By: Nurfauzani binti IbrahimShuhaida bt Che Shaffi
What it is?..A metabolic emergency that occurs in
diabetic patient usually Type 2 Diabetes Mellitus
in which it is characterised by uncontrolled hyperglycemia that induces
hyperosmolar state and dehydration without significant
ketoacidosis.
Diagnostic features• Plasma glucose level of 600 mg/dL or greater• Effective serum osmolality of 320 mOsm/kg or
greater• Profound dehydration (8-12 L) with elevated
serum urea nitrogen (BUN)-to-creatinine ratio
• Small ketonuria and absent-to-low ketonemia• Bicarbonate concentration greater than 15
mEq/L• Some alteration in consciousness
CausesDehydrationPneumonia and UTICounter-regulotary hormone (e.g cortisol, cathecolamine,
glucagon)Drugs - Diuretics - B-blocker - Histamine(H2) Blocker - Anti-psychotics (Clozapine, Olanzapine) - Alcohol abd cocaine - Dialysis, TPN, Fluid (Dextrose)Non-compliance to OHA or insulin therapy
Pathophysiology
Concomitant illness
Circulating insulin& of counte-regulatory hormones
renal clearance and peripheral utilization of glucose
Hyperglycemia Osmotic diuresis
Loss of electrocyte and water
dehydration
hyperosmolarity
FFA lipolysis no ketogenesis
Intracellular dehydration
Clinical featuresOccurs only in type 2 DMCould be initial presentation of the diabetic
stateElderlyObtundation to comaSevere dehydration invariableMay have associated lactic acidosis due to
hypoxiaPrecipitating factors similar to DKAMortality rate is high
SymptomsSymptoms of hyperglycemia :
PolydipsiaPolyuriaLethargic
Others :Weight lossLoss of consciousness
A wide variety of focal and global neurologic changes may be present, including the following:Drowsiness and lethargyDeliriumComaFocal or generalized seizuresVisual changes or disturbancesHemiparesisSensory deficits
Physical examination :Dehydrated : dry skin, lips, mucous
membrane, loss skin turgor
Vital sign : tachycardia (early dehydration), hypotension (later), temperature
Systemic examination to ruled out the cause.
Differential diagnosisAlcoholic ketoacidosisDelirium (altered mentation)DementiaOverdoseThyrotoxicosis (tachycardia, fever,
dehydration)
Lab studiesPlasma glucose
HyperglycemiaABG
PH> 7.3HCO3>15 mmol/l
Serum osmolality>320 mmol/l
othersUrinanalysis
Exclude utiProteinuria
Plasma ketonePlasma electrolyteRenal function test(Creatinine &BUN)FBCCreatine kinase
Imaging studiesChest radiograph
Exclude pnuemoniaCardiomegaly
CT scan of the headExclude heamorrhagic stroke, subdural
heamatomaLook for cerebral edema
ManagementAirway IV accessLab and radiographfluid deficit of an adult may be 10 L or more.Administer 1-2 L of isotonic saline in the first 2 hours. A
higher initial volume may be necessary in patients with severe volume depletion. Caution should be taken to not correct hypernatremia too quickly, as this could lead to 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 intravenous fluid.
Initiate insulin therapy infuse insulin at rate of 3 Units/hour for first 2-3 hours increase 6 Units/hour if glucose falling too slow
Replete K+ and Mg2+AntibioticReevaluationHospitalization