1. This document presents a case study of a 23-year-old man brought to the emergency department for decreased responsiveness. He was diagnosed with severe diabetic ketoacidosis (DKA) mixed with hyperosmolar hyperglycemic state (HHS).
2. He required aggressive fluid resuscitation, electrolyte replacement, insulin therapy, and was eventually intubated due to worsening acidosis. Despite intensive treatment, he developed cardiogenic shock and passed away.
3. Key learning points from the case include ensuring adequate but gradual fluid resuscitation and electrolyte correction in DKA/HHS patients, as well as accounting for their higher risk of cardiac complications and rhabdomy
Morbidity and Mortality Acute Inferior MI.pptxShafiqIzzuddin4
- A 57-year-old woman presented with acute inferior myocardial infarction with right ventricular involvement and decreased consciousness.
- She was intubated after her Glasgow Coma Scale dropped during streptokinase infusion to treat the myocardial infarction.
- Computed tomography of the brain was requested urgently to rule out intracranial hemorrhage from the previous ischemic stroke or as a complication of the streptokinase.
- Her diagnosis was revised to rule out intracranial bleeding and she continued to be closely monitored in intensive care.
This document describes the case of an 8-year-old girl brought to the emergency department with vomiting, breathlessness, fever, and altered mental status due to diabetic ketoacidosis (DKA). Her history of type 1 diabetes and discontinuing insulin therapy for 2 days contributed to the development of DKA. On examination, she had a low blood pressure, tachycardia, and altered mental status. Laboratory findings showed high blood glucose, low bicarbonate, and ketones in the urine, consistent with DKA. She was treated according to the Milwaukee protocol for DKA, which involves slow correction of dehydration with intravenous fluids, administration of insulin, and monitoring of electrolytes and mental status. Her
This document presents a case study of a 38-year-old male patient who presented with shortness of breath, easy fatigability, cough, fever, puffy eyelids, and lower limb edema. Initial tests found decreased kidney function, blood in the urine, low albumin and complement levels. A differential diagnosis was made which included glomerulonephritis and vasculitis. The patient was started on antibiotics, diuretics, and steroids. Follow up labs showed improved kidney function and edema resolution, with rheumatoid factor now positive, suggesting the diagnosis is rheumatoid vasculitis.
A 10-year-old boy presented with 5 days of fever, 1 day of melena, and altered consciousness for 1 hour. He was in shock and had a tender, enlarged liver. After fluid resuscitation with crystalloids and dextran, his pulses became palpable but he remained tachycardic. Over subsequent days, his platelet count and hematocrit dropped as fluid amounts were increased. He eventually required a packed red blood cell transfusion and crystalloids were gradually tapered.
1. The document outlines the key initial management steps for several acute medical emergencies including rapid assessment, timely management, asking for help, liaising with consultants, and avoiding harm.
2. For each condition, it provides guidance on important investigations, treatments, and management decisions. The conditions covered include acute coronary syndrome, acute heart failure, acute kidney injury, severe asthma, diabetic ketoacidosis, sepsis, headache, gastrointestinal bleed, stroke, and pulmonary embolism.
3. The overall objective is to provide concise guidance to support rapid evaluation and treatment of acute medical emergencies to optimize patient outcomes.
Clinical case discussion.pptx diabetic ketoacidosisViraj Shinde
This document summarizes the clinical case of a 30-year-old female patient admitted with diabetic ketoacidosis. Over the course of two weeks of treatment, the patient's vital signs and lab results were monitored and she received IV fluids, insulin therapy, electrolyte replacement including potassium, and antibiotics. The treatment largely followed standard guidelines for diabetic ketoacidosis management, though some aspects like antibiotic use and fluid management could have been more rational.
The patient is a 4-year-old girl presenting with rapid breathing for 1 week and fever and cough for 1 month. On examination, she is tachypnic, tachycardic, and hypoxic. Investigations show metabolic acidosis, leukocytosis, and chest x-ray findings consistent with pneumonia. She deteriorates and requires intubation for septic shock secondary to severe pneumonia. Management involves fluid resuscitation, antibiotics, and supportive care including ventilation as she progresses to multi-organ dysfunction. Early recognition and goal-directed therapy are emphasized to prevent progression to irreversible shock.
The document summarizes a patient's medical report during hemodialysis treatment. It includes information on the patient's medical history, physical examination findings, lab results, dialysis monitoring, diagnosis of end stage renal disease due to diabetes and hypertension, and treatment plan to address issues like intradialytic hypotension and anemia management through diet, medication, and ensuring adequate dialysis.
Morbidity and Mortality Acute Inferior MI.pptxShafiqIzzuddin4
- A 57-year-old woman presented with acute inferior myocardial infarction with right ventricular involvement and decreased consciousness.
- She was intubated after her Glasgow Coma Scale dropped during streptokinase infusion to treat the myocardial infarction.
- Computed tomography of the brain was requested urgently to rule out intracranial hemorrhage from the previous ischemic stroke or as a complication of the streptokinase.
- Her diagnosis was revised to rule out intracranial bleeding and she continued to be closely monitored in intensive care.
This document describes the case of an 8-year-old girl brought to the emergency department with vomiting, breathlessness, fever, and altered mental status due to diabetic ketoacidosis (DKA). Her history of type 1 diabetes and discontinuing insulin therapy for 2 days contributed to the development of DKA. On examination, she had a low blood pressure, tachycardia, and altered mental status. Laboratory findings showed high blood glucose, low bicarbonate, and ketones in the urine, consistent with DKA. She was treated according to the Milwaukee protocol for DKA, which involves slow correction of dehydration with intravenous fluids, administration of insulin, and monitoring of electrolytes and mental status. Her
This document presents a case study of a 38-year-old male patient who presented with shortness of breath, easy fatigability, cough, fever, puffy eyelids, and lower limb edema. Initial tests found decreased kidney function, blood in the urine, low albumin and complement levels. A differential diagnosis was made which included glomerulonephritis and vasculitis. The patient was started on antibiotics, diuretics, and steroids. Follow up labs showed improved kidney function and edema resolution, with rheumatoid factor now positive, suggesting the diagnosis is rheumatoid vasculitis.
A 10-year-old boy presented with 5 days of fever, 1 day of melena, and altered consciousness for 1 hour. He was in shock and had a tender, enlarged liver. After fluid resuscitation with crystalloids and dextran, his pulses became palpable but he remained tachycardic. Over subsequent days, his platelet count and hematocrit dropped as fluid amounts were increased. He eventually required a packed red blood cell transfusion and crystalloids were gradually tapered.
1. The document outlines the key initial management steps for several acute medical emergencies including rapid assessment, timely management, asking for help, liaising with consultants, and avoiding harm.
2. For each condition, it provides guidance on important investigations, treatments, and management decisions. The conditions covered include acute coronary syndrome, acute heart failure, acute kidney injury, severe asthma, diabetic ketoacidosis, sepsis, headache, gastrointestinal bleed, stroke, and pulmonary embolism.
3. The overall objective is to provide concise guidance to support rapid evaluation and treatment of acute medical emergencies to optimize patient outcomes.
Clinical case discussion.pptx diabetic ketoacidosisViraj Shinde
This document summarizes the clinical case of a 30-year-old female patient admitted with diabetic ketoacidosis. Over the course of two weeks of treatment, the patient's vital signs and lab results were monitored and she received IV fluids, insulin therapy, electrolyte replacement including potassium, and antibiotics. The treatment largely followed standard guidelines for diabetic ketoacidosis management, though some aspects like antibiotic use and fluid management could have been more rational.
