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Hyperosmolar Hyperglycemic Nonketotic Coma (hhnc, Hyperosmolar Hyperglycemic Nonketotic Syndrome)

Hyperosmolar Hyperglycemic Nonketotic Coma (hhnc, Hyperosmolar Hyperglycemic Nonketotic Syndrome)

Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC, Hyperosmolar Hyperglycemic Nonketotic Syndrome) Hyperosmolar hyperglycemic syndrome (HHS) is a clinical condition that arises from a complication of diabetes mellitus. This problem is most commonly seen in type 2 diabetes. Won Frerichs and Dreschfeld first described the disorder around 1880. They described diabetic patients with profound hyperglycemia and glycosuria without the classic Kussmaul breathing or acetone in the urine seen in diabetic ketoacidosis. This clinical condition was formerly called non-ketotic hyperglycemic coma; hyperosmolar hyperglycemic non-ketotic syndrome, and hyperosmolar non-ketotic coma (HONK). Diabetes mellitus is a clinical condition associated with hyperglycemia as the main metabolic disorder.This is as a result of an absolute or relative deficiency of insulin. Insulin is an anabolic hormone produced by the beta cells in the islets of Langerhans in the pancreas. The main function of this hormone is to lower the level of glucose in the blood by promoting the uptake of glucose by the adipose tissue and skeletal muscle, known as glycogenesis. Insulin also inhibits the breakdown of fat in the adipose tissue,known as lipolysis. The metabolic effect of insulin is countered by hormones such as glucagon and catecholamines. In type 1 diabetes, there is the autoimmune destruction of the beta cells in the pancreas. Only about 5% to 10% of all diabetes falls into this category. The most common complication of type 1 diabetes is diabeticketoacidosis (DKA). Type 2 diabetes accounts for about 90% to 95% of diabetes cases. It is most commonly seen in obese patients. As a consequence of the obesity and high body mass index (BMI), there is the resistance of the peripheral tissue to the action of insulin. Th Continue reading >>

Acute Complications Of Diabetes - Hyperosmolar Hyperglycemic Nonketotic State

Acute Complications Of Diabetes - Hyperosmolar Hyperglycemic Nonketotic State

- [Voiceover] Diabetes mellitus and its associated complications are the 8th leading cause of death worldwide. Now normally we think of both type 1 and type 2 diabetes as being more chronic conditions that result in complications such as kidney disease and cardiovascular disease over years to decades. And this is true, but there are also a couple of very important acute complications of diabetes mellitus. And these are known as diabetic ketoacidosis, or DKA for short, and hyperosmolar hyperglycemic non-ketotic state, or HHNS for short. And unfortunately these acute complications can be very serious, especially HHNS, which has a mortality rate of eight to 20%. In this video, let's discuss hyperosmolar hyperglycemic non-ketotic state. Now the name hyperosmolar hyperglycemic non-ketotic state is pretty descriptive in regards to the metabolism that underlies the disease. However, it does not really describe the clinical presentation of the condition. So let's start with that. And most commonly, someone with HHNS has already been diagnosed with diabetes, and this occurs sometime after their initial diagnosis. And since they have diabetes, they likely will have hyperglycemia, which is one of the defining characteristics of diabetes mellitus. And as we'll discuss in just a minute, it's this hyperglycemia that's driving a lot of the events that are occurring in HHNS. Now over a period of days to weeks, someone with HHNS is gonna become pretty sick, and they're gonna have symptoms of fatigue, maybe some weight loss. They're gonna have extreme thirst and frequent urination. On physical exam they'll have signs of dehydration, such as a high heart rate, known as tachycardia, a low blood pressure known as hypotension, the mucus membranes in their mouth may be dry, and their skin may Continue reading >>

Hyperglycaemic Hyperosmolar Nonketotic Coma (honk)

Hyperglycaemic Hyperosmolar Nonketotic Coma (honk)

