Therapeutic Handbook - GGC Prescribing

Management of HyperglycaemicHyperosmolar State / HyperosmolarNon-Ketotic Coma (HONC)This condition carries a significant mortality and close monitoring within a well staffed clinical area isessential. The following regimen is a guide only; because of the co-morbidities associated with thiscondition each case must be treated on an individual basis.IntroductionDiagnostic criteria include:• Severe hyperglycaemia (blood glucose > 30 mmol/L)• Total osmolality > 340 mosmol/kg• Serum bicarbonate > 15 mmol/L (not acidotic)• Urinary ketones < + plusClinical features include:• Insidious onset• Severe dehydration• Impaired level of consciousness (degree correlates with plasma osmolality).• May have concurrent illness e.g. MI, stroke or pneumonia.This condition occurs in patients with type 2 diabetes mellitus (which may or may not have beenpreviously diagnosed). There is marked hyperglycaemia and dehydration without significant ketosisand acidosis. The condition usually develops over a period of days, often made worse by diureticsand consumption of glucose rich drinks.The aim should be for a gradual restoration of blood biochemistry avoiding a rapid reduction inplasma osmolality (which can precipitate cerebral oedema). These patients commonly have coexistingmedical problems and mortality is much higher than for DKA. There is also a significant risk ofthromboembolism and thromboprophylaxis should always be used in the absence of contraindication.Key steps in the management of HHS / HONC• Establish correct diagnosis• Monitor closely in a well staffed clinical area• Aim to reduce blood glucose gradually• Appropriate fluid resuscitation must be guided by clinical assessment, hydration status andco-morbidity.• Regular monitoring of potassium level must guide appropriate replacement• Consider and treat the underlying cause.Endocrine SystemContinues on next pagePage 279