Difference between revisions of "Hyperosmolar hyperglycemic state"

(Text replacement - "*UA" to "*Urinalysis")
 
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*Ketosis usually absent (may be mild)
 
*Ketosis usually absent (may be mild)
 
*Cerebral edema is uncommon complication (case reports)
 
*Cerebral edema is uncommon complication (case reports)
 +
*Estimated mortality 10-20%, usually due to underlying precipitant<ref>Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care.  2014; 37(11):3124-31.</ref>
 +
**In contrast to [[DKA]], in which mortality is 1-5%
 +
**Incidence of HHS < 1% of hospital admissions of patients with diabetes
  
 
===Precipitants===
 
===Precipitants===
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==Clinical Features==
 
==Clinical Features==
*Dehydration
+
*[[Dehydration]]
 
**[[Hypotension]]
 
**[[Hypotension]]
 
*[[Seizure]] (15% of patients)
 
*[[Seizure]] (15% of patients)
 
*[[Altered mental status]]
 
*[[Altered mental status]]
*Lethargy/coma
+
*Lethargy/[[coma]]
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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==Evaluation==
 
==Evaluation==
 
===Work Up===
 
===Work Up===
*Chem
+
*Chemistry
*Serum Osm
+
*Serum osm
*Lactate
+
*[[Lactate]]
 
*Serum ketones
 
*Serum ketones
 
*CBC
 
*CBC
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**Blood cultures
 
**Blood cultures
 
**[[Urinalysis]]/Urine culture  
 
**[[Urinalysis]]/Urine culture  
**LFTs
+
**[[LFTs]]
 
**Lipase
 
**Lipase
**Troponin
+
**[[Troponin]]
 
**[[CXR]]
 
**[[CXR]]
 
**[[ECG]]
 
**[[ECG]]
**Head CT
+
**[[Head CT]]
  
===Evaluation===
+
===Diagnosis===
 
*Glucose >600
 
*Glucose >600
*Osm >315
+
*Osm >320
 
*Bicarb >15
 
*Bicarb >15
 
*pH >7.3
 
*pH >7.3
 
*Serum ketones negative or mildly positive
 
*Serum ketones negative or mildly positive
 +
*Neurologic abnormalities frequently present (coma in 25-50% of cases)
  
 
==Management==
 
==Management==

Latest revision as of 16:06, 28 September 2019

Background

  • Prototypical patient is elderly with 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)
  • Estimated mortality 10-20%, usually due to underlying precipitant[1]
    • In contrast to DKA, in which mortality is 1-5%
    • Incidence of HHS < 1% of hospital admissions of patients with diabetes

Precipitants

Clinical Features

Differential Diagnosis

Hyperglycemia

Evaluation

Work Up

Diagnosis

  • Glucose >600
  • Osm >320
  • Bicarb >15
  • pH >7.3
  • Serum ketones negative or mildly positive
  • Neurologic abnormalities frequently present (coma in 25-50% of cases)

Management

  1. Fluid replacement
    • Average fluid deficit is 8-12L
      • 50% should be replaced over the initial 12hr
      • May have to replace slower if patient has cardiac/renal impairment
      • Aggressiveness of fluid replacement must be weighed against the risk of cerebral edema, which increases with younger age[2]
  2. Hypokalemia
    • Must treat aggressively
    • Once adequate urinary output has been established K+ replacement should begin
  3. Hyperglycemia
    • Do not start insulin until K > 3.3 and adequate urinary output has been established
  4. Hypomagnesemia
  5. Hypophosphatemia
    • Routine correction unnecessary unless phos <1.0

HHS.jpg

Disposition

  • Most patients require ICU admission

See Also

References

  1. Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care. 2014; 37(11):3124-31.
  2. Stoner GD. Hyperosmolar Hyperglycemic State. Am Fam Physician. 2005 May 1;71(9):1723-1730. http://www.aafp.org/afp/2005/0501/p1723.html