Hyperglycaemic Hyperosmolar Nonketotic Coma Hyperglycaemic Hyperosmolar Nonketotic Coma (HONK) HONK can occur with very high blood glucose levels Hyperglycaemic hyperosmolar non-ketotic coma is a dangerous condition brought on by very high blood glucose levels in type 2 diabetes (above 33 mmol/L). Hyperglycaemic hyperosmolar non-ketotic coma is a short term complication requiring immediate treatment by a healthcare professional. Before loss of consciousness and coma takes place, patients will display signs of very high blood sugar levels which may include: The condition of very high blood glucose without signs of ketosis may also be known as Hyperosmolar Hyperglycaemic State (HHS). Causes of hyperglycaemic hyperosmolar non-ketotic coma may include undiagnosed type 2 diabetes that has been developing over a number of years. Alternatively, HONK could be brought on by diabetic medication not being taken or very high blood glucose resulting from a period of illness . Treatment for hyperglycaemic hyperosmolar non-ketotic coma will include fluids being given to the patient and insulin administered intravenously. Hyperglycaemic hyperosmolar non-ketotic coma is coma resulting from very high blood glucose levels in a patient with normal ketone levels. If very high blood glucose levels are combined with high ketone levels, the state is likely to be ketoacidosis . Explore Hyperglycaemic Hyperosmolar Non-ketotic Coma Continue reading >>

Diabetic Hyperosmolar Syndrome

Diabetic Hyperosmolar Syndrome

Print Overview Diabetic hyperosmolar (hi-pur-oz-MOE-lur) syndrome is a serious condition caused by extremely high blood sugar levels. The condition most commonly occurs in people with type 2 diabetes. It's often triggered by illness or infection. As a result of diabetic hyperosmolar syndrome, your body tries to rid itself of the excess blood sugar by passing it into your urine. Left untreated, diabetic hyperosmolar syndrome can lead to life-threatening dehydration. Prompt medical care is essential. Symptoms Diabetic hyperosmolar syndrome can take days or weeks to develop. Possible signs and symptoms include: Blood sugar level of 600 milligrams per deciliter (mg/dL) or 33.3 millimoles per liter (mmol/L) or higher Excessive thirst Dry mouth Increased urination Warm, dry skin Fever Drowsiness, confusion Hallucinations Vision loss Convulsions Coma When to see a doctor Consult your doctor if your blood sugar is persistently higher than the target range your doctor recommends, or if you have signs or symptoms of diabetic hyperosmolar syndrome, such as: Excessive thirst Increased urination Warm, dry skin Dry mouth Fever Seek emergency care if: Your blood sugar level is 400 mg/dL (22.2 mmol/L) or higher and doesn't improve despite following your doctor's instructions for treatment. Don't wait until your blood sugar is high enough to cause diabetic hyperosmolar syndrome. You have confusion, vision changes or other signs of dehydration. Causes Diabetic hyperosmolar syndrome may be triggered by: Illness or infection Not following a diabetes treatment plan or having an inadequate treatment plan Certain medications, such as water pills (diuretics) Sometimes undiagnosed diabetes results in diabetic hyperosmolar syndrome. Risk factors Your risk of developing diabetic hyperosmolar synd Continue reading >>

Hyperosmolar Non Ketotic Hypergycaemic Coma (honk) - Deranged Physiology

Hyperosmolar Non Ketotic Hypergycaemic Coma (honk) - Deranged Physiology

Hyperosmolar Non Ketotic Hypergycaemic Coma (HONK) Though a distinction is being made between diabetic ketoacidosis and HONK, the two really form a part of the same disease spectrum. Some ketoacidosis is present in HONK, and some hyperosmolarity is present in DKA. However, different mechanisms are at play. HONK is distinct form DKA, and the distinction is not entirely arbitrary, at least from the management point of view. For instance, even though the conditions co-exist 30% of the time, it is possible to treat pure HONK without any supplemental insulin (because there is a satisfactory amount of it in circulation already).DKA is 3 times more common, but HONK has 3 times greater mortality. The chapter on DKA presents a table of discriminating features to help distinguish HONK from DKA. Past CICM SAQs involving HONk have included the following: Question 24 from the first paper of 2017 (management strategy) Question 1 from the second paper of 2016 (DKA vs HONK) Question 17 from the first paper of 2014 (DKA vs HONK) Question 18.1 from the second paper of 2008 (diagnosis and complications) Question 13 from the first paper of 2002 (pathophysiology, complications and treatment) Similarly to DKA, a stress response which mobilises metabolic substrates in a Type 2 diabetic will result in HONK. Precipitating Factors for Hyperosmolar Hyperglycaemia The key distinction between DKA and HONK seems to be the fact that in HONk, there is still enough insulin to overcome the ketogenic effects of glucagon. Glucagon inhibits acetyl-CoA carboxylase, which normally converts acetyl-CoA into malonyl-CoA. Malonyl CoA inhibits acyl-carnitine synthesis; if this is uninhibited, it results in a stream of fatty acids being sucked up into the mitochondria to be converted into ketones. Thus, we have a Continue reading >>

