KOMA HIPEROSMOLAR NONKETOTIK

Fatimah Eliana

DKA and HHS

Curriculum Module III-6 Slide of 55

What is HHS?

Ketosis may be present Coma not always present Primarily in older people with/without history of type 2 diabetes Always associated with severe dehydration and hyperosmolar state Develops over weeks

Kitabchi et al 2001

DKA and HHS

Curriculum Module III-6 Slide of 55

HHS incidence and features

0.5% of primary diabetes hospital admissions ~15% mortality rate Can occur in type 1 diabetes and younger people

Kitabchi et al 2001

DKA and HHS

Curriculum Module III-6 Slide of 55

HHS causes or triggers

Incidence Infection New-onset diabetes 40-60% 33%

Acute illness
Medicines, steroids Insulin omission

10-15%
<10% 5-15%

DKA and HHS

Curriculum Module III-6 Slide of 55

HHS key features

Marked hyperglycaemia Hyperosmolarity Absence of severe ketosis Altered mental awareness

KOMA HIPEROSMOLAR NON KETOTIK

Gejala klinis

Biasanya berusia > 50 tahun Kesadaran Tanda-tanda dehidrasi Hiperglikemia yang tinggi (> 600 mg/dl) Tanpa asidosis pH > 7.3 Ketosis ringan Hiperosmolaritas
[(2 plasma Na ) + plasma glukosa] > 320 mOsm/kg 2 (Na + K) + Urea + Glukosa > 350 mOsm/kg
+

18

DKA and HHS

Curriculum Module III-6 Slide of 55

Signs and symptoms of HHS

Initially polyuria and polydipsia
Altered mental status Profound dehydration Precipitating factors

DKA and HHS

Curriculum Module III-6 Slide of 55

HHS biochemical findings

Blood glucose Ketones Osmolality Electrolytes >33mmol/L (600mg/dl) Urine: negative small Blood: <0.6 mmol/L >320mOsm/kg - (raised Na, BG, urea) Raised Na, BG, urea creatinine

Anion gap
Blood gases

<12
pH >7.30 normal or raised HCO3

DKA and HHS

Treatment
Rehydration Caution!

Curriculum Module III-6 Slide of 55

Normal saline 1 l per hour initially Consider strength normal saline Potassium Insulin Only if hypokalaemic and renal function adequate give before insulin May be needed as slow infusion 0.1 unit/kg/hour to be increased with care if BG is slow to fall BG, BP, neurological function hourly until stable Electrolytes 2-hourly Cardiac or CVP monitoring

Monitoring

DKA and HHS

HHS complications
Complication Hypoglycaemia Prevention

Curriculum Module III-6 Slide of 55

Prevent by adding glucose infusion when glucose <14mmol/L (250 mg/dL) Early potassium replacement and monitoring Careful clinical monitoring and central line as needed NG tube and may be nursed on side Avoid fast blood glucose falls (should be <4mmol/L (72mg/dL) per hour; aggressive Mannitol treatment if any early signs of cerebral oedema

Hypokalaemia Fluid overload Vomiting/aspiration Cerebral oedema

DKA and HHS

DKA and HHS prevention is key

Curriculum Module III-6 Slide of 55

Identify and treat underlying cause Can be prevented by better public awareness improved access to medical care improved education in treating hyperglycaemia during illness emergency communication with healthcare provider