dehydration Uremia Hyperammonemia Drug overdose Sepsis

Serum Glucose Level

Serum glucose level usually is elevated dramatically, often to greater than 800 mg/dL. Accordingly, fingerstick glucose should be checked immediately; it will usually be greater than 600 mg/dL.

Serum Osmolarity or Osmolality

Serum osmolarity and/or osmolality are
usually greater than 320 mOsm/L. Osmolality can be measured directly by freezing point depression or osmometry. Osmolarity can be calculated by using the following formula:  Osmolarity = (2 Na) + (blood urea nitrogen/2.8) + (glucose/18)

Blood Gas Analysis

ABGs
In most cases of HHS the blood pH is greater than 7.30.

VBGs
Substituted in patients with normal oxygen saturation on room air. The pH measured by a VBG is 0.03 pH units less than the pH on an ABG.

Serum Electrolyte levels

SODIUM (Na) Hyponatremia (pseudo-hyponatremia ) Hypernatremia(Severe dehyderation) POTASSIUM (K) Hypokalemia Hyperkalemia MAGNESIUM Hypomagnecemia BICARBONATE greater than 15 mEq/L. ANION GAP usually less than 12 mmol/L.

Urinalysis
Elevated specific gravity Glucosuria Small ketonuria Evidence of urinary tract infection (UTI).

Blood and Urine Cultures

If clinically indicated. Blood cultures should be obtained to search for bacteremia. Urine cultures are useful because UTIs may be underdetected by urinalysis alone, particularly in patients with diabetes mellitus.

Cerebrospinal Fluid Studies

Cerebrospinal fluid (CSF) cell count, glucose, protein, and culture are indicated in patients with an acute alteration of consciousness and clinical features suggestive of possible CNS infection. When meningitis or subarachnoid hemorrhage is suspected, lumbar puncture (LP) is indicated.

Radiography
A chest radiograph is useful to screen for pneumonia. Abdominal radiographs are indicated if the patient has abdominal pain or is vomiting.

CT of the Head
indicated in many patients with focal or global neurologic changes who show no clinical improvement after several hours of treatment, even in the absence of clinical signs of intracranial pathology.

Management
American Diabetes Association management guidelines: Fluids and Electrolytes Insulin Detection and Treatment of underlying cause

Airway management
Endotracheal intubation may be indicated.

Fluid resuscitation
Fluid deficits in hyperosmolar hyperglycemic state (HHS) are large  May be 10 L or more  Bolus of 500 mL isotonic saline o 1 Ltr in 30 mins o 1 Ltr in 1 Hr o 1 Ltr in 2 Hrs o 1 Ltr in 4Hrs o 1 Ltr in 6 Hrs  Maintain UOP = 30 ~ 50 ml / hr


Fluid resuscitation (Cont)



High initial volume may be necessary in patients with severe volume depletion.

Slower initial rates may be appropriate in patients with significant cardiac or renal disease. Do not correct hypernatremia too quickly, to avoid cerebral edema. Switch to half-normal saline once blood pressure and urine output are adequate. Once serum glucose drops to 250 mg/dL, the patient must receive dextrose in the IV fluid.

Fluid resuscitation (Cont)

Comatos patients
50ml of 50% dextrose water is of benefit to many comatose patients with few adverse effects.  When possible, fingerstick glucose measurement is obtained prior to dextrose administration.


Insulin Therapy
Many patients respond to fluids alone  facilitates correction of hyperglycemia


Dosage 0.1 ~ 0.4 units / Kg STAT  0.1 / Kg / Hr  Maintain Blood glucose = 200 ~ 250 mg / dl *Insulin used without concomitant fluid replacement increases the risk of shock


Electrolyte Replacement
Potassium st  Not given in 1 Ltr unless K < 3 mmol / ltr  40 mmol / ltr if K < 3.5 mmol / ltr  20 mmol / ltr if K = 3.5 ~ 5 mmol / ltr  Do not add if K > 5 mmol / ltr Limits  20 mmol / Hr  40 mmol / Ltr  80 mmol / day

Electrolyte Replacement (Cont)

Bi-Carbonate No evidence of benefit to the patient  Given when PH< 7  Inotrops are required Dosage  500 ml NaHCO3 1.2% solution + 10 mmol KCl over 1 Hr


Plasma Expanders  When BP < 90 mm Hg systolic

When Blood Glucose Falls to 200 ~ 250 mg / dl, swap infusion fluid to 5% dextrose (1 Ltr + 20 mmol KCl 6 hourly)

Insulin with dose adjusted according to hourly blood glucose test results
(1 Unit insulin for 8 ~ 10 g of CHO)

Once Patient stable and able to eat and drink, transfer patient to 4 time daily subcutaneous insulin regime

Additional measures
(According to cause)

Antibiotics (Broad spectrum) Antipyretics Antiemetics NG tube (if drowsy) CVP pressure monitoring (if shocked or cardiac, renal impairment) Subcutaneous prophylactic heparin

Monitoring of Clinical and Laboratory Parameters

All patients diagnosed with HHS require hospitalization Frequent revaluation of the patients clinical and laboratory parameters Recheck glucose concentrations every hour. Electrolytes and venous blood gases should be monitored every 2-4 hours or as clinically indicated

Long-term Monitoring (Cont)

Diet

Long-term Monitoring (Cont)

BSL Control

Complications
Acute circulatory collapse

Complications
Thromboembolism

Complications
Cerebral edema

HONK vs DKA

Thank you

Dr. AIJAZ ZEESHAN KHAN CHACHAR