Diabetes Mellitus - Hyperglycaemic States

Diabetes Mellitus - Hyperglycaemic States

Diabetes mellitus - Hyperglycaemic states Globally the incidence of diabetes is likely to exceed 250 million people by 2025 that is a measure of the scale of the problem this condition is likely to present in the future. It is evidence of how diabetes will be one of the foremost public health challenges facing the world in the decades ahead. Recently, the series has been focusing on some of the acute complications that can occur with diabetes and this month Rita Forde discusses problems that arise from hyperglycaemic states. The last module focused on hypoglycaemia and this article will address hyperglycaemic states. Hyperglycaemic states present in the form of diabetic ketoacidosis (DKA) or hyper osmolar non ketotic acidosis (HONK). DKA is associated with a mortality rate of less than 5% in experienced centres while HONK has a much high mortality rate of approximately 15%. The prognosis of both is worsened by age and in the presence of coma and hypotension.2 DKA is associated with people with type 1 diabetes. It is defined as the triad of hyperglycaemia, acidosis and ketosis. The primary cause of this is insulin deficiency. This metabolic disturbance is associated with type 2 diabetes. It is characterised by an increase in serum osmolality, extreme hyperglycaemia and dehydration and the absence of ketones. It is caused by inadequate insulin levels. The pathophysiology of severe hyperglycaemia should be considered in relation to the glucose metabolism, acid-base balance, electrolyte changes and ketone body metabolism (DKA). The underlying mechanism for both of these conditions is relatively similar; a reduction in the circulating insulin and an elevation of the counter regulatory hormones. The counter regulatory hormones are glucagon, adrenaline, nor adrenaline, cortis Continue reading >>

Hyperosmolar Hyperglycaemic State

Hyperosmolar Hyperglycaemic State

Hyperosmolar hyperglycaemic state (HHS) (previously known as hyperosmolar non-ketotic coma (HONK)) is a serious metabolic derangement that can occurs in patients with diabetes mellitus, predominantly those with type 2. While there are no distinct imaging features, it is useful for a radiologist to be familiar with this condition. Epidemiology It usually occurs in type 2 diabetics who have some concomitant illness that leads to reduced fluid intake. Pathology High blood glucose levels lead to severe dehydration, increases in osmolarity (relative concentration of solute) and in turn carries a high risk of complications, coma and death. History and etymology HHS is thought to have been first described by von Frerichs and Dreschfeld in the 1880s 1. Continue reading >>

Diabetic Hyperglycemic Hyperosmolar Syndrome

Diabetic Hyperglycemic Hyperosmolar Syndrome

Diabetic hyperglycemic hyperosmolar syndrome Diabetic hyperglycemic hyperosmolar syndrome Also known as: HHS, Hyperglycemic hyperosmolar coma, Nonketotic hyperglycemic hyperosmolar coma (NKHHC), Hyperosmolar nonketotic coma (HONK), Hyperglycemic hyperosmolar non-ketotic state or Diabetes - hyperosmolar Diabetic hyperglycemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes . It involves extremely high blood sugar (glucose) level without the presence of ketones. Extremely high blood sugar (glucose) level Decreased alertness or consciousness (in many cases) Buildup of ketones in the body (ketoacidosis) may also occur. But it is unusual and is often mild compared with diabetic ketoacidosis . HHS is more often seen in people with type 2 diabetes who don't have their diabetes under control. It may also occur in those who have not been diagnosed with diabetes. The condition may be brought on by: Other illness, such as heart attack or stroke Medicines that decrease the effect of insulin in the body Medicines or conditions that increase fluid loss Normally, the kidneys try to make up for a high glucose level in the blood by allowing the extra glucose to leave the body in the urine. But this also causes the body to lose water. If you do not drink enough water, or you drink fluids that contain sugar and keep eating foods with carbohydrates, the kidneys may become overwhelmed. When this occurs, they are no longer able to get rid of the extra glucose. As a result, the glucose level in your blood can become very high. The loss of water also makes the blood more concentrated than normal. This is called hyperosmolarity. It is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's Continue reading >>

