Difference between revisions of "Hyperosmolar hyperglycemic state"

(Created page with "==Background== Precipitants: * Renal failure * Pneumonia, Sepsis * GI bleed * MI * CVA, bleed/ischemic * PE * Pancreatitis * Burns * Heat Stroke * Dialysis * Recent Surgery ...")
 
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==Background==
 
==Background==
 
+
===Precipitants===
 
+
# Renal failure  
Precipitants:
+
# Pneumonia, Sepsis
 
+
# GI bleed
* Renal failure  
+
# MI
* Pneumonia, Sepsis
+
# CVA, bleed/ischemic
* GI bleed
+
# PE
* MI
+
# Pancreatitis  
* CVA, bleed/ischemic
+
# Burns
* PE
+
# Heat Stroke
* Pancreatitis  
+
# Dialysis
* Burns
+
# Recent Surgery
* Heat Stroke
+
# Drugs, Meds: CCBs, Beta-blockers, carbamezapines, cimetidine, cocaine/alcohol, steroids, etc..
* Dialysis
 
* Recent Surgery
 
* Drugs, Meds: CCBs, Beta-blockers, carbamezapines, cimetidine, cocaine/alcohol, steroids, etc..
 
== ==
 
 
 
  
 
==Diagnosis==
 
==Diagnosis==
 +
===History===
 +
# Fever
 +
# Thirst
 +
# Polyuria or Oliguria or Polydipsia
 +
# Confusion
 +
# Seizures (focal)
 +
# Hallucinations
  
 
+
===Physical Exam===
History:
+
# decrease consciousness
 
+
# tachy, hypotension
* Fever
+
# fever
* Thirst
+
# focal seizures
* Polyuria or Oliguria or Polydipsia
+
# hemiparesis
* Confusion
+
# myoclonus
* Seizures (focal)
+
# quadriplegia
* Hallucinations
+
# nystagmus
== ==
 
 
 
 
 
Physical Exam:
 
 
 
* decrease consciousness
 
* tachy, hypotension
 
* fever
 
* focal seizures
 
* hemiparesis
 
* myoclonus
 
* quadriplegia
 
* nystagmus
 
 
  
 
==Work Up==
 
==Work Up==
 
+
# CBC
 
+
# UA
* CBC
+
# CXR
* UA
+
# EKG
* CXR
+
# cultures
* EKG
+
# Head CT, LP if suspecting intracranial process
* cultures
 
* Head CT, LP if suspecting intracranial process
 
== ==
 
 
 
  
 
* 50-65% have no history of diabetes
 
* 50-65% have no history of diabetes
Line 62: Line 46:
 
* Serum, Urine osmolarity: serum osmolarity > 320-350 mOsm/L
 
* Serum, Urine osmolarity: serum osmolarity > 320-350 mOsm/L
 
* Creatinine Kinase: often elevated due to rhabdo
 
* Creatinine Kinase: often elevated due to rhabdo
== ==
 
 
  
 
==Treatment==
 
==Treatment==
 
+
# Fluids- mean deficit is 9L. Start IV NS until BP and UOP OK.  Then, change to 1/2 NS & replace 50% deficit over 12h, & 50% over next 12-24h  
 
+
## ADA guidelines: 1/2 NS at 4-14 ml/kg/hr if corrected sodium normal or elevated
* Fluids- mean deficit is 9L. Start IV NS until BP and UOP OK.  Then, change to 1/2 NS & replace 50% deficit over 12h, & 50% over next 12-24h  
+
## ADA guidelines: NS at 4-14 ml/kg/hr if low corrected sodium
* ADA guidelines: 1/2 NS at 4-14 ml/kg/hr if corrected sodium normal or elevated
+
# Add dextrose once glucose fall <=300 mg/dl
* ADA guidelines: NS at 4-14 ml/kg/hr if low corrected sodium
+
# Replace potassium (5-10 meq per h) when level available and OK UOP
 
+
## if serum K <3.3 mEq/L add 40 mEq/L/hr
* Add dextrose once glucose fall <=300 mg/dl
+
## if serum K <5 mEq/L add 20 mEq to each liter of fluids
* Replace potassium (5-10 meq per h) when level available and OK UOP
+
## chemistry q1hr for first 4-6hrs of treatment
* if serum K <3.3 mEq/L add 40 mEq/L/hr
+
# Insulin: may be unnecessary in ED.  Consider starting once hemodynamically stable and UOP is adequate
* if serum K <5 mEq/L add 20 mEq to each liter of fluids
+
## consider 0.1 Unit/kg/hr IV and modify rate to lower glucose 50-75 dL/hour
* chemistry q1hr for first 4-6hrs of treatment
+
## once glucose is <=300 mg/dL, add D5 and decrease insulin to <= 0.5 Units/kg/hr
 
