Hyperosmolar Non Ketotic Dm [Autosaved]
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Hyperosmolar Non Ketotic Dm [Autosaved]

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This presentation was present by my friend during emergency posting seminar with Dr.Mohd. Kamal Mohd. Arshad. I upload this ppt here for all of us and my own reference too. Good luck in your life.

This presentation was present by my friend during emergency posting seminar with Dr.Mohd. Kamal Mohd. Arshad. I upload this ppt here for all of us and my own reference too. Good luck in your life.

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Hyperosmolar Non Ketotic Dm [Autosaved] Presentation Transcript

  • 1. By: Nurfauzani binti Ibrahim Shuhaida bt Che Shaffi
  • 2. 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.
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. Symptoms
    • Symptoms of hyperglycemia :
      • Polydipsia
      • Polyuria
      • Lethargic
    • Others :
      • Weight loss
      • Loss of consciousness
  • 8.
    • 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
  • 9.
    • 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.
  • 10. Differential diagnosis
    • Alcoholic ketoacidosis
    • Delirium (altered mentation)
    • Dementia
    • Overdose
    • Thyrotoxicosis (tachycardia, fever, dehydration)
  • 11. Lab studies
    • Plasma glucose
      • Hyperglycemia
    • ABG
      • PH> 7.3
      • HCO3>15 mmol/l
    • Serum osmolality
      • >320 mmol/l
  • 12. others
    • Urinanalysis
      • Exclude uti
      • Proteinuria
    • Plasma ketone
    • Plasma electrolyte
    • Renal function test(Creatinine &BUN)
    • FBC
    • Creatine kinase
  • 13. Imaging studies
    • Chest radiograph
      • Exclude pnuemonia
      • Cardiomegaly
    • CT scan of the head
      • Exclude heamorrhagic stroke, subdural heamatoma
      • Look for cerebral edema
  • 14. 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.
  • 15.
    • 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