Difference between revisions of "Hyperosmolar hyperglycemic state"

 
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==Background==
 
==Background==
#Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O
+
*Prototypical patient is elderly with 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
##Increased hepatic gluconeogenesis and glycogenolysis
+
**Increased hepatic gluconeogenesis and glycogenolysis
##Osmotic diuresis and dehydration followed by impaired renal excretion of glucose
+
**Osmotic diuresis and dehydration followed by impaired renal excretion of glucose
###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)
+
*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===
#PNA
+
*[[Pneumonia (Main)]]
#UTI
+
*[[Urinary tract infection]]
#Medication non-compliance
+
*Medication non-adherence
#Cocaine use
+
*[[Cocaine intoxication]]
#Meds: Beta-blockers, diuretics
+
*Meds: [[Beta-blockers]], diuretics
#GI hemorrhage
+
*[[GI bleed]]
#Pancreatitis
+
*[[Pancreatitis]]
#Heat-related illness
+
*[[Heat Emergencies|Heat related emergencies]]
#ACS
+
*[[Acute coronary syndrome]]
#CVA
+
*[[Stroke]]
  
 
==Clinical Features==
 
==Clinical Features==
*Dehydration
+
*[[Dehydration]]
**Hypotension
+
**[[Hypotension]]
*Seizure (15% of pts)
+
*[[Seizure]] (15% of patients)
*Altered mental status
+
*[[Altered mental status]]
*Lethargy/coma
+
*Lethargy/[[coma]]
  
==Diagnosis==
+
==Differential Diagnosis==
 +
{{Hyperglycemia DDX}}
 +
 
 +
==Evaluation==
 +
===Work Up===
 +
*Chemistry
 +
*Serum osm
 +
*[[Lactate]]
 +
*Serum ketones
 +
*CBC
 +
*Also consider:
 +
**Blood cultures
 +
**[[Urinalysis]]/Urine culture
 +
**[[LFTs]]
 +
**Lipase
 +
**[[Troponin]]
 +
**[[CXR]]
 +
**[[ECG]]
 +
**[[Head CT]]
 +
 
 +
===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)
  
==Work Up==
+
==Management==
#Chem
+
#[[Fluid replacement]]
#Serum Osm
+
#*Average fluid deficit is 8-12L
#Lactate
+
#**50% should be replaced over the initial 12hr
#Serum ketones
+
#**May have to replace slower if patient has cardiac/renal impairment
#CBC
+
#**Aggressiveness of fluid replacement must be weighed against the risk of cerebral edema, which increases with younger age<ref>Stoner GD. Hyperosmolar Hyperglycemic State. Am Fam Physician. 2005 May 1;71(9):1723-1730. http://www.aafp.org/afp/2005/0501/p1723.html</ref>
#Also consider:
+
#[[Hypokalemia]]
##Blood cx
+
#*Must treat aggressively
##UA/UCx
+
#*Once adequate urinary output has been established K+ replacement should begin
##LFTs
+
#[[Hyperglycemia]]
##Lipase
+
#*Do not start insulin until K > 3.3 and adequate urinary output has been established
##Troponin
+
#[[Hypomagnesemia]]
##CXR
+
#*Repletion will help correct [[hypokalemia]]
##ECG
+
#[[Hypophosphatemia]]
##Head CT
+
#*Routine correction unnecessary unless phos <1.0
 
 
==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==
 
==Disposition==
*Most pts require ICU admission
+
*Most patients require ICU admission
 
   
 
   
 
==See Also==
 
==See Also==
*[[DKA]]
+
*[[Diabetes mellitus (main)]]
*[[Diabetes (Meds)]]
+
*[[Diabetic ketoacidosis]]
 
*[[Hypoglycemia]]
 
*[[Hypoglycemia]]
  
==Source==
+
==References==
Tintinalli's
+
<references/>
 
+
[[Category:Endocrinology]]
[[Category:Endo]]
 

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