KOMA HIPEROSMOLAR

NONKETOTIK
Fatimah Eliana

DKA and HHS

Curriculum Module III-6

Slide of 55

What is HHS?

Ketosis may be present

Coma not always present
Primarily in older people with/without
history of type 2 diabetes
Always associated with severe
dehydration and hyperosmolar state
Develops over weeks

Kitabchi et al 2001

DKA and HHS

Curriculum Module III-6

Slide of 55

HHS incidence and

features
0.5% of primary diabetes hospital
admissions
~15% mortality rate
Can occur in type 1 diabetes and
younger people

Kitabchi et al 2001

DKA and HHS

Curriculum Module III-6

Slide of 55

HHS causes or
triggers Incidence
Infection
New-onset diabetes
Acute illness

40-60%
33%
10-15%

Medicines, steroids

<10%

Insulin omission

5-15%

DKA and HHS

Curriculum Module III-6

Slide of 55

HHS key features

Marked hyperglycaemia
Hyperosmolarity
Absence of severe ketosis
Altered mental awareness

KOMA HIPEROSMOLAR
NON KETOTIK
Gejala klinis

Biasanya berusia > 50 tahun

Kesadaran
Tanda-tanda dehidrasi
Hiperglikemia yang tinggi (> 600 mg/dl)
Tanpa asidosis pH > 7.3
Ketosis ringan
Hiperosmolaritas

[(2 plasma Na ) + plasma glukosa] > 320 mOsm/kg

2 (Na + K) + Urea + Glukosa
> 350 mOsm/kg
+

18

DKA and HHS

Curriculum Module III-6

Slide of 55

Signs and symptoms of

HHS
Initially polyuria and
polydipsia
Altered mental status
Profound dehydration
Precipitating factors

DKA and HHS

Curriculum Module III-6

Slide of 55

HHS biochemical
Blood glucose findings
>33mmol/L (600mg/dl)
Ketones

Urine: negative small

Blood: <0.6 mmol/L

Osmolality

>320mOsm/kg - (raised Na,

BG, urea)

Electrolytes

Raised Na, BG, urea creatinine

Anion gap

<12

Blood gases

pH >7.30
normal or raised HCO3

DKA and HHS

Treatment

Curriculum Module III-6

Slide of 55

Rehydration Caution!
Normal saline 1 l per hour initially
Consider strength normal saline
Potassium

Only if hypokalaemic and renal function

adequate give before insulin

Insulin

May be needed as slow infusion

0.1 unit/kg/hour to be increased with
care if BG is slow to fall

Monitoring

BG, BP, neurological function hourly until

stable
Electrolytes 2-hourly
Cardiac or CVP monitoring

DKA and HHS

HHS complications

Curriculum Module III-6

Slide of 55

Complication

Prevention

Hypoglycaemia

Prevent by adding glucose infusion

when glucose <14mmol/L (250
mg/dL)

Hypokalaemia

Early potassium replacement and

monitoring

Fluid overload

Careful clinical monitoring and

central line as needed

Vomiting/aspiration

NG tube and may be nursed on side

Cerebral oedema

Avoid fast blood glucose falls

(should be <4mmol/L (72mg/dL)
per hour; aggressive Mannitol
treatment if any early signs of
cerebral oedema

DKA and HHS

DKA and HHS

prevention is key

Curriculum Module III-6

Slide of 55

Identify and treat underlying cause

Can be prevented by
better public awareness
improved access to medical care
improved education in treating hyperglycaemia
during illness
emergency communication with healthcare
provider