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36. Неотложная помощь при гиперосмолярной коме у больных сахарным диабетом.

  1. Supportive measures
    • Patient must be managed in a monitored area
    • Supply high-flow oxygen
    • Monitoring:
    • ECG
    • Pulse oximetry
    • Vital signs q 15-30min
    • Blood levels of glucose and potassium q1-2 h


  • Circulatory supports:


  • The average fluid deficit in HHNK is 6-10 L
  •  One half of the estimated water deficit will need to be replaced        during the first 12hours


  • Labs : FBC, urea, electrolytes, creatinine, calcium, magnesium, phosphate, serum osmolality, ABGs, urinalysis


  • ECG, CXR to look for a cause of the HHNK state


  • Urinary catheter to monitor urine output



  1. Specific measures


  1. IV volume replacement
  • if the patient shows significant tissue hypoperfusion, use normal saline as a rapid bolus till perfusion improves and BP stabilizes.
  • 1st hour : 1.5L
  • 2nd hour: 1L
  • 3rd hour : 0.5 L
  • If the patient is hypertensive or has significant hypernatraemia >155mmol/l, use 0.45% NS and change to IV D5W ( 5% Dextrose water ) when the serum glucose level reaches16mmol/L



  1. Potassium replacement
  • Total body potassium depletion in HHNK states is usually greater than that in DKA.
  • Establish that there is urine output first, then replace as follows
  1. serum K+ < 3.3 mmol/L : give 20-40 mEq KCL in the first hour
  2. serum K+ 3.3-4.9 mmol/L : give 10-20 mEq K+ per litre of IV fluid                         ( can be given as 2/3 KCL and 1/3 KHPO4 ; phosphate replacement is indicated when serum phosphate less then 0.3% mmol/L)
  3. serum K+> 5.0 mmol/L, withhold K+ but check serum potassium every 1-2 hours.


            C. Insulin administration

  • bolus not needed since these patients can be exquisitely sensitive to insulin.
  • Administer an infusion of regular insulin at 0.1 units/kg body weight / hour
  • Adjust insulin infusion to keep blood glucose at 14-16mmol/L
  • PS: Russian approach IV bolus 10 units followed by 10units with 100ml saline.

31.05.2014; 23:30
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