Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNKS)
Patient Presentation:
N.F., a 72 year old male was found unresponsive in his home by his daughter. She had not seen him for three days and went to check on him; finding him unresponsive, she called 911. When EMS arrived, they found him to have a GCS 3, so they bag/mask ventilated him, started IV hydration, and transported him to the ED. Enroute they checked a blood glucose level, but their glucometer gave a reading of “>400”. N.F. was intubated in the ED for airway protection, chemistries were drawn, and again a fingerstick blood glucose read >400. N.F.’s daughter told the ED staff that he had a past medical history of hypertension, type 2 diabetes mellitus, and alcoholism.
Differential List:
Diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic syndrome
Diagnosis:
Labs: Na: 133, K: 4.6, Cl: 97, Glucose: 2250, CO2: 22, BUN: 40, creatinine: 2.1, serum osmolarity: 356
Urinalysis: No ketones
EKG: Sinus Tachycardia, HR 132
ABG: pH: 7.41, PaCO2: 34, PaO2: 85, HCO3: 23
Vital Signs: HR: 132, BP: 87/45, Temp: 37.5, RR: 15 (on vent), SpO2: 95% on 100% FiO2
Radiology: Head CT negative
Given the reasonably normal ABG and elevated blood glucose and serum osmolarity, the diagnosis was coma secondary to HHNKS.
Treatment:
First, 3 L 0.9% NS IV fluid was given to restore hemodynamic stability. Pt was transferred to ICU for further monitoring and ventilatory support. Once in the ICU, blood glucose was checked q hr x12, then per protocol; serial BMP were drawn q 2 hours x4, then q 4 hours x 48 hours. Once N.F. was hemodynamically stable, HR decreased to 85 and having a urine output of 40-50 mL/hr, IV regular insulin drip was started, following the hospital’s protocol for blood glucose control. The blood glucose was slowly brought down over 48 hours as to minimize risk of cerebral edema. IV rehydration continued, first with 0.9% NS, then once glucose was below 250, D5 0.45% NS. Potassium levels were closely monitored and supplemental KCl was given as needed.
Outcome:
Four days after being admitted, blood glucose levels had returned to normal, 100-130. N.F. was extubated but remained stuperous for many days, following simple commands but not able to feed himself, walk, communicate needs, or participate in activities of daily living. He was transfered out of the ICU on hospital day 5 and discharged to a skilled nursing facility on day 8, since he needed a great deal of nursing care for ADLs and DM management.
Case created by Nicole Fontenot, 2010.