PRE S E NT E D BY J UL I A MUS ACCHI A

Hyperosmolar Hyperglycemic State, new on set

Diabetes Mellitus & Complications
Seen in an Intellectual Disabled Patient

Hyperosmolar Hyperglycemic State
Hyperosmolar Hyperglycemic State
(HHS) is a potently deadly acute
metabolic complication of Diabetes
Mellitus.

HHS and DKA are both
hyperglycemic crises
seen in patients with
diabetes, however they
differ in the severity of
dehydration, ketosis and
metabolic acidosis
It is often seen in Type 2 Diabetes
Mellitus (T2DM), however it can
be seen in Type 1 Diabetes
Mellitus (T1DM) patients in
conjunction with Diabetic
Ketoacidosis (DKA).
Progression of Hyperglycemic Crises
Decreased
insulin
emission
Increased
gluconeogenesis
and enhanced
glycogenolysis &
reduced glucose
uptake by the
peripheral tissues

An alternate
physiological
mechanism must
occur in order for
the cells to receive
an energy source
Progression of Hyperglycemic Crises

Lipolysis, or
breaking down of
adipose tissue
occurs
Ketone bodies are
produced from the
fatty acids to be
used for energy
Patients that present with HHS, do not
usually have ketone production due to
insulin is still being produced which
prevents lipolysis from happening

Progression of Hyperosmolarity
Hyperosmolarity
Dehydration (decreased fluid intake)
Loss of water and electrolytes
Glycosuria (osmotic diuresis)
Hyperglycemia
Glucose Utilization Gluconeogenesis Glycogenolysis
Symptoms and Preliminary Labs
Polyuria
Polydipsia
Weight loss
Blurred vision
Vomiting
Weakness
Abdominal pain
Change in Mental Status
Plasma glucose
BUN/Creatinine
Electrolytes (with calculated
anion gap)
Serum ketone
Serum -Hydroxybutyrate (if
available)
Calcium
Phosphorus
Arterial blood gases
CBC Count
Urinalysis
Effect serum osmolality* must
be calculated if not ordered via
lab


Treatment
Rehydrate- 0.9% NaCl @ 1-1.5 L in first hour, if there is no
risk of a cardiac event; 0.45% NaCl @ 200-500mL/hr

Restore and Preserve Normal Glucose- Continuous IV
insulin- 0.1 units/kg per hour when blood glucose levels
reach 300mg/dL, the insulin infusion rate may decrease
to 0.01-0.05 units/kg per hour. Once plasma glucose
levels reach 200mg/dL Dextrose 5% can be added to
replacement fluid
Treatment
Correct electrolyte deficits- When Potassium levels fall
below 5.0 to 5.2 mEq/L, the upper end of normal, to
prevent hypokalemia, Potassium is given intravenous at a
concentration of 20 to 30 mEq/L.
With hypokalemia, insulin treatment should be delayed
until the serum potassium level is great than 3.3 mEq/L to
avoid life-threatening conditions,
Avoid Complications- Hypokalemia & Hypoglycemia with
excessive insulin therapy. Monitor patients blood glucose
every 1-2 hours to identify hypoglycemia & monitor
potassium levels
Medical Nutrition Therapy & HHS
Once the hyperglycemic crisis has been resolved, the
patient will need insulin therapy
Patients who, were previously on insulin therapy, can
resume their normal regimen
For patients with newly diagnosed diabetes, the basal-
bolus regimen should be started at 0.5 to 0.8 units/kg per
day
MNT Therapies- How to avoid future incidents, blood
glucose monitoring, provide diabetes teaching to prevent
recurrence with carbohydrate controlled diet, calorie
controlled if patient is overweight
Patient Background Information
P.A., 56 year old male, of Haitian descent
Lives with his sister, who is his healthcare proxy & caregiver
Has been intellectually disabled and non verbal since birth
Able to ambulate on his own, does need supervision at all
times to assist with his activities of daily living
Has not received a blood work up in a number of years,
secondary to becoming agitated, upset when health care
professionals attempt to draw blood
No known previous hospitalizations, patient does have a
history of lipid abnormalities, renal failure, seizures and
hypertension
Diagnosis of HHS
One week prior to admission patients sister reported
patient having flu like symptoms of nausea & vomiting
One day prior to admission, sister noticed P.A. was
weak/tired & not acting like his usual self
On 10/28/13, P.A. was admitted to Franklin Hospitals
Emergency room in a lethargic state with a glucose level
of 1808mg/dL & was retested to show 1806 mg/dL, P.A.
given insulin & began insulin infusion in the ER before
being admitted to the CCU with alternated mental status,
sepsis and hyperglycemia
Diagnosis Criteria
Effective Serum Osmolality=2[measured Na+(mEq/L)]+[glucose (mg/dL/18]
P.A. Eff. Serum Osmolality = 2 [ 134 mmol/L) + [1806 mg/dL/ 18] = 368.3 mOsm/kg
*Conversion factor of mEq/L to mmol/L of Na+ is 1
CriteriaforHHSDx ValuesforHHSDx ValuesseeninP.A.
PlasmaGlucose >600mg/dL 1806mg/dL
ArterialpH >7.30 7.28
SerumHC03(mEq/L) >18 14
UrineKetone Small negative
SerumKetone Small N/A
EffectSerumOsmolality >320mOsm/kg 368.3mOsm/kg
AnionGap Variable WNL
MentalStatus Stupor/coma Lethargic/Stupor
New on Set Diabetes
P.As HgbA1c= 9.3 % and C-peptide= 0.3
HgbA1c reflects at least 3 months of uncontrolled blood
glucose, and C-peptide reflects a decrease insulin output
by the pancreas
P.A. diagnosed with new on set diabetes, likely requiring
insulin therapy to help treat his diabetes

