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Understanding the Presentation of Hyperglycemic Hyperosmolar Nonketotic Syndrome

HHNS is most common in adults with type 2 diabetes. General and clinical data were collected. HAECs were treated with high concentration of glucose or hyperosmolar condition for 3 days. If the patient is conscious and can swallow, quick-acting sugar will be required, generally in the form of sweets, sugary fizzy drinks, oral glucose gel or chocolate. He had cool and mottled extremities, weak peripheral pulses and capillary refill of 4 seconds. A 9.6-year-old prepubertal white male presented with a week history of flu-like symptoms. The easiest and most urgent laboratory tests after a prompt history and physical examination are determination of blood glucose by finger-stick and urinalysis with reagent strips to assess qualitative amounts of glucose, ketones, nitrite, and leukocyte esterase in the urine.

Activities of p38 kinase in PKC-δ– but not PKC-β1–overexpressed SMC were increased compared with control cells. Four patients (24%) presented with lower limb ischemia. The involvement of AQP1 in hyperosmolarity-induced endothelial tubulization and angiogenesis [38–41] is of biological importance. The results suggest that hyperosmolar solutions enhance calcium availability in the hearts of diabetic animals. These data support the hypothesis that increased adhesion of neutrophils to retinal endothelial cells exposed to a hyperosmotic environment (as is present in diabetes) may play a significant role in the pathogenesis of diabetic retinopathy. Approximately 20 to 33 percent of the patients who suffer an acute onset of HHNS have no previous history of DM. These patients are at the highest risk since they often do not recognize the early warning signs and symptoms of severe dehydration.

Rapid transfusion of cold saline with the onset of hyperthermia is likely to have contributed to the acute rise of serum sodium from 149 to 169 mEq/L and chloride from 101 to 142 mEq/L. The authors provide links to two reviews of ADH as a progression factor in CKD: Nature Reviews Nephrology: Vasopressin: a novel target for the prevention and retardation of kidney disease?Current Opinion in Nephrology and Hypertension: Vasopressin beyond water: implications for renal diseases The article then turns to the aldose reductase pathway. We must document that the diabetes is “uncontrolled” or “out of control” for a coder to report it as uncontrolled. Among drugs, diuretics and corticosteroids were often accused of favoring diabetic hyperosmolarity. A decline in renal function, which is typically found in the elderly patient or in patients with renal disease, also contributes to a decrease in glucose clearance. Glycogenolysis may have a limited contribution to the hyperglycemic state since many of the patients are debilitated or suffer from an acute illness and have a poor diet as a result, causing the glycogen stores in the liver to deplete over time. Axial section (Fig.

Initially, this influx of fluid will maintain the blood pressure and perfusion. Click here to see the Library]. As the osmotic diuresis continues, the intravascular volume is profoundly depleted, which further decreases renal perfusion and the ability of the kidneys to remove glucose from the blood. À l’admission, la glycémie était à 40,0 mmol/l [26,3–60,8], la natrémie corrigée de 167 mmol/l [158–174] et l’osmolarité sanguine calculée de 384 mosmol/l [365–405]. A common cause of death is circulatory collapse. The change in the serum osmotic pressure may cause potassium, sodium, chloride, phosphate, magnesium and bicarbonate to be depleted from the tissues, even though the serum electrolyte levels may appear to be normal or elevated. Sodium, potassium, phosphate and magnesium are typically lost during the osmotic diuresis leading to electrolyte imbalances.

Unlike DKA, the patient with HHNS does not develop ketoacidosis. You need to be closely checked for brain swelling, kidney failure, and other serious problems. It is thought that the continued secretion and availability of small amounts of insulin decreases the mass release of counter-regulatory hormones and reduces the availability of free fatty acids needed to produce ketones. With no ketoacidosis, the patient will not present with Kussmaul’s respirations or a fruity (acetone) odor on the breath. A 2015 drug safety alert highlighted a small risk of DKA in patients using SGLT2 inhibitors. If the patient presents with an altered mental status or is comatose, it may be necessary to establish an airway by a manual maneuver. Parents reported that in the days prior to admission, he consumed at least 44 ounces per day of regular soda, sports drinks, and apple juice, resulting in an estimated daily intake of 451 g of carbohydrates and 56 mg of sodium.

Katsilambros N. (Hercules, California, USA); phosphocellulose squares (P-81) from Whatman Institute (Maidstone, United Kingdom); and plasmid maxi kit from QIAGEN Inc. Establish and maintain adequate oxygenation. Nonetheless, data provided here lend support to the hypothesis that hyperosmolarity is an important mechanism of vascular disease in diabetes and a potential target for future therapies, with several potential practical implications. Apply a pulse oximeter and determine the SpO2 reading. If either clinical evidence of hypoxia exists or a SpO2 reading of less than 95 percent on room air is present, administer a high concentration of oxygen via a nonrebreather mask. If the patient is exhibiting no signs of hypoxia or the SpO2 reading is greater than 95 percent, supplemental oxygen may be applied via a nasal cannula at two to 4 lpm.

Provide continuous ECG monitoring. Due to the electrolyte imbalance, cardiac dysrhythmias may occur. Also, many of the patients experiencing HHNS have preexisting cardiovascular disease making them prone to cardiac dysrhythmias. Initiate an intravenous line of normal saline. Patients lose significant amounts of fluid from the osmotic diuresis. Aggressive fluid resuscitation may be necessary in severe cases. Administer a bolus of 500 mL of normal saline in severely dehydrated patients.

Lactated Ringer’s may also be used if normal saline is not available. In patients with a history of cardiac disease, congestive heart failure, or renal insufficiency, a 250 mL bolus should be used. Continuously reassess the patient for a response to the fluid administration and for evidence of over-hydration. Continue to administer fluid based on the patient’s hemodynamic status. 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. Hyperglycemic hyperosmolar nonketotic syndrome may be the first indication that the patient has diabetes mellitus. Even though the major complication of the disease is severe dehydration, HHNS carries the highest mortality rate of the diabetic emergencies.

Guyton, A.C., and J.E. Hall. Textbook of Medical Physiology. 10th ed. Philadelphia: W.B. Sauders, 2001. Marx, J.A., R.S.

The initial evaluation of children with new onset diabetes is often performed by their pediatrician. Walls. In general, Western blotting techniques can detect changes of 20%–30% in our studies. 5th ed. St. Louis: Mosby, Inc., 2002. Sagarin, M.

Hyperosmolar Hyperglycemic Nonketotic Coma. http://www.emedicin.com/emerg/topic264.htm. January 13, 2005. Joseph J. Mistovich is the chairperson of the Department of Health Professions and a Professor at Youngstown State University in Youngstown, Ohio. He has more than thirty-three years of experience as an EMS educator. He received a Master of Education degree from Kent State University, a Bachelor of Science in Applied Science degree in Allied Health and an Associate in Applied Science degree in Emergency Medical Services from Youngstown State University.

He has authored fifteen EMS textbooks and more than fifty EMS journal articles. He is a frequent speaker at state and national EMS clinical and education conferences. He is a member of the Board of Directors for the Committee on Accreditation of Educational Programs for the EMS Professions. He has also served on numerous NHTSA committees and NREMT examination projects. To contact Joseph, email joseph.mistovich@ems1.com.

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