Documente Academic
Documente Profesional
Documente Cultură
H Y P E R G L Y C E M I C
N O N K E T O T I C
S Y N D R O M E
- is a life-threatening emergency. It is caused by very high blood sugar (hyperglycemia). Without prompt treatment HHNS can be fatal.
HHNS is most common in adults with type 2 diabetes. Having diabetes means that there is too much sugar (glucose) in your blood. Because type 2 diabetes can be a silent disease for many years, unless your blood sugar is checked, HHNS could happen before you know that you have diabetes.
HHNS is more common in the Type II NIDDM patient. This is because the Type II patients pancreas is able to still produce and secrete some insulin. Therefore, some glucose is still getting into the cells.
The glucose entering the cells keeps the amount of fat being burned for energy to a lesser amount than is seen in DKA. If a significant amount of fat is not being used, then less ketones will be produced as a byproduct of fat breakdown. Since a large amount of ketones do not collect and cause acid load in the body, the syndrome is termed nonketotic.
CAUSES OF HHNS
Age; HHNS is more common in elderly individuals with Types 1 and 2 DM Illness such as infections, MI, GI bleeds, uremia and arterial thrombosis Stress Massive fluid loss from prolonged osmotic diuresis
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 and chlorthalidone
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
Assessment:
Blood glucose level is from 600-1200mg/dl Postural Hypotension
Profound Dehydration(typically 8-12 L) dry mucous membranes, poor skin turgor)
Physical findings
Wide range of findings such as changes in vital signs and cognition to clear evidence of profound shock and coma may occur Normothermia or hypothermia is common due to vasodilation
Not surprising that misdiagnosis of stroke or organic brain disease is common in the elderly
LABORATORY
TESTS
Laboratory Tests
Other Consider CT of head Urinalysis and LP culture Toxicology Liver and pancreatic ABG enzymes Of value only if Cardiac enzymes suspicion of Thyroid function respiratory component to Coagulation profiles acid-base Chest x-ray abnormality ECG Both PCO2 and pH
can be predicted from bicarbonate concentration obtained from venous electrolytes
T R E A T M E N T
The primary goal is REHYDRATION. This is to restore circulating plasma volume and correct electrolyte imbalances. In addition, the precipitating event should be identified and corrected, and other goals similar to those described for treatment of DKA should be instituted, including providing adequate insulin to restore and maintain normal glucose metabolism. Glucose concentration is the major biochemical end point because patients with HHNS do not have ketosis or acidosis.
Treatment
The first emergency treatment is intravenous (IV) fluids so that your body has more fluid and your sodium and potassium levels can be brought back to normal.
Treatment
Electrolytes
K+
Initial levels may be normal or high in the presence of acidemia Levels < 3.3mEq/L represents severe deficit and are at risk for dysrhythmias. Replacement can begin once urinary output is assured.
Replace at a rate of 10-20mEq/h.
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 R insulin Loading dose is optional Once serum glucose reaches 250300mg/dL fluid can be to D5 1/2NS and insulin can be decreased to 0.05units/kg/h.
Treatment
Dextrose (50 g) should be given intravenously 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
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 not needed for reversal of acidosis in HHNS.
Patient Management:
Maintain safety and prevent injury related to changes in the patients sensorium secondary to HHNS.
Closely monitor fluid status and urine output
Nursing Care
Even though the major complication of the disease is severe dehydration, HHNS carries the highest mortality rate of the diabetic emergencies.
Nursing Care
Establish and maintain a patent airway.
manual maneuver mechanical device including endotracheal intubation may be necessary
Nursing Care
Provide continuous ECG monitoring
cardiac dysrhythmias may occur patients experiencing HHNS have preexisting cardiovascular disease making them prone to cardiac dysrhythmias
Nursing Care
Continuously reassess the patient for a response 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.