Hyperglycemic hyperosmolar nonketotic state – What are the signs and symptoms, relevant dDx., sequelae, work up, and treatment options?

Hyperglycemic hyperosmolar nonketotic state occurs in type II diabetics due to partial or relative insulin deficiency decreasing glucose utilization in muscle, fat and liver while inducing hyperglycemia and hepatic glucose production. There is significant dehydration, causing volume contraction and renal insufficiency, leading to hyperglycemia, hyperosmolarity and a shift of fluid from the neons to the extracellular fluid. HHNK is often precipitated by sepsis, stroke, myocardial infarction, congestive heart failure, renal failure or iatrogenic causes (glucocorticoids, immunosuppressants, phenytoin diuretics).

Sn. & Sx.:

• Constitutional symptoms (weakness, weight loss)
• Altered mental status (confusion)
• Polyuria
• Lethargy
• Dehydration
• Hypotension, orthostatic changes

dDx.:

• Diabetic ketoacidosis

Sequelae:

• Mental obtundation
• Coma

Work up:

• CBC
• Serum chemistry (elevated glucose, decreased Na, HCO3 and PO4, increased K)
• Kidney function tests (elevated blood urea nitrogen and creatine)
• Urinalysis (glucose)

Tx.:

• Rehydration (1 L/hr normal saline for 2 hr, add D5W when blood glucose ,15 mM to prevent hypoglycemia)
• Potassium (to avoid hypokalemia)
• Insulin (only regular insulin)

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This post was written by Omar Rifai