The patient is a 4-year-old girl presenting with rapid breathing for 1 week and fever and cough for 1 month. On examination, she is tachypnic, tachycardic, and hypoxic. Investigations show metabolic acidosis, leukocytosis, and chest x-ray findings consistent with pneumonia. She deteriorates and requires intubation for septic shock secondary to severe pneumonia. Management involves fluid resuscitation, antibiotics, and supportive care including ventilation as she progresses to multi-organ dysfunction. Early recognition and goal-directed therapy are emphasized to prevent progression to irreversible shock.
The document summarizes a patient's medical report during hemodialysis treatment. It includes information on the patient's medical history, physical examination findings, lab results, dialysis monitoring, diagnosis of end stage renal disease due to diabetes and hypertension, and treatment plan to address issues like intradialytic hypotension and anemia management through diet, medication, and ensuring adequate dialysis.
This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.
Presenter: Dr Yasmin Mohamed Gani, Infectious Disease Physician at Hospital Sungai Buloh, Malaysia.
#dengue #WorldNTDDay #BeatNTDs #BestScienceforAll
This case discusses a 79-year-old man who presented with respiratory distress and declining kidney function. He had recently been treated for H. pylori infection with a "triple therapy" of antibiotics that included clarithromycin. His calcium channel blocker medication levels were likely elevated due to a drug interaction with clarithromycin. He developed hypotension, lactic acidosis, and kidney injury consistent with calcium channel blocker toxicity. Management involved fluids, vasopressors, glucagon, and eventually renal replacement therapy. The "triple therapy" he received for H. pylori likely caused an interaction that led to calcium channel blocker overdose and subsequent multi-organ dysfunction.
One of lectures given during our Port said fifth neonatology conference, 23-24 October 2014 given by dr Dr El Sayed Khalaf MD Pediatrics,Consultant Pediatric and Neonatology
This document presents a case study of a 55-year-old male patient who was brought to the emergency room in cardiac arrest. The patient had a history of hypertension and ischemic heart disease. Despite resuscitation efforts and treatment in the intensive care unit over several days, the patient's condition deteriorated, developing sepsis, acute kidney injury, and anoxic brain injury. Despite treatment with antibiotics, vasopressors, and renal replacement therapy, the patient could not be revived from cardiac arrest on the fifth day of hospitalization and was declared deceased. The discussion notes that documentation and lab testing could have been improved, and the sepsis protocol was not fully implemented in the emergency room.
Charisma, an 11-year-old girl, was brought to the emergency room severely dehydrated and in diabetic ketoacidosis. Her blood glucose was 623 mg/dL and blood tests showed metabolic acidosis. She was admitted to the ICU for intravenous rehydration, bicarbonate therapy to correct acidosis, potassium replacement, and insulin infusion to lower her blood glucose levels. Her treatment involved careful monitoring, gradual rehydration and correction of electrolyte imbalances, transitioning from IV to subcutaneous insulin, and treatment of any underlying infections. The document outlines the management steps and monitoring for treating diabetic ketoacidosis.
This document provides information on diabetic ketoacidosis (DKA), including its pathophysiology, clinical manifestations, diagnosis, and management. DKA most commonly presents as the first symptom of type 1 diabetes. The main goals of DKA treatment are to correct acidosis, dehydration, and hyperglycemia. Treatment involves intravenous fluid resuscitation and insulin therapy to rehydrate and lower blood glucose levels. Electrolyte imbalances are also addressed. Complications of DKA include cerebral edema, which requires careful monitoring during treatment. Strict protocols are followed to resolve DKA and transition patients to subcutaneous insulin regimens.
This document provides guidance on the management of multi-system inflammatory syndrome in children (MIS-C) which has been linked to COVID-19. It outlines criteria for screening and diagnosis of MIS-C, recommends a tiered testing approach, and provides guidance on supportive care including IVIG, steroids, aspirin, and anticoagulation which may be needed in intensive care, especially for those with cardiac involvement. Early recognition and exclusion of alternative diagnoses is important in managing this emergent post-COVID syndrome in children.
Dr Neerav Goyal discusses the various aspects of acute liver failure that includes the criteria, pre transplant issues, critical care management, overall survival.
- A 9-year-old girl with beta thalassemia major was admitted to the PICU for respiratory distress following an allogenic stem cell transplant. She required intubation and mechanical ventilation support.
- Various ventilation modes were trialed, including PCV, HFOV, PSV and NIV. Weaning attempts were made but oxygen requirements increased, requiring reintubation. Bilateral infiltrates were seen on chest x-rays.
- After 19 days in the PICU receiving respiratory support and undergoing further weaning trials on various modes, the patient's condition remained critical with ongoing respiratory distress and oxygen needs.
1. Neonatal surgical emergencies are common in developing countries due to factors like high birth rate, consanguinity, and infections during pregnancy.
2. Anesthetizing neonates requires special considerations due to their underdeveloped organ systems and immature physiology. Their cardiovascular, respiratory, renal and thermoregulatory systems are particularly vulnerable.
3. Close monitoring of vital signs, oxygenation, hydration and glucose levels is essential during anesthesia and in the post-operative period when apnea and cardiac arrest risks are high. Maintaining normal temperature is also critical for neonates.
This document discusses neonatal surgical emergencies and anesthetic management considerations. It covers the physiological differences of the neonatal system including the cardiovascular, respiratory, renal and thermal regulation systems. It emphasizes the importance of maintaining normothermia, oxygenation, hydration and glucose levels. The document provides guidance on optimization, monitoring, induction, intubation, maintenance and recovery for neonatal anesthesia. Special attention is needed in the postoperative period to prevent complications like apnea, laryngospasm and cardiac arrest.
1. Neonatal surgical emergencies are common in developing countries due to factors like high birth rate, consanguinity, and infections during pregnancy.
2. Anesthetizing neonates requires special considerations due to their underdeveloped organ systems and immature physiology. Their cardiovascular, respiratory, renal and thermoregulatory systems are particularly vulnerable.
3. Close monitoring of vital signs, oxygenation, hydration and glucose levels is essential during anesthesia and in the post-operative period when apnea and cardiac arrest risks are high. Maintaining normal temperature is also critical for neonates.
1. Neonatal surgical emergencies are common in developing countries due to factors like high birth rate, consanguinity, and infections during pregnancy.
2. Anesthetizing neonates requires special considerations due to their underdeveloped organ systems and immature physiology. Their cardiovascular, respiratory, renal and thermoregulatory systems are particularly vulnerable.
3. Close monitoring of vital signs, oxygenation, hydration and glucose levels is essential during anesthesia and in the post-operative period when apnea and cardiac arrest risks are high. Maintaining normal temperature is also critical for neonates.
This document presents the case of an 11-year-old thalassemic girl who presented with drowsiness, irritability, and vomiting. Imaging revealed a large extradural hematoma that required surgical evacuation. Over the subsequent days, she was closely monitored and managed in the ICU. Her symptoms improved and she was eventually discharged with recommendations for outpatient follow up.
this power point descripe diabetic ketoacidosis in pediatric age group .. we talk about the risk of it .. management specially (fluid management) as case study .. complications and the treatment of brain oedema .. i hope to be auseful one .. enjoy
The Impact Of Sedatives On Sleep In The IcuKyleAmelung
The document discusses the impact of sedatives on sleep in the intensive care unit (ICU). It begins by explaining the normal sleep cycle and how it is disrupted in critically ill patients due to factors like mechanical ventilation and medications. Sedatives are commonly used in the ICU but can have both positive and negative effects on sleep. While they can induce sleep-like states, sedatives may disrupt the natural sleep pattern and decrease slow-wave sleep and REM sleep. Long-term sleep deprivation in the ICU has been linked to increased risks of delirium, immune dysfunction, hyperalgesia and mood changes. Overall, the complex relationship between sedatives and sleep in critically ill patients requires further study to optimize patient outcomes and quality
The morning report summarizes 6 patients admitted to the cardiology department. Patient 1 has congestive heart failure and a history of coronary artery disease. Patient 2 has unstable angina and diabetes. Echocardiogram shows normal left ventricular function. Patient 3 has unstable angina, a history of smoking, and previous coronary angiography showing 3-vessel disease.