Hyperosmolar Hyperglycemic State

Hyperosmolar Hyperglycemic State

Hyperosmolar hyperglycemic state (HHS) is a complication of diabetes mellitus in which high blood sugar results in high osmolarity without significant ketoacidosis.[4] Symptoms include signs of dehydration, weakness, legs cramps, trouble seeing, and an altered level of consciousness.[2] Onset is typically over days to weeks.[3] Complications may include seizures, disseminated intravascular coagulopathy, mesenteric artery occlusion, or rhabdomyolysis.[2] The main risk factor is a history of diabetes mellitus type 2.[4] Occasionally it may occur in those without a prior history of diabetes or those with diabetes mellitus type 1.[3][4] Triggers include infections, stroke, trauma, certain medications, and heart attacks.[4] Diagnosis is based on blood tests finding a blood sugar greater than 30 mmol/L (600 mg/dL), osmolarity greater than 320 mOsm/kg, and a pH above 7.3.[2][3] Initial treatment generally consists of intravenous fluids to manage dehydration, intravenous insulin in those with significant ketones, low molecular weight heparin to decrease the risk of blood clotting, and antibiotics among those in whom there is concerns of infection.[3] The goal is a slow decline in blood sugar levels.[3] Potassium replacement is often required as the metabolic problems are corrected.[3] Efforts to prevent diabetic foot ulcers are also important.[3] It typically takes a few days for the person to return to baseline.[3] While the exact frequency of the condition is unknown, it is relatively common.[2][4] Older people are most commonly affected.[4] The risk of death among those affected is about 15%.[4] It was first described in the 1880s.[4] Signs and symptoms[edit] Symptoms of high blood sugar including increased thirst (polydipsia), increased volume of urination (polyurea), and i Continue reading >>

Diabetic Ketoacidosis And Hyperglycaemic Hyperosmolar State

Diabetic Ketoacidosis And Hyperglycaemic Hyperosmolar State

The hallmark of diabetes is a raised plasma glucose resulting from an absolute or relative lack of insulin action. Untreated, this can lead to two distinct yet overlapping life-threatening emergencies. Near-complete lack of insulin will result in diabetic ketoacidosis, which is therefore more characteristic of type 1 diabetes, whereas partial insulin deficiency will suppress hepatic ketogenesis but not hepatic glucose output, resulting in hyperglycaemia and dehydration, and culminating in the hyperglycaemic hyperosmolar state. Hyperglycaemia is characteristic of diabetic ketoacidosis, particularly in the previously undiagnosed, but it is the acidosis and the associated electrolyte disorders that make this a life-threatening condition. Hyperglycaemia is the dominant feature of the hyperglycaemic hyperosmolar state, causing severe polyuria and fluid loss and leading to cellular dehydration. Progression from uncontrolled diabetes to a metabolic emergency may result from unrecognised diabetes, sometimes aggravated by glucose containing drinks, or metabolic stress due to infection or intercurrent illness and associated with increased levels of counter-regulatory hormones. Since diabetic ketoacidosis and the hyperglycaemic hyperosmolar state have a similar underlying pathophysiology the principles of treatment are similar (but not identical), and the conditions may be considered two extremes of a spectrum of disease, with individual patients often showing aspects of both. Pathogenesis of DKA and HHS Insulin is a powerful anabolic hormone which helps nutrients to enter the cells, where these nutrients can be used either as fuel or as building blocks for cell growth and expansion. The complementary action of insulin is to antagonise the breakdown of fuel stores. Thus, the relea Continue reading >>

