Hyperosmolar hyperglycemic state: Difference between revisions
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==Background== | ==Background== | ||
===Pathophysiology=== | ===Pathophysiology=== | ||
#Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O | |||
#Occurs due to 3 factors: | #Occurs due to 3 factors: | ||
##Insulin resistance or deficiency | ##Insulin resistance or deficiency | ||
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###May result in TBW losses of 8-12L | ###May result in TBW losses of 8-12L | ||
#Ketosis usually absent (may be mild) | #Ketosis usually absent (may be mild) | ||
# | #Cerebral edema is uncommon complication (case reports) | ||
===Precipitants=== | ===Precipitants=== | ||
| Line 53: | Line 54: | ||
==Treatment== | ==Treatment== | ||
#Fluid replacement | |||
##Average fluid deficit is 8-12L | |||
###50% should be replaced over the initial 12hr | |||
###May have to replace slower if pt has cardiac/renal impairment | |||
#Hypokalemia | |||
##Must treat aggressively | |||
##Once adequate urinary output has been established K+ replacement should begin | |||
#Hyperglycemia | |||
##Do not start insulin until K > 3.3 and adequate urinary output has been established | |||
#Hypomagnesemia | |||
##Repletion will help correct hypokalemia | |||
#Hypophosphatemia | |||
##Routine correction unnecessary unless phos <1.0 | |||
[[File:HHS.jpg]] | [[File:HHS.jpg]] | ||
==Disposition== | |||
*Most pts require ICU admission | |||
==See Also== | ==See Also== | ||
Revision as of 00:19, 28 September 2011
Background
Pathophysiology
- Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O
- Occurs due to 3 factors:
- Insulin resistance or deficiency
- Increased hepatic gluconeogenesis and glycogenolysis
- Osmotic diuresis and dehydration followed by impaired renal excretion of glucose
- May result in TBW losses of 8-12L
- Ketosis usually absent (may be mild)
- Cerebral edema is uncommon complication (case reports)
Precipitants
- PNA
- UTI
- Medication non-compliance
- Cocaine use
- Meds: Beta-blockers, diuretics
- GI hemorrhage
- Pancreatitis
- Heat-related illness
- ACS
- CVA
Clinical Features
- Dehydration
- Hypotension
- Seizure (15% of pts)
- ALOC
- Lethargy/coma
Diagnosis
- Glucose >600
- Osm >315
- Bicarb >15
- pH >7.3
- Serum ketones negative or mildly positive
Work Up
- Chem
- Hypokalemia must be aggressively treated
- Osm
- Lactate
- Serum ketones
- CBC
- Also consider:
- Blood cx
- UA/UCx
- LFTs
- Lipase
- Troponin
- CXR
- ECG
- Head CT
Treatment
- Fluid replacement
- Average fluid deficit is 8-12L
- 50% should be replaced over the initial 12hr
- May have to replace slower if pt has cardiac/renal impairment
- Average fluid deficit is 8-12L
- Hypokalemia
- Must treat aggressively
- Once adequate urinary output has been established K+ replacement should begin
- Hyperglycemia
- Do not start insulin until K > 3.3 and adequate urinary output has been established
- Hypomagnesemia
- Repletion will help correct hypokalemia
- Hypophosphatemia
- Routine correction unnecessary unless phos <1.0
Disposition
- Most pts require ICU admission
See Also
Source
Tintinalli's