David Collins gives an excellent lecture on Toxicology at the Sydney Intensive Care Network meeting for the Intensive Care Network (www.intensivecarenetwork.com). The podcast to go with this can be found on iTunes (Oli Flower's ICU Podcasts) or on www.intensivecarenetwork.com
Acute Kidney Injury-case management and discussion
AKI secondary to sepsis secondary to acute bacterial salphingitis vs TB salphingitis
KDIGO 2012 guidelines
AKI, harrison's 19th edition
ViewShift: Hassle-free Dynamic Policy Enforcement for Every Data LakeWalaa Eldin Moustafa
Dynamic policy enforcement is becoming an increasingly important topic in today’s world where data privacy and compliance is a top priority for companies, individuals, and regulators alike. In these slides, we discuss how LinkedIn implements a powerful dynamic policy enforcement engine, called ViewShift, and integrates it within its data lake. We show the query engine architecture and how catalog implementations can automatically route table resolutions to compliance-enforcing SQL views. Such views have a set of very interesting properties: (1) They are auto-generated from declarative data annotations. (2) They respect user-level consent and preferences (3) They are context-aware, encoding a different set of transformations for different use cases (4) They are portable; while the SQL logic is only implemented in one SQL dialect, it is accessible in all engines.
#SQL #Views #Privacy #Compliance #DataLake
This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.
Presenter: Dr Yasmin Mohamed Gani, Infectious Disease Physician at Hospital Sungai Buloh, Malaysia.
#dengue #WorldNTDDay #BeatNTDs #BestScienceforAll
This case discusses a 79-year-old man who presented with respiratory distress and declining kidney function. He had recently been treated for H. pylori infection with a "triple therapy" of antibiotics that included clarithromycin. His calcium channel blocker medication levels were likely elevated due to a drug interaction with clarithromycin. He developed hypotension, lactic acidosis, and kidney injury consistent with calcium channel blocker toxicity. Management involved fluids, vasopressors, glucagon, and eventually renal replacement therapy. The "triple therapy" he received for H. pylori likely caused an interaction that led to calcium channel blocker overdose and subsequent multi-organ dysfunction.
One of lectures given during our Port said fifth neonatology conference, 23-24 October 2014 given by dr Dr El Sayed Khalaf MD Pediatrics,Consultant Pediatric and Neonatology
This document presents a case study of a 55-year-old male patient who was brought to the emergency room in cardiac arrest. The patient had a history of hypertension and ischemic heart disease. Despite resuscitation efforts and treatment in the intensive care unit over several days, the patient's condition deteriorated, developing sepsis, acute kidney injury, and anoxic brain injury. Despite treatment with antibiotics, vasopressors, and renal replacement therapy, the patient could not be revived from cardiac arrest on the fifth day of hospitalization and was declared deceased. The discussion notes that documentation and lab testing could have been improved, and the sepsis protocol was not fully implemented in the emergency room.
Charisma, an 11-year-old girl, was brought to the emergency room severely dehydrated and in diabetic ketoacidosis. Her blood glucose was 623 mg/dL and blood tests showed metabolic acidosis. She was admitted to the ICU for intravenous rehydration, bicarbonate therapy to correct acidosis, potassium replacement, and insulin infusion to lower her blood glucose levels. Her treatment involved careful monitoring, gradual rehydration and correction of electrolyte imbalances, transitioning from IV to subcutaneous insulin, and treatment of any underlying infections. The document outlines the management steps and monitoring for treating diabetic ketoacidosis.
This document provides information on diabetic ketoacidosis (DKA), including its pathophysiology, clinical manifestations, diagnosis, and management. DKA most commonly presents as the first symptom of type 1 diabetes. The main goals of DKA treatment are to correct acidosis, dehydration, and hyperglycemia. Treatment involves intravenous fluid resuscitation and insulin therapy to rehydrate and lower blood glucose levels. Electrolyte imbalances are also addressed. Complications of DKA include cerebral edema, which requires careful monitoring during treatment. Strict protocols are followed to resolve DKA and transition patients to subcutaneous insulin regimens.
This document provides guidance on the management of multi-system inflammatory syndrome in children (MIS-C) which has been linked to COVID-19. It outlines criteria for screening and diagnosis of MIS-C, recommends a tiered testing approach, and provides guidance on supportive care including IVIG, steroids, aspirin, and anticoagulation which may be needed in intensive care, especially for those with cardiac involvement. Early recognition and exclusion of alternative diagnoses is important in managing this emergent post-COVID syndrome in children.
Dr Neerav Goyal discusses the various aspects of acute liver failure that includes the criteria, pre transplant issues, critical care management, overall survival.
- A 9-year-old girl with beta thalassemia major was admitted to the PICU for respiratory distress following an allogenic stem cell transplant. She required intubation and mechanical ventilation support.
- Various ventilation modes were trialed, including PCV, HFOV, PSV and NIV. Weaning attempts were made but oxygen requirements increased, requiring reintubation. Bilateral infiltrates were seen on chest x-rays.
- After 19 days in the PICU receiving respiratory support and undergoing further weaning trials on various modes, the patient's condition remained critical with ongoing respiratory distress and oxygen needs.
1. Neonatal surgical emergencies are common in developing countries due to factors like high birth rate, consanguinity, and infections during pregnancy.
2. Anesthetizing neonates requires special considerations due to their underdeveloped organ systems and immature physiology. Their cardiovascular, respiratory, renal and thermoregulatory systems are particularly vulnerable.
3. Close monitoring of vital signs, oxygenation, hydration and glucose levels is essential during anesthesia and in the post-operative period when apnea and cardiac arrest risks are high. Maintaining normal temperature is also critical for neonates.
This document discusses neonatal surgical emergencies and anesthetic management considerations. It covers the physiological differences of the neonatal system including the cardiovascular, respiratory, renal and thermal regulation systems. It emphasizes the importance of maintaining normothermia, oxygenation, hydration and glucose levels. The document provides guidance on optimization, monitoring, induction, intubation, maintenance and recovery for neonatal anesthesia. Special attention is needed in the postoperative period to prevent complications like apnea, laryngospasm and cardiac arrest.
1. Neonatal surgical emergencies are common in developing countries due to factors like high birth rate, consanguinity, and infections during pregnancy.
2. Anesthetizing neonates requires special considerations due to their underdeveloped organ systems and immature physiology. Their cardiovascular, respiratory, renal and thermoregulatory systems are particularly vulnerable.
3. Close monitoring of vital signs, oxygenation, hydration and glucose levels is essential during anesthesia and in the post-operative period when apnea and cardiac arrest risks are high. Maintaining normal temperature is also critical for neonates.
1. Neonatal surgical emergencies are common in developing countries due to factors like high birth rate, consanguinity, and infections during pregnancy.
2. Anesthetizing neonates requires special considerations due to their underdeveloped organ systems and immature physiology. Their cardiovascular, respiratory, renal and thermoregulatory systems are particularly vulnerable.
3. Close monitoring of vital signs, oxygenation, hydration and glucose levels is essential during anesthesia and in the post-operative period when apnea and cardiac arrest risks are high. Maintaining normal temperature is also critical for neonates.
