This document provides guidelines for managing hyperosmolar non-ketotic coma. It recommends assessing for the underlying cause, initiating fluid resuscitation slowly over 6 hours with 0.9% saline to avoid cerebral edema, administering insulin to gradually lower blood sugar levels, monitoring electrolytes and giving potassium supplementation if needed, providing thromboprophylaxis due to endothelial disruption, closely monitoring fluid balance and labs, and transferring to the ICU if certain criteria are met.

1. MANAGEMENT OF HYPEROSMOLAR
NON-KETOTIC COMA
Abubakar Ghali Abduljalil

2. ASSESSEMENT
• Absent ketones
• Osmolality >340mosmol/kg
• Check the underlying cause:- i.e. MI, drugs or
bowel infarct with ECG, CXR, UA, cultures, CBC

3. Fluid resuscitation
• Give 0.9 saline
• 1L first 2hrs
• 1L next 2-4hrs
• 1L over 4-6hrs
• Avoid rapid rehydration because of cerebral
edema.
• Avoid over-hydration & to rapid fall of BSL
(hypotension)

4. Insulin
• Give 50iu actrapid in 500ml of NS at 40ml/hr
• Aim for 3-5mmol/l per hr drop in blood sugar
BSL
• 10% dextrose when BSL 10-15mmol

5. Potassium
• K+ < 5.4 = 40mmol/L per hr
• K+ > 5.4 = hold

6. Anticoagulate
• Give LMWH if not contraindicate for
prophylaxis
• WHY?
• Severe dehydration/hypertonicity result in
disruption of endothelial cells = release
thromboplastins, elevate vasopressin =
enhanced coagulation.

7. Monitoring
• Fluid balance chart with hourly urine output.
• NG tube if vomiting and drowsy
• Repeat labs.
 check 2hrs after initiation of tx then 6hrs for first
24hrs
Blood sugar level and venous blood gas.

8. • Continuous observation
• If Osmolality increases (or fall <3mmol/kg/hr)
and Na increasing check fluid balance.
If inadequate increase infusion rate
If adequate consider changing to 0.45% saline at the
same rate.
• If Osmolality falling >8mosmol/kg/hr consider
 reducing the rate of IVF
Reduce rate of insulin infusion

9. Consider ICU if:-
• Osmolality is >350mmpl/kg
• BP <90mmHg
• Na >160mmol/L
• HR <60 or >100
• pH of <7.1
• Hypo/hyperkalemia
• Urine output <0.5ml/kg/hr
• GCS <12
• O2 <92%