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3% hypertonic saline
15%
11/72
Regular insulin
17%
12/72
Lactated ringer's solution
43%
31/72
Glargine insulin
0%
0/72
Regular insulin and potassium
25%
18/72
Select Answer to see Preferred Response
This patient has evidence of insulin-dependent type 2 diabetes mellitus, now presenting with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) that has resulted in hypovolemic shock. Aggressive volume repletion is the best initial step in management. The two main causes of severe hyperglycemia and altered mental status in diabetics are diabetic ketoacidosis and HHNS. Both conditions can be triggered by infection, insulin noncompliance, and/or trauma. HHNS is more likely in type 2 diabetes mellitus patients who present with altered mental status, serum glucose > 600 mg/dL in the absence of ketonuria and with normal bicarbonate. Patients with HHNS are severely dehydrated and hypovolemic due to glucose-induced osmotic diuresis. Hemodynamically stable patients are treated with isotonic crystalloid, potassium, and insulin, which can be initiated concurrently in many patients. However, if a patient is hemodynamically unstable (like this patient) due to hypovolemia, volume replacement is a priority and should be initiated first. Similarly, patients with a serum potassium level of <3.3 mEq/L should receive potassium repletion to above this level before administration of insulin as insulin will worsen the hypokalemia and could precipitate arrhythmia. Incorrect Answers: Answer 1: Hypertonic saline is not necessary. This patient has pseudohyponatremia secondary to hyperglycemia with a corrected serum sodium level of 145 mEq/L. Answer 2: Regular insulin is needed but needs to be administered with potassium because potassium shifts intracellularly due to insulin itself, decreasing serum potassium levels. Answer 4: Glargine is a long-acting insulin with a half-life of at least 18 hours, making it of low utility in acute management of HHNS. Answer 5: Before initiating insulin and potassium therapy, this hemodynamically unstable patient must be resuscitated with fluids. Bullet Summary: Patients who present with hyperosmolar hyperglycemic nonketotic syndrome with associated hypovolemic shock need aggressive fluid resuscitation prior to starting insulin and potassium therapy.
4.9
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