This document presents the case of an 11-year-old thalassemic girl who presented with drowsiness, irritability, and vomiting. Imaging revealed a large extradural hematoma that required surgical evacuation. Over the subsequent days, she was closely monitored and managed in the ICU. Her symptoms improved and she was eventually discharged with recommendations for outpatient follow up.
this power point descripe diabetic ketoacidosis in pediatric age group .. we talk about the risk of it .. management specially (fluid management) as case study .. complications and the treatment of brain oedema .. i hope to be auseful one .. enjoy
The Impact Of Sedatives On Sleep In The IcuKyleAmelung
The document discusses the impact of sedatives on sleep in the intensive care unit (ICU). It begins by explaining the normal sleep cycle and how it is disrupted in critically ill patients due to factors like mechanical ventilation and medications. Sedatives are commonly used in the ICU but can have both positive and negative effects on sleep. While they can induce sleep-like states, sedatives may disrupt the natural sleep pattern and decrease slow-wave sleep and REM sleep. Long-term sleep deprivation in the ICU has been linked to increased risks of delirium, immune dysfunction, hyperalgesia and mood changes. Overall, the complex relationship between sedatives and sleep in critically ill patients requires further study to optimize patient outcomes and quality
The morning report summarizes 6 patients admitted to the cardiology department. Patient 1 has congestive heart failure and a history of coronary artery disease. Patient 2 has unstable angina and diabetes. Echocardiogram shows normal left ventricular function. Patient 3 has unstable angina, a history of smoking, and previous coronary angiography showing 3-vessel disease.
David Collins gives an excellent lecture on Toxicology at the Sydney Intensive Care Network meeting for the Intensive Care Network (www.intensivecarenetwork.com). The podcast to go with this can be found on iTunes (Oli Flower's ICU Podcasts) or on www.intensivecarenetwork.com
Acute Kidney Injury-case management and discussion
AKI secondary to sepsis secondary to acute bacterial salphingitis vs TB salphingitis
KDIGO 2012 guidelines
AKI, harrison's 19th edition
ViewShift: Hassle-free Dynamic Policy Enforcement for Every Data LakeWalaa Eldin Moustafa
Dynamic policy enforcement is becoming an increasingly important topic in today’s world where data privacy and compliance is a top priority for companies, individuals, and regulators alike. In these slides, we discuss how LinkedIn implements a powerful dynamic policy enforcement engine, called ViewShift, and integrates it within its data lake. We show the query engine architecture and how catalog implementations can automatically route table resolutions to compliance-enforcing SQL views. Such views have a set of very interesting properties: (1) They are auto-generated from declarative data annotations. (2) They respect user-level consent and preferences (3) They are context-aware, encoding a different set of transformations for different use cases (4) They are portable; while the SQL logic is only implemented in one SQL dialect, it is accessible in all engines.
#SQL #Views #Privacy #Compliance #DataLake
Codeless Generative AI Pipelines
(GenAI with Milvus)
https://ml.dssconf.pl/user.html#!/lecture/DSSML24-041a/rate
Discover the potential of real-time streaming in the context of GenAI as we delve into the intricacies of Apache NiFi and its capabilities. Learn how this tool can significantly simplify the data engineering workflow for GenAI applications, allowing you to focus on the creative aspects rather than the technical complexities. I will guide you through practical examples and use cases, showing the impact of automation on prompt building. From data ingestion to transformation and delivery, witness how Apache NiFi streamlines the entire pipeline, ensuring a smooth and hassle-free experience.
Timothy Spann
https://www.youtube.com/@FLaNK-Stack
https://medium.com/@tspann
https://www.datainmotion.dev/
milvus, unstructured data, vector database, zilliz, cloud, vectors, python, deep learning, generative ai, genai, nifi, kafka, flink, streaming, iot, edge
End-to-end pipeline agility - Berlin Buzzwords 2024Lars Albertsson
We describe how we achieve high change agility in data engineering by eliminating the fear of breaking downstream data pipelines through end-to-end pipeline testing, and by using schema metaprogramming to safely eliminate boilerplate involved in changes that affect whole pipelines.
A quick poll on agility in changing pipelines from end to end indicated a huge span in capabilities. For the question "How long time does it take for all downstream pipelines to be adapted to an upstream change," the median response was 6 months, but some respondents could do it in less than a day. When quantitative data engineering differences between the best and worst are measured, the span is often 100x-1000x, sometimes even more.
A long time ago, we suffered at Spotify from fear of changing pipelines due to not knowing what the impact might be downstream. We made plans for a technical solution to test pipelines end-to-end to mitigate that fear, but the effort failed for cultural reasons. We eventually solved this challenge, but in a different context. In this presentation we will describe how we test full pipelines effectively by manipulating workflow orchestration, which enables us to make changes in pipelines without fear of breaking downstream.
Making schema changes that affect many jobs also involves a lot of toil and boilerplate. Using schema-on-read mitigates some of it, but has drawbacks since it makes it more difficult to detect errors early. We will describe how we have rejected this tradeoff by applying schema metaprogramming, eliminating boilerplate but keeping the protection of static typing, thereby further improving agility to quickly modify data pipelines without fear.
Analysis insight about a Flyball dog competition team's performanceroli9797
Insight of my analysis about a Flyball dog competition team's last year performance. Find more: https://github.com/rolandnagy-ds/flyball_race_analysis/tree/main
Global Situational Awareness of A.I. and where its headedvikram sood
You can see the future first in San Francisco.
Over the past year, the talk of the town has shifted from $10 billion compute clusters to $100 billion clusters to trillion-dollar clusters. Every six months another zero is added to the boardroom plans. Behind the scenes, there’s a fierce scramble to secure every power contract still available for the rest of the decade, every voltage transformer that can possibly be procured. American big business is gearing up to pour trillions of dollars into a long-unseen mobilization of American industrial might. By the end of the decade, American electricity production will have grown tens of percent; from the shale fields of Pennsylvania to the solar farms of Nevada, hundreds of millions of GPUs will hum.
The AGI race has begun. We are building machines that can think and reason. By 2025/26, these machines will outpace college graduates. By the end of the decade, they will be smarter than you or I; we will have superintelligence, in the true sense of the word. Along the way, national security forces not seen in half a century will be un-leashed, and before long, The Project will be on. If we’re lucky, we’ll be in an all-out race with the CCP; if we’re unlucky, an all-out war.
Everyone is now talking about AI, but few have the faintest glimmer of what is about to hit them. Nvidia analysts still think 2024 might be close to the peak. Mainstream pundits are stuck on the wilful blindness of “it’s just predicting the next word”. They see only hype and business-as-usual; at most they entertain another internet-scale technological change.
Before long, the world will wake up. But right now, there are perhaps a few hundred people, most of them in San Francisco and the AI labs, that have situational awareness. Through whatever peculiar forces of fate, I have found myself amongst them. A few years ago, these people were derided as crazy—but they trusted the trendlines, which allowed them to correctly predict the AI advances of the past few years. Whether these people are also right about the next few years remains to be seen. But these are very smart people—the smartest people I have ever met—and they are the ones building this technology. Perhaps they will be an odd footnote in history, or perhaps they will go down in history like Szilard and Oppenheimer and Teller. If they are seeing the future even close to correctly, we are in for a wild ride.
Let me tell you what we see.
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Data and AI
Discussion on Vector Databases, Unstructured Data and AI
https://www.meetup.com/unstructured-data-meetup-new-york/
This meetup is for people working in unstructured data. Speakers will come present about related topics such as vector databases, LLMs, and managing data at scale. The intended audience of this group includes roles like machine learning engineers, data scientists, data engineers, software engineers, and PMs.This meetup was formerly Milvus Meetup, and is sponsored by Zilliz maintainers of Milvus.
