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By: Nurfauzani binti Ibrahim Shuhaida bt Che Shaffi

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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Page 1: Hyperosmolar Non Ketotic Dm [Autosaved]

By: Nurfauzani binti IbrahimShuhaida bt Che Shaffi

Page 2: Hyperosmolar Non Ketotic Dm [Autosaved]

What it is?..A metabolic emergency that occurs in

diabetic patient usually Type 2 Diabetes Mellitus

in which it is characterised by uncontrolled hyperglycemia that induces

hyperosmolar state and dehydration without significant

ketoacidosis.

Page 3: Hyperosmolar Non Ketotic Dm [Autosaved]

Diagnostic features• Plasma glucose level of 600 mg/dL or greater• Effective serum osmolality of 320 mOsm/kg or

greater• Profound dehydration (8-12 L) with elevated

serum urea nitrogen (BUN)-to-creatinine ratio

• Small ketonuria and absent-to-low ketonemia• Bicarbonate concentration greater than 15

mEq/L• Some alteration in consciousness

Page 4: Hyperosmolar Non Ketotic Dm [Autosaved]

CausesDehydrationPneumonia and UTICounter-regulotary hormone (e.g cortisol, cathecolamine,

glucagon)Drugs - Diuretics - B-blocker - Histamine(H2) Blocker - Anti-psychotics (Clozapine, Olanzapine) - Alcohol abd cocaine - Dialysis, TPN, Fluid (Dextrose)Non-compliance to OHA or insulin therapy

Page 5: Hyperosmolar Non Ketotic Dm [Autosaved]

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

Page 6: Hyperosmolar Non Ketotic Dm [Autosaved]

Clinical featuresOccurs only in type 2 DMCould be initial presentation of the diabetic

stateElderlyObtundation to comaSevere dehydration invariableMay have associated lactic acidosis due to

hypoxiaPrecipitating factors similar to DKAMortality rate is high

Page 7: Hyperosmolar Non Ketotic Dm [Autosaved]

SymptomsSymptoms of hyperglycemia :

PolydipsiaPolyuriaLethargic

Others :Weight lossLoss of consciousness

Page 8: Hyperosmolar Non Ketotic Dm [Autosaved]

A wide variety of focal and global neurologic changes may be present, including the following:Drowsiness and lethargyDeliriumComaFocal or generalized seizuresVisual changes or disturbancesHemiparesisSensory deficits

Page 9: Hyperosmolar Non Ketotic Dm [Autosaved]

Physical examination :Dehydrated : dry skin, lips, mucous

membrane, loss skin turgor

Vital sign : tachycardia (early dehydration), hypotension (later), temperature

Systemic examination to ruled out the cause.

Page 10: Hyperosmolar Non Ketotic Dm [Autosaved]

Differential diagnosisAlcoholic ketoacidosisDelirium (altered mentation)DementiaOverdoseThyrotoxicosis (tachycardia, fever,

dehydration)

Page 11: Hyperosmolar Non Ketotic Dm [Autosaved]

Lab studiesPlasma glucose

HyperglycemiaABG

PH> 7.3HCO3>15 mmol/l

Serum osmolality>320 mmol/l

Page 12: Hyperosmolar Non Ketotic Dm [Autosaved]

othersUrinanalysis

Exclude utiProteinuria

Plasma ketonePlasma electrolyteRenal function test(Creatinine &BUN)FBCCreatine kinase

Page 13: Hyperosmolar Non Ketotic Dm [Autosaved]

Imaging studiesChest radiograph

Exclude pnuemoniaCardiomegaly

CT scan of the headExclude heamorrhagic stroke, subdural

heamatomaLook for cerebral edema

Page 14: Hyperosmolar Non Ketotic Dm [Autosaved]

ManagementAirway IV accessLab and radiographfluid deficit of an adult may be 10 L or more.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.

switch to half-normal saline once blood pressure and urine output are adequate.

Once serum glucose drops to 250 mg/dL, the patient must receive dextrose in the intravenous fluid.

Page 15: Hyperosmolar Non Ketotic Dm [Autosaved]

Initiate insulin therapy infuse insulin at rate of 3 Units/hour for first 2-3 hours increase 6 Units/hour if glucose falling too slow

Replete K+ and Mg2+AntibioticReevaluationHospitalization