By: Nurfauzani binti Ibrahim Shuhaida 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.

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

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

Causes Dehydration Pneumonia and UTI Counter-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

Dehydration

Pneumonia and UTI

Counter-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 features Occurs only in type 2 DM Could be initial presentation of the diabetic state Elderly Obtundation to coma Severe dehydration invariable May have associated lactic acidosis due to hypoxia Precipitating factors similar to DKA Mortality rate is high

Occurs only in type 2 DM

Could be initial presentation of the diabetic state

Elderly

Obtundation to coma

Severe dehydration invariable

May have associated lactic acidosis due to hypoxia

Precipitating factors similar to DKA

Mortality rate is high

Symptoms Symptoms of hyperglycemia : Polydipsia Polyuria Lethargic Others : Weight loss Loss of consciousness

Symptoms of hyperglycemia :

Polydipsia

Polyuria

Lethargic

Others :

Weight loss

Loss of consciousness

A wide variety of focal and global neurologic changes may be present, including the following: Drowsiness and lethargy Delirium Coma Focal or generalized seizures Visual changes or disturbances Hemiparesis Sensory deficits

A wide variety of focal and global neurologic changes may be present, including the following:

Drowsiness and lethargy

Delirium

Coma

Focal or generalized seizures

Visual changes or disturbances

Hemiparesis

Sensory 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.

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 diagnosis Alcoholic ketoacidosis Delirium (altered mentation) Dementia Overdose Thyrotoxicosis (tachycardia, fever, dehydration)

Alcoholic ketoacidosis

Delirium (altered mentation)

Dementia

Overdose

Thyrotoxicosis (tachycardia, fever, dehydration)

Lab studies Plasma glucose Hyperglycemia ABG PH> 7.3 HCO3>15 mmol/l Serum osmolality >320 mmol/l

Plasma glucose

Hyperglycemia

ABG

PH> 7.3

HCO3>15 mmol/l

Serum osmolality

>320 mmol/l

others Urinanalysis Exclude uti Proteinuria Plasma ketone Plasma electrolyte Renal function test(Creatinine &BUN) FBC Creatine kinase

Urinanalysis

Exclude uti

Proteinuria

Plasma ketone

Plasma electrolyte

Renal function test(Creatinine &BUN)

FBC

Creatine kinase

Imaging studies Chest radiograph Exclude pnuemonia Cardiomegaly CT scan of the head Exclude heamorrhagic stroke, subdural heamatoma Look for cerebral edema

Chest radiograph

Exclude pnuemonia

Cardiomegaly

CT scan of the head

Exclude heamorrhagic stroke, subdural heamatoma

Look for cerebral edema

Management Airway IV access Lab and radiograph fluid 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.

Airway

IV access

Lab and radiograph

fluid 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+ Antibiotic Reevaluation Hospitalization

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+

Antibiotic

Reevaluation

Hospitalization