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 40-60%
New-onset diabetes 33%
Acute illness 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
 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 findings

Blood glucose >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
Curriculum Module III-6
Slide of 55

Treatment
Rehydration Caution!

Normal saline 1 l per hour initially

Consider ½ 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
Curriculum Module III-6
Slide of 55

HHS – complications

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
Curriculum Module III-6
Slide of 55

DKA and HHS – prevention is key

• 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
 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

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