Hyperglycemic Hyperosmolar Nonketotic State
last authored: Susan Tyler, Dal medical student, March 2009
last reviewed:
Introduction
Hyperglycemic Hyperosmolar Nonketotic State (HONK) is a clinical picture occurring in Type II diabetes, characterized by hyperglycemia, hyperosmolarity (> 350 mOsm/L), and marked dehydration WITHOUT ketosis.
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
HONK is often precipitated by the same 6 I’s as diabetic ketoacidosis:
- infection (pneumonia, UTI)
- ischemia/infarct (myocardial, cerebral, gut)
- missed insulin
- inflammation (pancreatitis, cholecystitis)
- iatrogenic (glucocorticoids, diuretics, immunosuppressants)
- intoxication (ETOH, drugs), as well CHF, renal failure, trauma
Pathophysiology
In situations of partial/relative insulin deficiency, decreased use of of glucose in fat, muscle, liver leads to increased glucagon secretion. This, in turn, leads to increased hepatic glucose production via gluconeogenesis. However, unlike diabetic ketoacidosis, the small amount of insulin still present precludes ketotic development via inhibition of lipolysis.
Volume contraction leads to renal insufficiency. Hyperglycemia and increased osmolality leads to fluid shift from neurons to ECF, and changes in mental status can occur.
Signs and Symptoms
- history
- physical exam
History
HONK has an insidious onset. Gradually worsening symptoms include polyuria, polydipsia, weakness, and nausea and vomiting.
reduced fluid intake and ingesting large amounts of glucose containing fluids (OJ!)
Physical Exam
dehydration c/ orthostasis
Reduced LOC
No Kussmaul’s respiration (unless there is a concomitant underlying metabolic acidosis)
Changes to mental status include confusion, delerium, obtundation, coma, or seizures.
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Blood tests
- blood glucose is very high, with readings of 44-100 mM possible
- TRUE hypernatremia
- NO ketosis
- increased osmolality
Arterial blood gas
- no metabolic acidosis for HONK
- pH and bicarb usually normal
Urine
- glycosuria
- negative for ketones unless there is marked starvation
Diagnostic Imaging
Differential Diagnosis
Treatments
Manage the patient's ABCs, especially if they are in a stupor or coma.
Carefully monitor HR, BP, urine output, JVP.
Rehydration
Use caution, as aggressive rehydration can lead to overhydration and even cerebral edema in pediatric patients!
1L/h NS first 2 hrs, then 300-500 ml/h 0.45% NS, once BG reaches 13.9 mM switch to D5W and keep BG in 13.9 to 16.6 mM range.
Electrolytes
Sodium: If sodium is high or normal, switch NS to ½ NS, if low Na, maintain infusion with NS
Potassium: If K < 3.5, hold insulin and give 40 mEq K replacement. If [3.3-5.4] range, give KCl 20-30 mEq/L in IVF
Bicarbonate: if ph < 7.0, low BP, arrhythmia, coma give bicarb in half NS
Insulin therapy
A lower insulin level is requirement than DKA.
- Insulin R with loading bolus of 0.15 U/kg body weight
- Maintenance 0.1 U/kg/h insulin R
Check blood glucose hourly.
Consequences and Course
Overall, mortality can approach 10-50%, as HONK occurs primarily in older and frailer patients.
Resources and References
Topic Development
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