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Data and AI
Round table discussion of vector databases, unstructured data, ai, big data, real-time, robots and Milvus.
A lively discussion with NJ Gen AI Meetup Lead, Prasad and Procure.FYI's Co-Found
3. Case study
Mr. A, 23 years old Malay Male brought by family members to ED at 4.30pm due to less responsive
since yesterday evening.
Further history from family members:
- Patient previously NKMI
- Was unwell for past 5/7
- Having fever x5/7, non-productive cough x5/7 and vomiting x3/7, unsure amount and episodes,
last episode yesterday
- Noted to be less responsive since yesterday evening, not answering questions, appears drowsy
- Visited GP in the morning, treated as acute tonsillitis and discharged with T.Augmentin 625mg BD,
T.Ponstan 500mg TDS, T.Papase II/II TDS and Lozenges I/I PRN.
- Claimed patient was able to ambulate when going to clinic, but after came back from clinic became
more drowsy and not responding to questions.
4. Otherwise,
- Denied diarrhoea/abdominal pain
- Denied SOB/chest pain
- Denied UTI sx
- Denied recent history of jungle trekking/water activities/ fogging activities in the
neighbourhood
- Denied taking any illicit drug
- Denied any fitting episode
- Denied any history head trauma
5. Physical examination
GCS: E4V2M5 (11/15), pupils bilateral 2 mm/ 2 mm reactive, pink, lethargic looking, CRT less than
2 seconds, good pulse volume, warm peripheries, dry lips, tongue coated, patient is obese
(estimated weight of 120kg)
•BP: 185/101 mmHg
•PR: 135 bpm
•RR: 22
•Temp: 38.6 OC
•SPO2 : 91% under RA
•DXT: HI
•Blood ketone: 6.3
6. Systemic examination
•Throat: Injected, Tonsils enlarged Grade II, No exudate seen, Uvula central
•Lungs: Clear, equal air entry
•CVS: DRNM
•P/A: Soft, not tender
•Neurology:
Bilateral UL and LL tone normal
Bilateral UL and LL power at least 4
Bilateral UL and LL reflexes normal
Bilateral Babinski downgoing
Bilateral clonus absent
7. Bedside scan:
•No free fluid
•IVC kissing
•Good heart contractility
•No pericardial effusion or pleural effusion
(Poor view due to thick chest/abdominal wall)
12. Management
•Uptriage Redzone
•Put on NpO2 3L/min
•Put on cardiac monitoring
•Start fluid resuscitation 10cc/kg: IVD Sterofundin 1L over 1H
•Insert CBD, strict I/O charting
•Start IVI insulin fixed rate 0.1 units/kg/hour = 12 cc/H
•T.Paracetamol 1g stat
•IV Omeprazole 40 mg stat
•IV Rocephine 2g stat
•DXT monitoring hourly
•GCS charting
Estimated weight 120kg
Adjusted weight 90kg
13. Time Progress Plan
6/5/23
5.50pm
- Completed IVD Sterofundin 1L
- Urine output since insertion: 100cc
- GCS E3V2M5, pupils 2/2 reactive, BP 114/82mmHg,
PR 145bpm, SPO2 96% under NPO2 3L/min
- DXT: Hi
- Bedside scan: IVC still kissing
• Run another
20cc/kg: 1.8L NS
over I hour
• Cont. IVI insulin
fixed scale 12cc/H
• Keep NPO2 3L/min
• For CT brain as
planned
• DXT monitoring
hourly
1L
Sterofundin
14. Time Progress Plan
6/5/23
6.25pm
Given 1L Sterofundin, Ongoing 1.8L Normal
saline
Blood investigations came back:
FBC Hb 18.1/HCT 65/PLT351 /WBC 14.53
Urea 16.8/ Creat 289/ Na 139(176) /K 4.4/ Ch
94/Ca 2.61/ PO4 1.73/ Mg 1.5
INR 1.1 /PT 14.8/ APPT 29.7
Alb 38/ Glo 59/ ALT 32/ AST 40/ ALP 178/ CK
165/ LDH 268
RBS 93.3
Serum osmolality: 371.3
CXR: Right perihilar haziness
Case D/w Dr Nazrul (EP oncall):
• To treat as DKA mixed with
HHS, cover for
meningoencephalitis
• To complete 30cc/kg fluid
bolus as planned
• Then to start fluid
replacement 1L/1H, then
1L/2H, then 1L/4H and then
1L/6H with IVD 6pint/24H
with K+ supplement
• Cont. IVI insulin fixed scale
12cc/H
• To proceed CT brain as
planned
• No need for intubation for
now, KIV for intubation if
worsening acidosis/GCS
• To repeat VBG & RP post
bolus and 2 hourly
15. Time Progress Plan
6/5/23
8.15pm
Total fluid in 2.8L, ongoing IV 1L NS/1H
Urine output 700cc
Noted BP hypotensive 88-91/53-70mmHg
Started on IVI Noradrenaline 6.8cc/H
(0.2mcg/kg/min)
BP pick up to 118/74, PR 141, SPO2 96% under
NPO2
Done CT brain: No ICB/infarct seen
Required sedation IV Midazolam 4mg
Revised Imp:
1. Severe DKA mixed with HHS
2. Septic shock secondary to CAP
3. Cover for meningoencephalitis
4. AKI
• Cont. fluid replacement
1L/2H with 1g KCL in each
pint, then 1L/4H and then
1L/6H
• IVD 6pint/24H with 1g KCL
in each pint
• Fast correct KCL 1g in 100cc
NS/1H
• Cont. IVI insulin fixed scale
12cc/H
• Titrate IVI Noradrenaline
• S/C Fondaparinux 2.5mg
stat
• DXT monitoring hourly
• Strict I/O hourly
• Repeat RP and VBG 2 hourly
• KIV for intubation if
worsening acidosis/ GCS
• Referred to medical team at
8.45pm
16. Time Progress Plan
6/5/23
9.00pm
• Noted GCS E1V2M5 (8/15) with acidotic breathing
• Was put on HFMO2 15L/min
BP 125/74 (on IVI Noradrenaline 10.2cc/H- 0.3mcg/kg/min)
PR 115
SPO2 98% under HFMO2
• Given IV Flumazenil total 1mg
6/5/23
9.30pm
Attended by Dr Nazrul (EP oncall), to proceed with
intubation
Pre-medications: IV Midazolam 3mg stat
IV Fentanyl 100mcg stat
IV Rocuronium 50mg stat
Intubated with single attempt using video laryngoscope with
ETT size 8, anchored at 22cm
17. Time Progress Plan
6/5/23
10.00pm
• Post intubation:
BP 129/90 mmHg (on IVI Noradrenaline 13.5cc/H)
0.4mcg/kg/min
PR 131
SPO2 98% under ventilator
DXT HI
Blood ketone 0.4 6.3
18. Time Progress Plan
Imp:
1. Severe DKA with HHS
2. Septic shock secondary to CAP
3. Cover for meningoencephalitis
4. AKI
• Ventilation (SIMV, PEEP 8, TV 540, Rate
24, PS 15, FiO2 1.0)
• Change fluid to half saline and cont.
fluid regime 1L HS/4H then 1L HS/6H
• IVD maintenance 6pint HS/24H with 1g
KCl in each pint
• Fast correct another 1g KCL in 100cc
NS/IH
• Reduce IVI insulin fixed scale to 6cc/H
• Start sedation with IV Midazolam 30mg
and IV Fentanyl 300mcg infusion run
8cc/H
• Insert Ryle tube
• Strict I/O charting
• Repeat blood investigation at 11.30pm
- ABG, RBS, BUSE
• DXT monitoring hourly
• VBG and BUSE 2 hourly
• ECG, CXR post intubation
• Titrate IVI Noradrenaline
• Insert CVL
19. Time Progress Plan
Cont.
