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8/3/2019 HONK by Aijaz
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Case ScenarioA 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.
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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 / mino BSL = 650 mg / dl
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Hyperglycaemic Hyperosmolar Non-Ketotic
Comma (HONK)
Diabetic Ketoacidosis (DKA)
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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
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Pathophysiology
DM
Acute Illness Dehydration
Decreased insulin
Increased Glucagon, catecholamine's, cortisol,
Hyperglycemia, Hyperosmolarity
Osmotic diuresis, Dehydration, Electrolyte Loss
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No Significant Ketosis seen
Factors
Relative Insulin availability
Decreased Lipolysis
Relatively low Counter regulatory
hormones
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A preceding or inter current infection
(pneumonia, UTIs). Unknown concomitant illness
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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)
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Polydipsia
Polyuria
Weight loss
Weakness
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Vital signs
Tachycardia
Hypotension
Tachypnea
Temperature (Increase or decrease)
(Hypothermia is a poor prognostic factor)
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kin examination
Decrease turgor Sunken eyes,
Dry mouth
Cranial neuropathies
Visual field losses
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Diagnostic Considerations
The differential diagnosis includes any cause ofaltered mental status
Central nervous system infection
Hypoglycemia
Hyponatremia
Severe dehydration
Uremia
Hyperammonemia
Drug overdose
Sepsis
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Serum Glucose Level
Serum glucose level usually is elevated
dramatically, often to greater than 800mg/dL. Accordingly, fingerstick glucose should
be checked immediately; it will usually be
greater than 600 mg/dL.
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Serum OsmolarityorOsmolality
Serum osmolarity and/or osmolality areusually 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)
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Blood Gas AnalysisABGs
In most cases of HHS the blood pH is greaterthan 7.30.
VBGs
Substituted in patients with normal oxygensaturation on room air.
The pH measured by a VBG is 0.03 pH units
less than the pH on an ABG.
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Serum Electrolyte levels
SODIUM (Na)
Hyponatremia (pseudo-hyponatremia )
Hypernatremia(Severe dehyderation)
POTASSIUM (K)
HypokalemiaHyperkalemia
MAGNESIUM
Hypomagnecemia
BICARBONATE
greater than 15 mEq/L.
ANION GAP
usually less than 12 mmol/L.
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Urinalysis
Elevated specific gravity
Glucosuria
Small ketonuria Evidence of urinary tract infection (UTI).
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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 inpatients with diabetes mellitus.
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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 subarachnoidhemorrhage is suspected, lumbar
puncture (LP) is indicated.
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Radiography
A chest radiograph is useful to screen
for pneumonia. Abdominal radiographs are indicatedif
the patient has abdominal pain or is
vomiting.
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CT of the Head
indicated in many patientswith focal or global
neurologic changes whoshow no clinical improvementafter several hours oftreatment, even in theabsence of clinical signs of
intracranial pathology.
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Management
American Diabetes Associationmanagement guidelines:
Fluids and Electrolytes
Insulin
Detection and Treatment of underlyingcause
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Airway management
Endotracheal intubation may be indicated.
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Fluid resuscitation
Fluid deficits in hyperosmolar hyperglycemicstate
(HHS) are large
May be 10 L or more
Bolus of 500 mL isotonic salineo 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
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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 cerebraledema.
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.
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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.
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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
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Electrolyte Replacement
Potassium
Not given in 1st 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 ifK
> 5 mmol / ltr
Limits
20 mmol / Hr
40 mmol / Ltr 80 mmol / day
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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
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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)
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Once Patient stable and able to
eat and drink, transferpatient to 4
time dail y subcutaneous insulin
regime
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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
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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
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Long-term Monitoring (Cont)
Diet
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Long-term Monitoring (Cont)
BSL Control
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Complications
Acute circulatory collapse
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Complications
Thromboembolism
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Complications
Cerebral edema
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HONK vs DKA
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Thank you
Dr. AIJAZ ZEESHAN KHAN CHACHAR