Complications
P.A. has a history of renal failure and a prolonged
hyperglycemic state may have further progressed his
renal function decline
Hyperglycemia leads to the formation of cytokines &
growth factors which can lead to structural change in the
kidneys, which ultimately can lead to functional changes
as well
Four days after admission (10/31/2013), P.As
BUN/Creatinine= 68/7.44, based on the MDRD
calculation his GFR= 9 mL/min/1.73m
2
, indicative of
ESRD, P.A. was placed on hemodialysis
Medication Contraindication
Four days after admission, P.A. presented with acute
pancreatitis, Amylase=176, Lipase=1171, while PA was
NPO
It is undetermined the root origin of P.As pancreatitis, a
contraindication with propofol infusion while P.A was
placed on a mechanical ventilator could have
exacerbated his pancreatitis
The reasoning behind this is that propofol is administered
as a fat emulsion and it has a fat content very similar to
10% fat emulsion in a total parenteral nutrition solution
Admission 10/28/13
Ht= 52, Wt= 177#, BMI= 32.4 (obese), IBW=118 10%,
UBW= Unknown by sister, couldnt recall the last time P.A. has
had his weight checked
10/28/13- Nothing by mouth (NPO), P.A sister stated that he
didnt follow any special diets at home & had a good appetite.
No problems chewing or swallowing
Lantus 20u X 1 daily
D5% NS 0.45% @ 150mL/hr
Insulin infusion @ 7u/hr
Glucose= 1806 mg/dL, F.S= 522, 558, Urine Glucose=
1000mg/dL , BUN/Crea= 71/3.15, Effective Serum osmolality=
368.3 mOsm/kg

Five days after admission- 11/1/13

P.A. placed on a mechanical ventilator due to acute respiratory failure
(10/31/13)
Wt= 194.8# (10/31/13), P.A has gained 17.8#, 10% weight gain since
admission, noted generalized +2 edema
Nasogastric tube feeding, Glucerna 1.2 @ 55mL/ hr (1584 kcal, 79 g of
protein, 110% to meet DV) , Questionable with renal failure and on HD
Lantus 20u X 1 daily
D5% NS 0.45% @ 150mL/hr
Insulin infusion @ 7u/hr
IV Antibiotics to treat sepsis
Propofol infusion (10/31/13)
10/31/13- BUN/Crea= 68/7.44, started dialysis treatment every other
day until 11/8/13. Glucose= 279 mg/dL, F.S= 305, 222, 292- continue
insulin infusion, rate decreased, Effective Serum Osmolality= 286
mOsm/kg