Hyperosmolar Hyperglycemic State

Hyperosmolar Hyperglycemic State

Author: Dipa Avichal, DO; Chief Editor: George T Griffing, MD more... Hyperosmolar hyperglycemic state (HHS) isone of two serious metabolic derangements that occurs in patients with diabetes mellitus (DM). [ 1 ] It is alife-threatening emergency that, although less common than its counterpart, diabetic ketoacidosis (DKA), has a much higher mortality rate, reaching up to 5-10%. (See Epidemiology.) HHS was previously termed hyperosmolar hyperglycemic nonketotic coma (HHNC); however, the terminology was changed because coma is found in fewer than 20% of patients with HHS. [ 2 ] HHS is most commonly seen in patients with type 2DM who have some concomitant illness that leads to reduced fluid intake, as seen, for example, in elderly institutionalizedpersons with decreased thirst perception andreduced ability to drink water. [ 3 ] Infection is the most common preceding illness, but many other conditions, such as stroke or myocardial infarction, can cause this state. [ 3 ] Once HHS has developed, it may be difficult to identify or differentiate it from the antecedent illness. (See Etiology.) HHS is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis. Most patients present with severe dehydration and focal or global neurologic deficits. [ 2 , 4 , 5 ] The clinical features of HHS and DKA overlap and are observed simultaneously (overlap cases) in up toone thirdof cases. According to the consensus statement published by the American Diabetes Association, diagnostic features of HHS may include the following (see Workup) [ 4 , 6 ] : Plasma glucose level of 600 mg/dL or greater Effective serum osmolality of 320 mOsm/kg or greater Profound dehydration, up to an average of 9L Bicarbonate concentration greater than 15 mEq/L Small ketonuria a Continue reading >>

Hyperosmolar Hyperglycaemic State (hss Or Honk)

Hyperosmolar Hyperglycaemic State (hss Or Honk)

consider need for central line if co-morbid conditions such as congestive cardiac failure acute major illnesses such as myocardial infarction, cerebrovascular accident or pancreatitis drugs that affect carbohydrate metabolism including glucocorticoids, second-generation antipsychotic agents poor compliance with insulin or oral hypoglycaemic regimen newly recognised Type 2 Diabetes Mellitus patients often have severe intravascular depletion due to prolonged periods of hyperglycaemia resulting in fluid loss from osmotic diuresis. usual fluid deficit is around 4-5 litres. a typical rate of replacement (tempered by co-morbidities such as history of congestive cardiac failure , ischaemic heart disease (IHD) ): once the blood glucose 20mmol/L, (aim is to achieve this gradually over the 1st 24 hrs), commence 8 hourly 1L 5% Dextrose in addition to Normal Saline until re-hydration is complete. if BGL < 15mmol/L, cease insulin infusion and contact endocrine unit if BGL 15mmol/L and falling by 4mmol/hr, reduce insulin infusion rate by 1 unit/hr if BGL 15mmol/L and not falling by 2mmol/hr, increase insulin infusion rate by 1 unit/hr if intravenous access is temporarily not possible, subcutaneous quick acting insulin can be given (low doses eg 4-6 units, and observe response over next 2 to 4 hours) when the patient is recovering and eating normally, they should be stepped down to a basal bolus or premixed insulin regimen. Ultimately many patients will return to their usual medications if appropriate or initiated on oral hypoglycemic agents if newly diagnosed Type 2 Diabetes. do not try to normalise blood glucose quickly as this can lead to cerebral disequilibrium and worsening of confusion these patients are at high risk of developing hypokalaemia during Rx while on an insulin infu Continue reading >>

