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A Diabetic Patient with HHNK Presenting for An Emergent Surgery

A Diabetic Patient with HHNK Presenting for An Emergent Surgery. Presented by R1 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 treatment

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A Diabetic Patient with HHNK Presenting for An Emergent Surgery

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  1. A Diabetic Patient with HHNK Presenting for An Emergent Surgery Presented by R1胡念之

  2. 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 treatment 4. Old CVA, basilar artery territory (hemianopia) in this Jan and Feb 5. R’t intertrochanter fx s/p op this Feb

  3. Present Illness • Fell down on his right hip  CHS for right intertrochanter fracture on Feb. 26th • Smooth post-op course. Discharged on Mar. 8th • OPD f/u on Mar. 16th: “doing well” • Agitation noted since Mar. 16th. • Sent to our ER on Mar. 17th due to consciousness change

  4. 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/L • ABG: PH: 7.38/ PaO2: 80.6/ CO2: 24.5/ HCO3: 19.8 • U/A: ketone (-) • Leukocytosis, shift to left • Na+: 143, K+: 4.9, Cl-: 107 • Anion gap: 16

  5. At ER • PE: a sacral bedsore and right hip redness • Tentative diagnosis: • HHNK • Previous op wound infection, R/O necrotizing fasciitis • Plastic surgeon and infection man were both consulted.

  6. 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 IVstat, then 5 U/hr • Empirical antibiotics

  7. 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

  8. 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

  9. The Time Course in 4FI • Fluid supplement & RI infusion • 3/18 7AM: SBP down to 60~70 mmHg / HR: 120 bpm / CVP: 5 cmH2O / decreased U/O • Septic shock with dehydration was suspected • Fluid challenge • Dopamine & Levophed • BP was kept around 140/70 mmHg

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

  11. The Time Table in 4C1 • 3/19: GCS: E1M1V t Pupil dilated, no light reflex • Head CT: Recent multiple posterior circulation infarcts. Some old lacunar infarcts. • 3/20: DNR permission • 3/20 12:30AM: DC all treatment including insulin, ATx, ventilator, lab, and IVF…. • 3/23 PM: expired

  12. 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

  13. 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)

  14. D.D. of DKA and HHNK

  15. Treatment of HHNK • Administration of insulin *loading dose 15~20 U followed by continuous infusion around 7 U/hr *the correction rate of sugar should not > 75 mg/dL *standard insulin therapy begun when plasma glucose < 250 mg/dL, and RI infusion is discontinued

  16. *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

  17. Correction of fluid deficit *Average fluid lost is up to 8~10 L (glucose osmotic diuresis) *generally begun with isotonic saline (> 1L/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

  18. Correction of electrolyte abnormalities *hypokalemia may begin after insulin and fluid supplement, 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

  19. 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

  20. 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 disease Clin Chest Med 24 (2003) 583– 606

  21. Hyperglycemia → dehydration & hyperosmolarity→ increasing possibility of intravascular thromboses and altered cerebral water balance→ increase the risk of ischemic stroke • Previously poor cerebral vascular circulation

  22. Intra-op Sugar Control

  23. 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 minimize the risk for ketosis and acidosis during fasting and the stress of surgery

  24. 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 surgery *post-op diabetic care

  25. Thanks For Your Attention ~Have A nice Day~

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