• Input: 6300 cc (1000cc sterofundin+ 4800cc NS+ 500cc HS)
• Output: 798 cc
• Positive balance: 5502 cc
Given IV 1g KCl in 100cc NS x 2
20. Time Progress Plan
6/5/23
10.00pm
Seen by Medical team
Imp:
1. Septic shock secondary to bacterial pharyngitis
2. HHS/DKA secondary to 1
3. AKI secondary to 1
4. TRO metabolic syndrome
5. TRO OSA
• To increase IVI insulin
fixed scale to 8 cc/hour
• IVD 1 L HS over 4 hours
• IVD maintenance 7 pints
HS/24H with 0.5g KCL
• IV Ceftriaxone 2 g OD
• S/C Clexane 60 mg OD
• IV Omeprazole 4omg OD
• T. Paracetamol 1g PRN
6/5/23
10.50pm
Seen by Anaest team: plan for admission to ICU Patient was subsequently
admitted to ICU around
12.00 am
21.
22. Admitted to ICU @ 12.20am
• Actual weight 150kg, estimated height 170cm
• Ventilated with PSIMV PEEP 10, PC 10, PS 14, FiO2 0.6, rate 12, I:E 1:2
• Sedated with IVI midafentanyl 8ml/h
• IVI noradrenaline 0.24mcg/kg/min
• IVI insulin 8u/H fixed scale
• ABG : pH7.29/ pCO2 42/ pO2 75/ HCO3 20.2/ BE -6.2/ lac 4.0/ DXT >27.8/ PF ratio 125
• Hydration improve, skin turgor fair, good pulse volume, CRT< 2sec
• Urine output upon admission 0.75cc/kg/h
• Lung bibasal crepitations, no pedal edema
• IVD maintenance 6pint sterofundin/ 24hour with 1g KCL each pint
23. • IVI noradrenaline trend slowly increasing since 5am
• At 6.10am, IVI noradrenaline increased to 1.0mcg/kg/min, started IVI adrenaline
0.5mcg/kg/min, tachycardia HR 150bpm
• Good pulse volume, regular pulse, CVS DRNM, CRT < 2sec
• ECG stat: ST elevation at lead III; ST depression at aVL; T inversion at lead I, aVL, V3-V6
• ABG : pH 7.27/ pCO2 40/ pO2 65/ HCO3 18.4/ BE -8.0/ lac 3.4/ K+ 2.6/ Na 162/ PF ratio 108
• IV MgSO4 10mmol stat x1
• IV KCL 1g fast correct x 2
24.
25. • Develop VF x 2 around 6.49am, shock (200J) x 2, and started CPR pulse VT x1, synchronized cardioversion (150J) x1
• Total adrenaline 1mg x 2, CPR x 6min
• ROSC at 6.55am
• Develop VF again at 7.15am, shock (200J) x 1 and started CPR
• CPR x 45min
• IV adrenaline 1 mg x 17
• IV Ca gluconate 10mmol x 1
• IV KH2PO4 10mmol x1
• IV amiodarone 300mg x1
• IV NaHCO3 100ml x 1
• No ROSC, death pronounce at 8.05am 7/5/2023
• Cause of Death : HHS with multiorgan failure
30. Pitfalls/Learning points
1. Fluid deficit correction
• Duration of correction 48 - 72hours
• Fluid status is dynamic, treatment should be adjusted accordingly
• Fluid deficit (150kg) : 23.1L, total corrected from ED till 6am : 7.2L (over 14hours)
• Possibility of false good CRT/BP/ pulse volume due to rapid fluid shift
• CXR: ARDS feature, PF ratio < 150, lung bibasal crepitations
2. Electrolyte correction
• K+/ Mg/ PO4/ Ca
• Total K+ corrected 6g @ ED, 3g @ ICU
• KH2PO4 10 mmol x 1
• Pt developed VF likely due to hypokalemia, differential myocardial infarct
• PO4 correction as PO4 will be depleted in HHS patient , further drop if supported with Noradrenaline
• Severe PO4 deficiency can worsen respiratory failure, precipitate cardiac arrhythmias and cause rhabdomyolysis
31. 3. Higher risk of cardiac event due to
• Morbid obesity
• HHS
• Hyperviscosity , Hb 18.1/ Hct 68
• S/C Fondaparinux 2.5mg x1 @ ED, S/C Clexane 60mg OD x1 @ 6am
4. Timing of starting and withhold of insulin
• Persistent low K+ < 3.0, can omit insulin for 1-2 hours, with aggressive K+ correction (max K+ correction 3g/hour via central line)
• To start IVI insulin when blood glucose persistent high despite adequate fluid resuscitation
5. High risk of rhabdomyolysis in HHS patient
• CK level
• Urine colour and output monitoring
32. 6. Calculate! Make it a habit in practice
• Proper calculation will reveal the adequacy/ inadequacy of treatment and resuscitation
• Sodium ↓ over 14 h -> 8 mmol/L (adequate)
• Serum osmolarity ↓ over 14h -> 0.71 mOsm/kg/h (inadequate)
• Serum glucose ↓ over 14 h -> 4.85mmol/L/h (adequate)
• Free water deficit -> 23.1L -> corrected 7.2L over 14 hours
Aim for gradual reduction in serum osmolality at the rate of 3-8 mosm/kg/hr.
Aim for reduction in blood glucose of 4-6 mmol/L/hr
Rate of fall of plasma sodium should not exceed 10 mmol/L in 24 hours.
39. CLINICAL PARAMETERS OF SEVERE DKA
•Venous bicarbonate <5 mmol/L
•Venous pH <7.1
•Plasma ketones >6 mmol/L
•Hypokaemia on admission <3.5mmol/L
•GCS <12
•O2 saturation <92% on air
•SBP <90mmHg
•Pulse rate >100bpm
•Anion gap >16 (Anion gap = [Na++ K+ ] – [Cl- + HCO3- ])
40. PRINCIPLES OF MANAGEMENT
•Correction of
dehydration
•Correction of
electrolyte
imbalance
Insulin
therapy
•Treatment of
precipitating
factor
•Prevention of
complications
41.
42.
43. AIMS OF TREATMENT
•Rate of fall of ketones of at least 0.5 mmol/L/hr, OR
•Bicarbonate rise of 3 mmol/L/hr, AND
•Plasma glucose fall of at least 3 mmol/L/hr, AND
•Maintain serum potassium within normal range.
44. CORRECTION OF DEHYDRATION
•Fluid deficits in DKA may be up to 10% of total body weight. Restoration
of circulating volume is a priority.
•SBP on admission <90 mmHg (likely due to low circulating volume,
but consider other causes such as heart failure or sepsis).
• Start administration of fluid as shown below:
45. SBP on admission is ≥90 mmHg, start administration of fluid as
shown below:
46. The rate of hydration should be guided by:
•Haemodynamic status
•State of hydration
•Serum electrolyte levels
•Urinary output
More cautious fluid replacement in:
•Young people <18 y/o
•Elderly
•Pregnant
•Existing heart or renal failure
In the above instances, consider HDU/ICU admission & insertion and monitoring via central line
47. CORRECTION OF ELECTROLYTE IMBALANCE
Potassium replacement:
Aim to maintain serum potassium between 4-5 mmol/L.
Withhold K + replacement if there is no urine output.
1 g KCl = 13.3 mmol K +
Maximum potassium replacement per hour is 40 mmol/h.
