honk by aijaz

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

honk by aijaz

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