8 days after admission 11/5/13

Wt= 200.6, P.A. has gained 23.6#, 13% wt. gain since
admission, Generalized +2 edema (11/5), Generalized +3
edema (11/4), Generalized +4 edema (11/3) noted. P.A
also receiving making IVF, IV Antibiotics at this time
P.A remained on NGT Glucerna 1.2 @ 55mL/hr, tolerating
TF well no residuals
BUN/Crea= 33/3.88, s/p 3 HD treatments. Glucose=
203mg/dL, F.S= 199, 220, 310, discontinue insulin
infusion, P.A. receiving Lantus 15 u X 2 daily and Humalog
corrective regimen PRN

Two weeks after admission-11/11/13
Wt= 184.7#, P.A has lost 16#,8 % wt. loss X 6 days due to
edema reduction from +5 to +2
Swallow evaluation conducted, recommended ground
consistency, diet advanced to consistent carbohydrate
with no snack, low sodium and 60 gram protein diet (Pt.
not receiving HD at this time)
BUN/Crea= 63/ 6.82 (11/9- BUN/Crea= 40/4.53). F.S= 389,
275, 102, 130 , F.S. began going below 100 on 11/12/13,
Lantus dose changed to Lantus 12u X 1 daily

Non-Verbal Communication and Dietary Intake
11/13/13- Nurse and Physician's Assistant reported P.A.
coughing while eating, another swallow evaluation ordered.
Observed P.A tolerating regular consistency food, speech
language pathologist (SLP)to keep P.A. at a ground
consistency, P.A. did resist SLP on attempts to feed him
11/15/13- Poor Po intake, P.A consuming about < 50% of his
meals, Pt. has wrist restraints in place, CNA or family member
has to feed pt. Suplena with Carb Steady TID ( 425kcal, 10.6 g
protein)
Non- Verbal Communication with food preferences and lack of
ability to eat food on his own may have been demonstrated by
P.A.

Hemodialysis
Treatment dates- 10/31, 11/2, 11/4, 11/6, 11/8
3.5 hours
Dialysate (mL/minute): 500
3 K
+
Potassium bath
Dialysate Bath Calcium: 2.5 mEq/L
Access- internal jugular central venous
w/o heparin
Maintain systolic blood pressure > (mmHg): 110
Desired weight loss/E.D.W: 3 kg
11/12/13- s/p insertion of Quinton PermaCath into right
internal jugular vein, P.A. pending medical clearance for AV
fistula

Evaluation of nutrient requirements
Calories: 35 kcal/kg of IBW/day= 1,875 kcal
Protein: 1.2 g/kg/IBW: 65 grams of Protein
Fluid: 750-1000mL/day urine output
Sodium: 2-3 g/day
Potassium: 2-3 g/day
Phosphorus= 0.8-1.2 g/day
* Needs based on that patient is most likely going to
requirement long term dialysis
Nutrition Diagnoses
Inability to manage self-care (NB 2.3) related to impaired
cognitive ability secondary to intellectual disability as
evidenced by patient unable to recognize or understand
self-care required in new diagnoses of Diabetes Mellitus
& End Stage Renal Disease.

Impaired ability to prepare foods/meals (NB 2.4) related
to impaired cognitive ability related to intellectual
disability as evidenced by patients caregivers being the
providers of patients foods/ meals prior to admission.
Nutrition Interventions
Nutrition Education: Verbal and written to patients sister
on dietary recommendations for diabetic patient
receiving hemodialysis
Medical Food Supplement: If sister feels P.A. isnt meeting
needs with food alone, discuss supplements such as
Nepro with Carb Steady and RenaMent
Coordination of Care: With registered dietitian at dialysis
center (if possible) and with social worker in hospital.
Discussion along with social worker about placement in a
group home
Goals and Plans
Goal: Patients intake to meet estimated nutritional needs
and nutrient recommendations for a diabetic receiving
hemodialysis

Plan: Patients food and meals to be provided by
caregivers (sister, home health aide) to meet estimated
nutritional needs and nutrient requirements for a diabetic
receiving hemodialysis

Monitoring and Evaluation
Monitor: Check for understanding of dietary
recommendations with caregivers and monitor patients
PO intake.
See if feasible for caregivers to document via a food log to
with what foods they are providing to patient and how
much is he consuming
Evaluation: Patients caregivers will verbalize nutritional
recommendations for diabetic patient receiving
hemodialysis and patient intake will reflect dietary
recommendations for a diabetic patient receiving
hemodialysis.

