hhns cabais

8/13/2019 hhns cabais

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Hyperosmolar Hyperglycemic

Nonketotic Syndrome (HHNS)

- is a life-threatening emergency. It is

caused by very high blood sugar

(hyperglycemia). Without prompt

treatment HHNS can be fatal.


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HHNS is also called.

Hyperosmolar Nonketotic State (HNS)

Hyperosmolar Hyperglycemic Syndrome

Diabetic Hyperosmolar State

Hyperosmolar Hyperglycemic Nonketotic

coma

Hyperosmolar Coma

Nonketotic Hypertonicity.


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How does it occur?

HHNS is most common in adults with type

2 diabetes. Having diabetes means thatthere is too much sugar (glucose) in yourblood. Because type 2 diabetes can be a

silent disease for many years, unless yourblood sugar is checked, HHNS could

happen before you know that you havediabetes.


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HHNS is more common in the Type II NIDDMpatient. This is because the Type II patients

pancreas is able to still produce and secretesome insulin. Therefore, some glucose is stillgetting into the cells.

The glucose entering the cells keeps the amount

of fat being burned for energy to a lesseramount than is seen in DKA. If a significantamount of fat is not being used, then lessketones will be produced as a byproduct of fatbreakdown.

Since a large amount of ketones do not collect andcause acid load in the body, the syndrome is

termed nonketotic.


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CAUSES OF HHNS

Age; HHNS is more common in elderly

individuals with Types 1 and 2 DM

Illnesssuch as infections, MI, GI

bleeds, uremia and arterial thrombosis

Stress

Massive fluid loss from prolonged

osmotic diuresis


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CAUSES OF HHNS

Hypertonic feedings such as prolonged

parenteral nutrition via IV infusion,

high-protein or gastric tube feedings Pharmacologic agents such as

thiazides, propranolol, phenytoin,

steroids, flurosemide andchlorthalidone


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FOUR MAJOR CLINICAL

FEATURES

Severe hyperglycemia

No or slight ketosis

Profound dehydration

Hyperosmolality


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Risk Factors

Older age

Poor kidney function Poor management of diabetes-not

following the treatment plan as

directed Stopping insulin or other medications

that lower the glucose levels


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Assessment:

Blood glucose level is from600-1200mg/dl

Postural Hypotension

Profound Dehydration-

(typically 8-12 L) dry mucousmembranes, poor skinturgor)

Tachycardia

Mental status changes

Neurological deficits

Seizures


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Physical findings


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HHNS: Physical findings

Non-specific

Clinical signs of volume depletion:

Poor skin turgor

Dry mucus membranes

Sunken eyeballs

Hypotension

Wide range of findings such as changes in vital signs

and cognition to clear evidence of profound shockand coma may occur

Normothermia or hypothermia is common due to

vasodilation


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Seizures Up to 15% may present with seizures

Typically focal

Generalized seizures that are often resistant to

anticonvulsants may occur

Other CNS symptoms may include: Tremor

Clonus

Hyperreflexia

Hyporeflexia

Positive plantar response

Reversible hemiplegia or hemisensory defects withoutCVA or structural lesion


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Degree of lethargy and coma isproportional to the level of osmolality

Those with coma tend to have:

Higher osmolality

Higher hyperglycemia

Greater volume contraction

Not surprising that misdiagnosis of strokeor organic brain disease is common in theelderly


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LABORATORYTESTS


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Essential Laboratory Tests

1. Serum osmolality (concentration ofparticles) of 320 mOsm/kg

2. Plasma glucose level greater than 33.3

mmol/L (600 mg/dL)3. Intense dehydration shown by elevated

serum sodium levels.

