- 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
- Specific measures
- 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
- ДАЛЕЕ ПО 300МЛ В ЧАС
- 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
- 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
- serum K+ < 3.3 mmol/L : give 20-40 mEq KCL in the first hour
- 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)
- 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.