Proposed Follow Up
Plan: If caregivers kept a food journal, review food journal to see
how P.A. has been eating and if his caregivers are providing the
appropriate foods. Ask caregivers how they feel about the food
the are providing to P.A., what about these recommendations do
they find the most difficulty and why
Interventions: From what the caregivers are saying, discuss ways
to solve the issues with the diet. If can isnt being managed
properly at home, discuss placement in a group home
Goal: For P.A. to be in an environment where he will receive the
proper care regarding his medical and nutritional needs.
Prognosis and Discharge
P.A. was discharged from Franklin Hospital on 11/18/13,
to a sub-acute rehab facility for rehabilitation to help with
getting him ambulatory again, and his family wishes for
him to return home after.
It will be very difficult for P.A.s caregivers to manage
both his nutritional care and medical care as they both
involve continual involvement since the patient himself
cannot manage his own self-care
Empowering patients to self manage their care is
something that is preached often by nutrition
professionals to both diabetic patients and dialysis
patients, however this is unfeasible with P.A.

Objective To describe & compare the dietary intake of adults with mild to
moderate mental retardation among three different community
residential settings.
Case Report 325 adults (178 males, 147 females) with mild to moderate mental
retardation were interviewed along with their direct care provider
using a Dietary Fat Screener and Fruit and Vegetable Screener to
obtain a recall of typical food consumed over the past year.
Results Women who lived in group homes scored significantly higher on the
F & V screener than those who lived in semi-independent setting or
with family members (p < .001). The men who resided in group
homes also scored similarly higher, though not statistically
significant.
Conclusions The researchers concluded that the greater fruit and vegetable
intake seen group homes may be due to staff training, higher levels
of supervision of meals, planned menus, or reduced personal
freedom to choose unhealthy foods.
Draheim , C. C., Stanish , H. I., Williams , D. P., & McCubbin, J. A. (2007). Dietary
intake of adults with mental retardation who reside in community settings.
American Journal on Mental Retardation, 112(5), 392-400.
Prevalence of Dietary Intake Estimates for Men and Women (%) by
Residential Settings
EstimateofDietaryIntake GroupHomen=169 WithFamilyn=48 Semiindepend.n=108
Men n=91 n=28 n=59
DietaryFatScreenerScores
<30%ofcalories 15.4 28.6 25
3035%ofcalories 15.4 10.7 23.3
>35%ofcalories 15.3 21.4 16.7
4050%ofcalories 54.9 39.3 35
FruitandVegetableScreenerscores
5ormorefruits/veggies/day 4.4 0 1.7
3or4fruits/veggies/day 45.1 28.6 38.3
<3fruits/veggies/day 50.5 71.4 60
Women n=78 n=20 n=49
DietaryFatScreenerScores
<30%ofcalories 20.5 30 28.6
3035%ofcalories 20.5 25 16.3
>35%ofcalories 15.4 10.1 12.2
4050%ofcalories 43.3 35 42.9
FruitandVegetableScreenerscores
5ormorefruits/veggies/day 6.4 0 0
3or4fruits/veggies/day 65.4 55 36.7
<3fruits/veggies/day 28.2 45 63.3
Nutrition Quality of Life
P.AS nutrition quality of life may improve if he is placed in
group home residence.
His dietary requirements are difficult to manage, even for
a patient that has total understanding of what these
recommendations entail
It is unlikely that P.As family will be able to provide proper
medical and nutritional therapies required by P.As current
condition without resistance from P.A.
A group home setting will provided an environment
where a more positive outcome may occur