48. IV bicarbonate:
•The use of IV HCO3 - is not indicated to correct acidosis in DKA due to:
- Rise of partial pressure of carbon dioxide (pCO2 ) in cerebrospinal fluid (CSF) which may
lead to a paradoxical increase in CSF acidosis
- Delay in the fall of plasma lactate and ketone level
- Risk of cerebral oedema especially in younger age group
•IV HCO3 - may be considered if pH is persistently <6.9 despite adequate
hydration and insulin treatment
49. INSULIN THERAPY
•Start a fixed rate IV insulin infusion (FRIII): 0.1 unit/kg/hr based on estimate of
weight.
•50 units short-acting human insulin or rapid-acting insulin analogue made up to 50 ml
with 0.9% saline solution.
•Delay insulin infusion if the initial potassium <3.5mmol/L until serum potassium is
corrected.
50. MONITORING
•Measure blood ketones and capillary glucose hourly (note: if meter reads
“blood glucose Hi” venous blood should be sent to the laboratory hourly or
measured using venous blood in a blood gas analyser until the point of care
testing meter is within its QA range)
•Vital signs and input-output charting hourly
•Venous HCO3 - and K+ at 60 minutes, 2 hours and 2-hourly thereafter
•6-hourly BUSE and blood/urine ketones
51. •Review the response to FRIII hourly by calculating the rate of change of ketone level fall (or rise
in bicarbonate or fall in glucose)
•If blood ketone measurement is available and blood ketones are not falling by at least 0.5
mmol/L/hr, increase the insulin infusion rate by 1.0 unit/hr increments hourly until the ketones
are falling at target rates (also check infusion**)
•If blood ketone measurement is not available, use venous bicarbonate. If the bicarbonate is not
rising by at least 3.0 mmol/L/hr, increase the insulin infusion rate by 1 unit/hr increments
hourly until the bicarbonate is rising at this rate**
•Alternatively use plasma glucose. If the glucose is not falling by at least 3.0 mmol/L/hr, increase
the insulin infusion rate by 1.0 unit/hr increments hourly until glucose falls at this rate. Glucose
level is not an accurate indicator of resolution of acidosis in ketoacidosis, so the acidosis
resolution should be verified by venous gas analysis
52. •If ketones and glucose are not falling as expected always check the insulin infusion pump is
working and connected and that the correct insulin residual volume is present (to check for
pump malfunction)
•If the potassium is outside the reference range (4.0 – 5.5 mmol/L), assess the appropriateness of
the potassium replacement and check it hourly.
•If the glucose falls below 14.0 mmol/L, commence 10% glucose(D10%) given at 125 ml/ hour
alongside the 0.9% sodium chloride solution. In addition consider reducing the rate of
intravenous insulin infusion to 0.05 units/kg/hr.
•Continue the FRIII until the ketone measurement is less than 0.6 mmol/L and/or venous pH over
7.3
•Do not rely on urinary ketone clearance to indicate resolution of DKA, because these will still be
present when the DKA has resolved
53. RESOLUTION
Resolution is defined as:
•pH >7.3
•Plasma ketone <0.6mmol/L
Do not rely on bicarbonate alone to assess the resolution of DKA at this point due to the
possible hyperchloraemia secondary to high volumes of 0.9% sodium chloride solution. The
hyperchloraemic metabolic acidosis will lower the bicarbonate and thus lead to difficulty is
assessing whether the ketosis has resolved. The hyperchloraemic acidosis may cause renal
vasoconstriction and be a cause of oliguria.
55. • Hyperglycaemic hyperosmolar state (HHS) is a life-threatening emergency and should be
suspected in patients with T2DM who are very ill with significant hyperglycaemia.
• The elderly with multiple co-morbidities are prone to HHS.
• It has a higher mortality than DKA and vascular complications such as MI, stroke or
peripheral arterial thrombosis are common.
• Well-described complications such as seizures, cerebral oedema and osmotic
demyelination syndrome though uncommon can occur due to rapid changes in osmolality
during treatment.
• Whilst the presentation of DKA is rapid (within hours), HHS progresses over many days. As
a result, the dehydration and metabolic disturbances are more profound
56. Pathophysiology of HHS
American Diabetes Association. Hyperosmolar Hyperglycemic State: A Historic Review of the Clinical Presentation, Diagnosis and Treatment. Diabetes Care 2014; 37: 3124-3131
57. Principles of HHS treatment
1. Use intravenous (IV) 0.9% sodium chloride solution as the principle fluid to restore circulating
volume and reverse dehydration
2. Measure or calculate osmolality every hour for the first 6 hours, then 2 hourly for the next 6
hours to monitor the response to treatment and to avoid sudden osmotic shifts
3. Only switch to 0.45% sodium chloride solution if the osmolality is not declining despite
adequate positive fluid balance.
4. An initial rise in sodium is expected due to the reversal of relative pseudohyponatraemia in
the context of hyperglycaemia and is not itself an indication for hypotonic fluids.
5. The rate of change of serum sodium should not exceed 10 mmol in 24 hours
6. Underlying precipitants of HHS must be identified and treated
Joint British Diabetes Societies for Inpatient Care. The Management of Hyperosmolar Hyperglycemic State (HHS) in Adults. February 2022
58. 6. The fall in osmolality should not be more than 3.0-8.0 mOsm/kg/hr to minimise the risk of
neurological complications
7. The fall in glucose should not be more than 5.0 mmol/L/hr
8. ONLY commence insulin infusion quickly in the following circumstances:
◦ If there is HHS and ketonaemia (blood ketones >1.0 - ≤3.0 mmol/L or urine ketones < 2+) and not
acidotic (venous pH >7.3 and bicarbonate >15.0 mmol/L) then use 0.05 units/kg/hr OR
◦ If there is significant ketonaemia (blood ketones >3.0 mmol/L) or ketonuria (≥ 2+) with a pH <7.3 and
bicarbonate <15 mmol/L (i.e. mixed DKA and HHS) then use the DKA guidelines at 0.1 units/kg/hr
9. IV fluid replacement should aim to achieve a positive balance of 3-6 litres during the first 12
hours and the remaining replacement of estimated fluid loss during the following 12 hours,
although complete normalisation of biochemistry may take up to 72 hours
Joint British Diabetes Societies for Inpatient Care. The Management of Hyperosmolar Hyperglycemic State (HHS) in Adults. February 2022
59. Type of fluid
•The goal of the initial therapy is expansion of the intravascular and extravascular volume and to
restore peripheral perfusion.
•There are almost no data on the benefits or risks of particular fluid replacement regimens in
HHS.
•Rapid changes in osmolality may be harmful. 0.9% sodium chloride solution should be used as
the principle fluid to restore circulating volume and reverse dehydration because it is relatively
hypotonic compared to the serum in someone with HHS
•However, if the osmolality is no longer declining despite adequate fluid replacement with 0.9%
sodium chloride solution AND an adequate rate of fall of plasma glucose is not being achieved,
then 0.45% sodium chloride solution should be substituted.
•There are no data to justify using fluids that are less hypotonic than 0.45% sodium chloride
solution.
Joint British Diabetes Societies for Inpatient Care. The Management of Hyperosmolar Hyperglycemic State (HHS) in Adults. February 2022
60. •Fluid replacement alone (without insulin) will lower glucose concentrations which will lower
measured or calculated serum osmolality by causing a shift of water into the intracellular space.
