A Diabetic Patient with HHNK Presenting for An Emergent Surgery

Presented byR1 胡念之

Patient Profile• Age: 67 y/o• Sex: Male• Past history: 1. Type II DM, poor controlled for many years 2. Hypertension, poor controlled 3. HIV carrier diagnosed in 1996, but refused trea

tment 4. Old CVA, basilar artery territory (hemianopia) i

n this Jan and Feb 5. R’t intertrochanter fx s/p op this Feb

Present Illness• Fell down on his right hip CHS for right

intertrochanter fracture on Feb. 26th • Smooth post-op course. Discharged on M

ar. 8th • OPD f/u on Mar. 16th : “doing well” • Agitation noted since Mar. 16th.• Sent to our ER on Mar. 17th due to consci

ousness change

At ER (3/17 10:08 AM)• Initial vital signs: BT: 38.6; BP: 166/124; HR:

118; RR: 22• GCS: E4M6V3 • Lab:

Sugar: 656 Estimated osmolarity: 330 mOsm/LABG: PH: 7.38/ PaO2: 80.6/ CO2: 24.5/ HCO3: 19.8U/A: ketone (-) Leukocytosis, shift to leftNa+: 143, K+: 4.9, Cl-: 107Anion gap: 16

At ER

• PE: a sacral bedsore and right hip redness• Tentative diagnosis:

1. HHNK 2. Previous op wound infection, R/O

necrotizing fasciitis• Plastic surgeon and infection man were b

oth consulted.

Management in ER

• On central venous catheter: 3 cm H2O

• IVF supplement: H/S 2L stat, then 2L QD (less than 4L)

• Insulin: RI 8 U IV stat, then 5 U/hr• Empirical antibiotics

Pre-op Data

• Sugar: 205 mg/dL (one touch)• Na: 143; K: 4.9• BUN: 62.3; Cre: 2.0• Estimated osmolarity: 320 mOso/L• Hb: 11.4• GCS: E2M4V1

Post-op Data in 4FI

1:15 AM on 3/18• BP: 209/66; HR: 119; BT: 36.5• GCS: E1M3~4Vt• Na: 150; K: 4.2• One touch sugar: 254; Osmo: 303

The Time Course in 4FI

• Fluid supplement & RI infusion• 3/18 7AM: SBP down to 60~70 mmHg / HR: 1

20 bpm / CVP: 5 cmH2O / decreased U/O• Septic shock with dehydration was suspect

ed• Fluid challenge• Dopamine & Levophed• BP was kept around 140/70 mmHg

Transferred to 4C1 on 3/18 1PM

• 3/18 1 PM: Rightward deviation of the head and the eyes GCS: E1M2~3Vt Pupil size: 2.5/2.0 Light reflex: +/+• 3/18 3 PM: Head CT -- Decreased density at cere

bellum (more on left side), right occipital lobe and part of brain stem, ischemic change over posterior circulation is compatible.

The Time Table in 4C1• 3/19: GCS: E1M1V t Pupil dilated, no light reflex• Head CT: Recent multiple posterior circul

ation infarcts. Some old lacunar infarcts.• 3/20: DNR permission• 3/20 12:30AM: DC all treatment including i

nsulin, ATx, ventilator, lab, and IVF….• 3/23 PM: expired

Discussion Topics

• What is the peri-op management for a patient with HHNK requiring an emergent operation?

• What is the possible reason of the ischemic stroke?

• Perioperative evaluation and management of the patient with diabetes

Definition of HHNK

• Severe dehydration (hyperosmolarity, >320 mOsm/L) and hyperglycemia (>600 mg/dL) in patients who have enough endogenous insulin to prevent ketosis (Type II DM)

• Usually precipitated by a physiological stress (e.g, infection, trauma)

D.D. of DKA and HHNK

Treatment of HHNK

• Administration of insulin *loading dose 15~20 U followed by con

tinuous infusion around 7 U/hr *the correction rate of sugar should no

t > 75 mg/dL *standard insulin therapy begun when

plasma glucose < 250 mg/dL, and RI infusion is discontinued

*subcutaneous insulin is generally not advised for intra-op glucose control -- potentially erratic absorption secondary to altered regional blood flow, tissue edema, or fluid shifts during surgery

• Correction of fluid deficit *Average fluid lost is up to 8~10 L (glucos

e osmotic diuresis) *generally begun with isotonic saline (> 1

L/hr), and switched to half saline at some points to correct free water deficit

*I L of saline within the first 30 to 60 minutes, followed by a continuous infusion of 250 to 500 mL/hour

• Correction of electrolyte abnormalities *hypokalemia may begin after insulin and fluid suppleme

nt, add KCl (20~40 mEq/L)to IVF (H/S) once the serum K falls below 4.5 mEq/L

*After therapy for has been initiated, serum potassium levels often decrease precipitously, due to:

# insulin-mediated intracellular shift of K # IV saline therapy dilutes circulating potassium # stimulates urinary K excretion *hypernatremia may begin after insulin therapy due to the

lower osmolarity

The Peri-op Complication of The Diabetes• Infection• Metabolic disorders, e.g hypoglycemia• Electrolyte imbalance• Renal failure • Cardiovascular complications

Med Clin N Am 87 (2003) 175–192

The Effect of Hyperglycemia on The Patient

• Osmotic diuresis: reduces vascular volume and results in decreased cardiac output and impaired tissue perfusion

• Several immune system abnormalities: impaired leukocyte chemotaxis, impaired phagocytosis, and decreased immunoglobulin function and complement fixation

• Increased prevalence of cardiovascular diseaseClin Chest Med 24 (2003) 583– 606

• Hyperglycemia → dehydration & hyperosmolarity → increasing possibility of intravascular thromboses and altered cerebral water balance → increase the risk of ischemic stroke

• Previously poor cerebral vascular circulation

Intra-op Sugar Control

Intra-op IV fluid

• The IV fluids during surgery should be D5W/0.45NS at 100cc/hr

• prevent hypoglycemia• provide a source of carbohydrate to mini

mize the risk for ketosis and acidosis during fasting and the stress of surgery

Take Home Message

• DM p’t who undergo surgery have an increased risk of developing perioperative complications

• Steps to achieve a safe and effective outcome includes:

*decide the op timing *the pre-op evaluation *a plan for managing diabetes during surge

ry *post-op diabetic care

Thanks For Your Attention

~Have A nice Day~