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.

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Hyperosmolar Non Ketotic Dm [Autosaved]

  1. 1. By: Nurfauzani binti Ibrahim Shuhaida bt Che Shaffi
  2. 2. What it is?.. <ul><li>A metabolic emergency that occurs in diabetic patient usually Type 2 Diabetes Mellitus </li></ul><ul><li>in which it is characterised by </li></ul><ul><li>uncontrolled hyperglycemia that induces hyperosmolar state </li></ul><ul><li>and dehydration without significant ketoacidosis. </li></ul>
  3. 3. Diagnostic features <ul><li>Plasma glucose level of 600 mg/dL or greater </li></ul><ul><li>Effective serum osmolality of 320 mOsm/kg or greater </li></ul><ul><li>Profound dehydration (8-12 L) with elevated serum urea nitrogen (BUN)-to-creatinine ratio </li></ul><ul><li>Small ketonuria and absent-to-low ketonemia </li></ul><ul><li>Bicarbonate concentration greater than 15 mEq/L </li></ul><ul><li>Some alteration in consciousness </li></ul>
  4. 4. Causes <ul><li>Dehydration </li></ul><ul><li>Pneumonia and UTI </li></ul><ul><li>Counter-regulotary hormone (e.g cortisol, cathecolamine, glucagon) </li></ul><ul><li>Drugs </li></ul><ul><li>- Diuretics </li></ul><ul><li>- B-blocker </li></ul><ul><li>- Histamine(H2) Blocker </li></ul><ul><li>- Anti-psychotics (Clozapine, Olanzapine) </li></ul><ul><li>- Alcohol abd cocaine </li></ul><ul><li>- Dialysis, TPN, Fluid (Dextrose) </li></ul><ul><li>Non-compliance to OHA or insulin therapy </li></ul>
  5. 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. 6. Clinical features <ul><li>Occurs only in type 2 DM </li></ul><ul><li>Could be initial presentation of the diabetic state </li></ul><ul><li>Elderly </li></ul><ul><li>Obtundation to coma </li></ul><ul><li>Severe dehydration invariable </li></ul><ul><li>May have associated lactic acidosis due to hypoxia </li></ul><ul><li>Precipitating factors similar to DKA </li></ul><ul><li>Mortality rate is high </li></ul>
  7. 7. Symptoms <ul><li>Symptoms of hyperglycemia : </li></ul><ul><ul><li>Polydipsia </li></ul></ul><ul><ul><li>Polyuria </li></ul></ul><ul><ul><li>Lethargic </li></ul></ul><ul><li>Others : </li></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Loss of consciousness </li></ul></ul>
  8. 8. <ul><li>A wide variety of focal and global neurologic changes may be present, including the following: </li></ul><ul><ul><li>Drowsiness and lethargy </li></ul></ul><ul><ul><li>Delirium </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><ul><li>Focal or generalized seizures </li></ul></ul><ul><ul><li>Visual changes or disturbances </li></ul></ul><ul><ul><li>Hemiparesis </li></ul></ul><ul><ul><li>Sensory deficits </li></ul></ul>
  9. 9. <ul><li>Physical examination : </li></ul><ul><li>Dehydrated : dry skin, lips, mucous membrane, loss skin turgor </li></ul><ul><li>Vital sign : tachycardia (early dehydration), hypotension (later), temperature </li></ul><ul><li>Systemic examination to ruled out the cause. </li></ul>
  10. 10. Differential diagnosis <ul><li>Alcoholic ketoacidosis </li></ul><ul><li>Delirium (altered mentation) </li></ul><ul><li>Dementia </li></ul><ul><li>Overdose </li></ul><ul><li>Thyrotoxicosis (tachycardia, fever, dehydration) </li></ul>
  11. 11. Lab studies <ul><li>Plasma glucose </li></ul><ul><ul><li>Hyperglycemia </li></ul></ul><ul><li>ABG </li></ul><ul><ul><li>PH> 7.3 </li></ul></ul><ul><ul><li>HCO3>15 mmol/l </li></ul></ul><ul><li>Serum osmolality </li></ul><ul><ul><li>>320 mmol/l </li></ul></ul>
  12. 12. others <ul><li>Urinanalysis </li></ul><ul><ul><li>Exclude uti </li></ul></ul><ul><ul><li>Proteinuria </li></ul></ul><ul><li>Plasma ketone </li></ul><ul><li>Plasma electrolyte </li></ul><ul><li>Renal function test(Creatinine &BUN) </li></ul><ul><li>FBC </li></ul><ul><li>Creatine kinase </li></ul>
  13. 13. Imaging studies <ul><li>Chest radiograph </li></ul><ul><ul><li>Exclude pnuemonia </li></ul></ul><ul><ul><li>Cardiomegaly </li></ul></ul><ul><li>CT scan of the head </li></ul><ul><ul><li>Exclude heamorrhagic stroke, subdural heamatoma </li></ul></ul><ul><ul><li>Look for cerebral edema </li></ul></ul>
  14. 14. Management <ul><li>Airway </li></ul><ul><li>IV access </li></ul><ul><li>Lab and radiograph </li></ul><ul><li>fluid deficit of an adult may be 10 L or more. </li></ul><ul><li>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. </li></ul><ul><li>switch to half-normal saline once blood pressure and urine output are adequate. </li></ul><ul><li>Once serum glucose drops to 250 mg/dL, the patient must receive dextrose in the intravenous fluid. </li></ul>
  15. 15. <ul><li>Initiate insulin therapy </li></ul><ul><ul><li>infuse insulin at rate of 3 Units/hour for first 2-3 hours </li></ul></ul><ul><ul><li>increase 6 Units/hour if glucose falling too slow </li></ul></ul><ul><li>Replete K+ and Mg2+ </li></ul><ul><li>Antibiotic </li></ul><ul><li>Reevaluation </li></ul><ul><li>Hospitalization </li></ul>