This inevitably results in a rise in serum sodium (a fall in blood glucose of 5.5 mmol/L will result
in a 2.4 mmol/L rise in sodium). This is not necessarily an indication to give hypotonic solutions
•A rising sodium is only a concern if the osmolality is NOT declining concurrently. If the inevitable
rise in serum sodium is much greater than 2.4 mmol/L for each 5.5mmol/L fall in BG this would
suggest insufficient fluid replacement
•The aim of treatment should be to replace approximately 50% of estimated fluid loss within the
first 12 hours and the remainder in the following 12 hours. However, this will in part be
determined by the initial severity, degree of renal impairment and co-morbidities such as heart
failure, which may limit the speed of correction
•Complete normalisation of electrolytes and osmolality may take up to 72 hours
Joint British Diabetes Societies for Inpatient Care. The Management of Hyperosmolar Hyperglycemic State (HHS) in Adults. February 2022
61.
62.
63.
64. Other consideration
•VTE prophylaxis
• Everyone with HHS should receive prophylactic low molecular weight heparin (LMWH) for the full duration of
admission unless contraindicated.
•Other electrolyte imbalances and complications associated with HHS
• Hypophosphataemia and hypomagnesaemia are common in HHS.
•Foot protection
• People with HHS are at high risk of pressure related foot ulceration. An initial foot assessment should be
undertaken on admission and daily during admission. Heel protectors and an appropriate mattress should be
provided for those with immobility, neuropathy, peripheral vascular disease or lower limb deformity.
•HHS can be considered to be resolved when the following criteria are met: when measured or
calculated serum osmolality falls to <300 mOsm/kg, hypovolaemia has been corrected (urine output
≥0.5 ml/kg/hr), cognitive status has returned to the premorbid state and blood glucose <15 mmol/L
•At all times, if the individual is not improving, senior advice should be sought
Joint British Diabetes Societies for Inpatient Care. The Management of Hyperosmolar Hyperglycemic State (HHS) in Adults. February 2022
65.
66.
67. Take home message
For HHS with no ketosis, the main principle of treatment is fluid resuscitation followed by K+ correction then
only insulin.
The high DXT and high serum osmolality is due to the shrinkage of intravascular volume, DXT is seemed to be
very high because of the concentrated intravascular fluid. With the fluid administration alone, serum
osmolality will reduce.
So, when to start insulin in HHS without ketosis? When there is a positive balance but DXT remains plateau,
then can start insulin.
So, remember run fluid first, insulin later in HHS with no ketosis.
If ketone raised at initial point (>3.0), then can start insulin at rate of 0.1u/kg/H (use estimated weight NOT
adjusted weight). If ketone level <3.0, insulin rate is 0.05u/kg/H.
Serum osmolality >360 is considered to be high risk. (Criteria >320 to diagnose HHS)
Once ketone level is 0 or reduced, can actually off the insulin for 1-2H. Use this period of time, to correct the
K+
68. K+ need to be monitored closely once start insulin infusion. Make sure to add K+ in the IVD and fast correct if
needed. If peripheral line, 1g KCL per hour. If has CVL, can correct 2-3g/H with cardiac monitoring
Don’t forget the Phosphate, another important electrolyte. Although at initial time, it found to be within
normal range, as insulin goes in, PO4- level will be reduced. So, monitor PO4- level and correct it.
Fluid of choice is still 0.9% NaCl as patient still has sodium loss of about 5-15mmol/L/kg. Later can be changed
to Half saline if serum Na+ level keep increasing and serum osmolality decreasing.
Aim reduction of serum osmolality 3-8mOsm/kg/H and blood sugar 4-6mmol/L/H
If blood pressure noted to be hypotensive while ongoing of fluid replacement, it is likely to due to intracellular
dehydration. So, need to consider re-start back the fluid resuscitation.
Hourly DXT, Na+ (corrected Na+) and K+ monitoring. Calculate Serum osmolality Hourly too. VBG is useful tool
to guide if unable to send the blood to lab hourly.
Strict I/O charting, make sure to chart urine output hourly
70. References
•Joint British Diabetes Societies for Inpatient Care. The Management of Hyperosmolar
Hyperglycemic State (HHS) in Adults. February 2022
•American Diabetes Association. Hyperosmolar Hyperglycemic State: A Historic Review of the
Clinical Presentation, Diagnosis and Treatment. Diabetes Care 2014; 37: 3124-3131
•Joint British Diabetes Societies for Inpatient Care. The Management of Diabetic Ketoacidosis
(DKA)in Adults. March 2023
•MOH CPG Management of T2DM (6TH edition). December 2020
Editor's Notes
HHS is characterized by extreme elevations in serum glucose concentrations and hyperosmolality without significant ketosis (Fig. 1). These metabolic derangements result from synergistic factors including insulin deficiency and increased levels of counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone) (31–33). Hyperglycemia develops because of an increased gluconeogenesis and accelerated conversion of glycogen to glucose (glycogenolysis) and by inadequate use of glucose by peripheral tissues, primarily muscle. From the quantitative standpoint, increased hepatic glucose production represents the major pathogenic disturbance responsible for hyperglycemia in DKA (34). As the glucose
concentration and osmolality of extracellular fluid increase, an osmolar gradient is created that draws water out of the cells. Glomerular filtration is initially increased, which leads to glucosuria and osmotic diuresis. The initial glucosuria prevents the development of severe hyperglycemia as long as the glomerular filtration rate is normal. However, with continued osmotic diuresis, hypovolemia eventually occurs, which leads to a progressive decline in glomerular filtration rate and worsening hyperglycemia. Higher hepatic and circulating insulin concentration as well as lower glucagon are present in HHS compared with patients with ketoacidosis (32,33). The higher circulating ratio of insulin/glucagon in patients with HHS prevents ketogenesis and the development of ketoacidosis. This concept is supported by clinical studies both in animals and in humans, which have shown that the half-maximal concentration of insulin for antilipolysis is lower than for glucose
use by peripheral tissues (35). Finally, a direct role of hyperosmolarity by inhibiting lipolysis and free fatty acid release from adipose tissue has been shown in experimental animals (36). Severe hyperglycemia is associated with a severe inflammatory state characterized by an elevation of proinflammatory cytokines (tumor necrosis factor-a, interleukin (IL)b, IL6, and IL8) and reactive oxygen species, with insulin secretion and action. Hyperglycemia causes an increase in oxidative stress markers such as membrane lipid peroxidation (37). The degree of lipid peroxidation is directly proportional to the glucose concentrations in diabetic patients. This is thought to occur via several well-studied mechanisms, including increased polyol pathway flux, increased intracellular formation of advanced glycation end products, activation of protein kinase C, or overproduction of superoxide by the mitochondrial electron transport chain (37,38). By interest, elevations of
circulating proinflammatory cytokines are reduced to normal levels promptly in response to insulin therapy and normalization of blood glucose concentration
The rate of rehydration will be determined by assessing the combination of initial severity and any pre-existing co-morbidities. Caution is needed, particularly in the elderly, where too rapid rehydration may precipitate heart failure but insufficient may fail to reverse acute kidney injury.
Having diabetes is associated with an increased risk of developing venous thromboembolic disease (VTE) (44). People with HHS have an increased risk of arterial and VTE (45; 46). A study of hyperglycaemia (not necessarily with HHS) during
COVID-19 admissions suggested that the risk of arterial and VTE was three times higher than those without hyperglycaemia (47). Other work has estimated that people with diabetes and hyperosmolality have a risk of VTE similar, or only marginally above those with acute renal failure, acute sepsis or acute connective tissue disease (48; 49). The risk of venous thromboembolism is greater than in diabetic ketoacidosis (45; 50; 51). Other factors, such as hypernatraemia and increasing vasopressin concentrations can promote thrombogenesis by producing changes in haemostatic function consistent with a hypercoagulable state