+
# Empiric phosphate repletion, SC Heparin, Broad Spectrum PPx ABx may be needed
* Insulin: may be unnecessary in ED.  Consider starting once hemodynamically stable and UOP is adequate
+
# Avoid phenytoin for seizures since this agent inhibits the release of exogenous insulin and is associated with HHS   
* consider 0.1 Unit/kg/hr IV and modify rate to lower glucose 50-75 dL/hour
+
# Admit ICU, consider central line if underlying cardiac, or renal disease
* once glucose is <=300 mg/dL, add D5 and decrease insulin to <= 0.5 Units/kg/hr
 
 
 
* Empiric phosphate repletion, SC Heparin, Broad Spectrum PPx ABx may be needed
 
* Avoid phenytoin for seizures since this agent inhibits the release of exogenous insulin and is associated with HHS   
 
* Admit ICU, consider central line if underlying cardiac, or renal disease
 
 
   
 
   
 
 
==See Also==
 
==See Also==
 
 
 
Endo: DKA
 
Endo: DKA
  
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Endo: Hypoglycemia
 
Endo: Hypoglycemia
 
 
  
 
==Source==
 
==Source==
 
 
 
Sotelo 11/3/2009
 
Sotelo 11/3/2009
 
 
 
  
 
[[Category:Endo]]
 
[[Category:Endo]]

Revision as of 05:28, 13 March 2011

Background

Precipitants

  1. Renal failure
  2. Pneumonia, Sepsis
  3. GI bleed
  4. MI
  5. CVA, bleed/ischemic
  6. PE
  7. Pancreatitis
  8. Burns
  9. Heat Stroke
  10. Dialysis
  11. Recent Surgery
  12. Drugs, Meds: CCBs, Beta-blockers, carbamezapines, cimetidine, cocaine/alcohol, steroids, etc..

Diagnosis

History

  1. Fever
  2. Thirst
  3. Polyuria or Oliguria or Polydipsia
  4. Confusion
  5. Seizures (focal)
  6. Hallucinations

Physical Exam

  1. decrease consciousness
  2. tachy, hypotension
  3. fever
  4. focal seizures
  5. hemiparesis
  6. myoclonus
  7. quadriplegia
  8. nystagmus

Work Up

  1. CBC
  2. UA
  3. CXR
  4. EKG
  5. cultures
  6. Head CT, LP if suspecting intracranial process
  • 50-65% have no history of diabetes
  • Chem-10: Glucose> 600mg/dl (often > 1000), BUN/Cr ratio >30
  • Acetone: no ketosis (lactic acidosis +/- present)
  • Serum, Urine osmolarity: serum osmolarity > 320-350 mOsm/L
  • Creatinine Kinase: often elevated due to rhabdo

Treatment

  1. Fluids- mean deficit is 9L. Start IV NS until BP and UOP OK. Then, change to 1/2 NS & replace 50% deficit over 12h, & 50% over next 12-24h
    1. ADA guidelines: 1/2 NS at 4-14 ml/kg/hr if corrected sodium normal or elevated
    2. ADA guidelines: NS at 4-14 ml/kg/hr if low corrected sodium
  2. Add dextrose once glucose fall <=300 mg/dl
  3. Replace potassium (5-10 meq per h) when level available and OK UOP
    1. if serum K <3.3 mEq/L add 40 mEq/L/hr
    2. if serum K <5 mEq/L add 20 mEq to each liter of fluids
    3. chemistry q1hr for first 4-6hrs of treatment
  4. Insulin: may be unnecessary in ED. Consider starting once hemodynamically stable and UOP is adequate
    1. consider 0.1 Unit/kg/hr IV and modify rate to lower glucose 50-75 dL/hour
    2. once glucose is <=300 mg/dL, add D5 and decrease insulin to <= 0.5 Units/kg/hr
  5. Empiric phosphate repletion, SC Heparin, Broad Spectrum PPx ABx may be needed
  6. Avoid phenytoin for seizures since this agent inhibits the release of exogenous insulin and is associated with HHS
  7. Admit ICU, consider central line if underlying cardiac, or renal disease

See Also

Endo: DKA

Endo: Diabetes (Meds)

Endo: Hypoglycemia

Source

Sotelo 11/3/2009