4. No ketoacidosis

5. PH of 7.3

6. HCO3 - greater than 15 mEq/L

7. BUN and creatinine-elevated


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Laboratory Tests

Consider Urinalysis and

culture

Liver and pancreaticenzymes Cardiac enzymes Thyroid function Coagulation profiles

Chest x-ray ECG

Other CT of head LP

Toxicology ABG Of value only if

suspicion ofrespiratorycomponent toacid-base

abnormality Both PCO2and pH

can be predictedfrom bicarbonateconcentrationobtained fromvenous

electrolytes


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The primary goal is REHYDRATION. Thisis to restore circulating plasma volume

and correct electrolyte imbalances. In addition, the precipitating event

should be identified and corrected, andother goals similar to those described for

treatment of DKA should be instituted,includingproviding adequate insulin torestore and maintain normal glucosemetabolism.

Glucose concentration is the majorbiochemical end point because patientswith HHNS do not have ketosis oracidosis.


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Treatment

The first emergency

treatment is

intravenous (IV) fluidsso that your body has

more fluid and your

sodium and potassium

levels can be brought

back to normal.


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Electrolytes

K+

Initial levels may be normal or high in the

presence of acidemia

Levels < 3.3mEq/L represents severe deficitand are at risk for dysrhythmias.

Replacement can begin once urinary output

is assured.

Replace at a rate of 10-20mEq/h.

Na+

Replaced rapidly w/ the amount of NS

required for fluid resuscitation.

Treatment


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Treatment

Insulin

As in DKA IV administration preferred over

IM or SubQ due to poor adsorption.

IV infusion at rate of 0.1 units/kg/h Rinsulin

Loading dose is optional

Once serum glucose reaches 250-

300mg/dL fluid can be to D5 1/2NS and

insulin can be decreased to 0.05units/kg/h.


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Treatment

Dextrose (50 g) should be givenintravenously every 8 hours and insulin dose

adjusted accordingly (decreased 1 to 3 U/h)

based on plasma glucose measurements

every 4 hours.

Bicarbonate therapy is contraindicated in

absence of acidosis


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Patient Management:

Similar to treatment for DKA

Includes fluid replacement, correction of

electrolyte imbalances, and insulin

administration

Insulin plays a less critical role in the

treatment of HHNS than it does for the

treatment of DKA because insulin is notneeded for reversal of acidosis in HHNS.


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Patient Management:

Maintain safety and prevent injury

related to changes in the patients

sensorium secondary to HHNS.

Closely monitor fluid status and urine

output


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Emergency Nursing Care


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Nursing Care

Even though the major complication of

the disease is severe dehydration, HHNS

carries the highest mortality rate of thediabetic emergencies.


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Nursing Care

Establish and maintain a patent airway. manual maneuver

mechanical device including endotracheal intubationmay be necessary

Establish and maintain adequateventilation. provide positive pressure ventilation

Establish and maintain adequateoxygenation Assess the patient for evidence of hypoxia

pulse oximeter

determine the SpO2 reading


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Nursing Care

Provide continuous ECG monitoring cardiac dysrhythmias may occur

patients experiencing HHNS have preexisting cardiovasculardisease making them prone to cardiac dysrhythmias

Initiate an intravenous line of normal saline

Aggressive fluid resuscitation may be necessary insevere cases

Administer a bolus of 500 mL of normal saline inseverely dehydrated patients

Lactated Ringers may also be used

In patients with a history of cardiac disease,congestive heart failure, or renal insufficiency, a250 mL bolus should be used


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Nursing Care

Continuously reassess the patient for aresponse to the fluid administration and for

evidence of over-hydration

Assess the blood glucose level of any patient

with preexisting disease who presents with

signs and symptoms of dehydration or an

altered mental status, especially the elderly,regardless of a positive history of diabetes

mellitus.


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How to Prevent HHNS

Ask your provider when you should callabout high blood sugar--for example, ablood sugar higher than 250 milligrams perdeciliter (mg/dL), or 13.9 millimoles per

liter (mmol/L). Report any symptoms of infection, such as

fever, a cough, or cloudy urine right awayto your provider.

Check your blood sugar every 4 hourswhen you are sick. Work with yourhealthcare provider to develop a sick-dayplan.


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