Hyperosmolar Hyperglycaemic State

Hyperosmolar Hyperglycaemic State

Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Type 2 Diabetes article more useful, or one of our other health articles. Synonyms: hyperosmolar hyperglycaemic nonketotic coma (HONK), diabetic nonketotic coma, hyperosmolar nonketotic state, hyperosmolar nonketotic hyperglycaemia (HNKH) See also separate articles Coma, Diabetes and Intercurrent Illness, Management of Type 2 Diabetes Mellitus, Diabetic Ketoacidosis and Childhood Ketoacidosis. Hyperosmolar hyperglycaemic state (HHS) occurs in people with type 2 diabetes. Very high blood glucose levels (often over 40 mmol/L) develop as a result of a combination of illness, dehydration and an inability to take normal diabetes medication due to the effect of illness. HHS is characterised by severe hyperglycaemia with marked serum hyperosmolarity, without evidence of significant ketosis. HHS is a potentially life-threatening emergency. Hyperglycaemia causes an osmotic diuresis with hyperosmolarity leading to an osmotic shift of water into the intravascular compartment, resulting in severe intracellular dehydration. Ketosis does not occur due to the presence of basal insulin secretion sufficient to prevent ketogenesis but insufficient to reduce blood glucose. A mixed picture of HHS and diabetic ketoacidosis (DKA) may occur. There is no precise definition of HHS but there are characteristic features that differentiate it from other hyperglycaemic states such as DKA. These are:[1] Hypovolaemia. Marked hyperglycaemia (30 mmol/L or more) without significant hyperketonaemia (<3 mmol/L) or acidosis (pH>7.3, bicarbonate >15 mmol/L). Osmolality usually 320 mosmol/kg or more. Causative conditions Continue reading >>

Diabetes India - Hyperglycemic Honk

Diabetes India - Hyperglycemic Honk

HONK is a slowly progressive disease and it is not uncommon to have 3-10 day history of increasing thirst, polyuria, and malaise. Patients usually have evidence of dehydration such as dry mucus membranes, tachycardia, poor skin turgor, and sometimes a low grade fever. The blood pressure is usually well preserved unless there is severe dehydration or infection. Respiratory symptoms are usually absent unless the patient has pneumonia. Central nervous system dysfunction is relatively common in patients with HONK. Lethargy and disorientation are common, but frank coma is rare. It is critical to remember that these CNS symptoms rarely present unless the effective osmolarity is greater than 340-350 mOsm/L. Patients with altered sensorium and osmolarity less than this should have a different etiology searched for. Any area within the brain can be affected, and while focal neurologic findings are uncommon in DKA, they are fairly common in patients with HONK. Seizures may be present in up to one-fourth of patients and can be focal or generalized. Cerebral edema is very rare in patients with HONK. In general, HONK is defined as those individuals with: serum glucose levels in excess of 600 mg/dl, serum osmolality greater than 330 mOsm/kg, absent or minimal serum ketones, arterial pH above 7.3, and a serum bicarbonate above 20 mEq/L. HONK is characterized by severe fluid and electrolyte depletion due to the osmotic diuresis produced by the extreme levels of glucose in the serum. Serum potassium levels can be normal, high, or low, but as was true in DKA the total body amount of potassium is significantly depleted. Elevations in white blood cell count are not uncommon in patients with HONK. Leukocytosis can result simply from the stress of HONK and not necessarily from infection. Ho Continue reading >>

Diabetic Hyperglycemic Hyperosmolar Syndrome

Diabetic Hyperglycemic Hyperosmolar Syndrome

HHS is a condition of: Extremely high blood sugar (glucose) level Decreased alertness or consciousness (in many cases) Buildup of ketones in the body (ketoacidosis) may also occur. But it is unusual and is often mild compared with diabetic ketoacidosis. HHS is more often seen in people with type 2 diabetes who don't have their diabetes under control. It may also occur in those who have not been diagnosed with diabetes. The condition may be brought on by: Infection Other illness, such as heart attack or stroke Medicines that decrease the effect of insulin in the body Medicines or conditions that increase fluid loss Normally, the kidneys try to make up for a high glucose level in the blood by allowing the extra glucose to leave the body in the urine. But this also causes the body to lose water. If you do not drink enough water, or you drink fluids that contain sugar and keep eating foods with carbohydrates, the kidneys may become overwhelmed. When this occurs, they are no longer able to get rid of the extra glucose. As a result, the glucose level in your blood can become very high. The loss of water also makes the blood more concentrated than normal. This is called hyperosmolarity. It is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's other organs, including the brain. Risk factors include: Impaired thirst Limited access to water (especially in people with dementia or who are bedbound) Older age Poor kidney function Poor management of diabetes, not following the treatment plan as directed Stopping insulin or other medicines that lower glucose level Continue reading >>

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