HYPEROSMOLAR HYPERGLYCEMIC
STATE
Ach Najich RF, dr.
Terminologi
• KHONK ( KOMA HIPEROSMOLAR NON
KETOTIK)
• HHNK (HIPERGLIKEMI HIPEROSMOLAR
NONKETOTIK KOMA)
• Terminologi diatas pada saat ini telah berubah
karena koma hanya ditemukan <20% kasus
HHS
Epidemiologi
• Hyperosmolar hyperglycemic state (HHS) is 1 of
2 serious metabolic derangements that occurs
in patients with diabetes mellitus (DM) and can
be a life-threatening emergency . 1
• Secara Keseluruhan Insiden HHS 1 kasus/1000
penduduk dalam 1 tahun. (USA 1989-1991). 2
• Rata-rata pasien HHS terdiagnosa pada
beberapa laporan kasus berusia 57-69 tahun. 2
Etiologi
• DM TIPE 2
• Fluid Intake
• Major Ilness
• Stress Response
• Abused/ Neglected in older Patient
Insulin Deficiency
Hyperglycemia
Hyper-
osmolality
Glycosuria
Δ MS
Dehydration
Electrolyte
Renal Failure Losses
Shock CV
Collapse 5
Hyperosmolar Hyperglycemic State:
Pathophysiology
Unchecked gluconeogenesis Hyperglycemia
Osmotic diuresis Dehydration
• Presents commonly with renal failure
• Insufficient insulin for prevention of hyperglycemia but
sufficient insulin for suppression of lipolysis and
ketogenesis
• Absence of significant acidosis
• Often identifiable precipitating event (infection, MI)
6
Clinical Presentation
• Compared to DKA, in HHS there is greater
severity of:
– Dehydration
– Hyperglycemia
– Hypernatremia
– Hyperosmolality
• Because some insulin typically persists in HHS,
ketogenesis is absent to minimal and is
insufficient to produce significant acidosis
Clinical Presentation of
Hyperglycemic Hyperosmolar State
Patient Profile Disease Characteristics
• Older • More insidious development
• More comorbidities than DKA (weeks vs
• History of type 2 diabetes, hours/days)
which may have been • Greater osmolality and mental
unrecognized status changes than DKA
• Dehydration presenting with a
shock-like state
8
Diagnosis
• 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
• Serum pH greater than 7.30
• Bicarbonate concentration greater than 15
mEq/L
• Small ketonuria and absent-to-low ketonemia
• Some alteration in consciousness
Differential Diagnosis
• KAD ( Ketoasidosis Diabetes)
Treatment
Fase I 1. Rehidrasi: Nacl 0,9% / RL 2 liter/ 2
jam, 80 tts/mt 4 jam, 30 tts/mt 18
jam, 20 tts/mt 24 jam.
2. IDRIV: minus satu
3. K: 25 meq (3-35) dst
4. Bikarbonat:
pH≤7,2-7,3 50-100 meq drip dlm 2 j BIK
<12 20 tts/mt
pH < 7 25 meq bolus sisanya 20 ttsx/mt
5. Antibiotik
Glukosa +/- 250 mg/dl atau reduksi ±
Fase II 1. Maintenance: Nacl 0,9% Potacol R ( RI
4U - 8U ) , Maltosa 10% (RI6-12U)
bergantian 20 tts/mt (start slow, go slow,
stop slow)
2. K < 4 parenteral, per os dg air tomat/
kaldu
3. RI: rumus kali dua
4. Makanan lunak:KH kom pleks per-os
Fase I 1. Rehidrasi: Kadar
Na < 150 meq :
Nacl 0,9% ; Na >
150 meq pakai
Nacl 0,45%;
Rumus sama: 2
liter/ 2 jam, 80
tts/mt 4 jam, 30
tts/mt 18 jam,
20 tts/mt 24
jam.
2. IDRIV: minus satu
3. K: 25 meq (3-35) dst
4. Antibiotik
Glukosa +/- 250 mg/dl atau reduksi ±
Fase II 1. Maintenance: Nacl
0,9% Potacol R ( RI 4U -
8U ) , Maltosa 10% (RI6-
12U) bergantian 20
tts/mt (start slow, go
slow, stop slow)
2. K < 4 parenteral, per
os dg air tomat/ kaldu
3. RI: rumus kali dua
4. Makanan lunak:KH
kom pleks per-os
Refference
• 1. Pasquel FJ, Umpierrez GE. Hyperosmolar
hyperglycemic state: a historic review of the
clinical presentation, diagnosis, and treatment.
Diabetes Care. 2014 Nov. 37 (11):3124-31.
[Medline]
• 2. Nugent BW. Hyperosmolar hyperglycemic
state. Emerg Med Clin North Am. 2005 Aug.
23(3):629-48,
