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==
 +
*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<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===
 +
*[[Pneumonia (Main)]]
 +
*[[Urinary tract infection]]
 +
*Medication non-adherence
 +
*[[Cocaine intoxication]]
 +
*Meds: [[Beta-blockers]], diuretics
 +
*[[GI bleed]]
 +
*[[Pancreatitis]]
 +
*[[Heat Emergencies|Heat related emergencies]]
 +
*[[Acute coronary syndrome]]
 +
*[[Stroke]]
  
Precipitants:
+
==Clinical Features==
 +
*[[Dehydration]]
 +
**[[Hypotension]]
 +
*[[Seizure]] (15% of patients)
 +
*[[Altered mental status]]
 +
*Lethargy/[[coma]]
  
* Renal failure
+
==Differential Diagnosis==
* Pneumonia, Sepsis
+
{{Hyperglycemia DDX}}
* GI bleed
 
* MI
 
* CVA, bleed/ischemic
 
* PE
 
* Pancreatitis
 
* Burns
 
* Heat Stroke
 
* Dialysis
 
* Recent Surgery
 
* Drugs, Meds: CCBs, Beta-blockers, carbamezapines, cimetidine, cocaine/alcohol, steroids, etc..
 
== ==
 
  
 +
==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==
+
===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==
 +
#[[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<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>
 +
#[[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]]
  
History:
+
==Disposition==
 
+
*Most patients require ICU admission
* Fever
 
* Thirst
 
* Polyuria or Oliguria or Polydipsia
 
* Confusion
 
* Seizures (focal)
 
* Hallucinations
 
== ==
 
 
 
 
 
Physical Exam:
 
 
 
* decrease consciousness
 
* tachy, hypotension
 
* fever
 
* focal seizures
 
* hemiparesis
 
* myoclonus
 
* quadriplegia
 
* nystagmus
 
 
 
 
==Work Up==
 
 
 
 
 
* CBC
 
* UA
 
* CXR
 
* EKG
 
* cultures
 
* 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==
 
 
 
 
 
* 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
 
* ADA guidelines: NS at 4-14 ml/kg/hr if low corrected sodium
 
 
 
* Add dextrose once glucose fall <=300 mg/dl
 
* 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
 
* if serum K <5 mEq/L add 20 mEq to each liter of fluids
 
* chemistry q1hr for first 4-6hrs of treatment
 
 
 
* Insulin: may be unnecessary in ED.  Consider starting once hemodynamically stable and UOP is adequate
 
* consider 0.1 Unit/kg/hr IV and modify rate to lower glucose 50-75 dL/hour
 
* 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==
 +
*[[Diabetes mellitus (main)]]
 +
*[[Diabetic ketoacidosis]]
 +
*[[Hypoglycemia]]
  
 
+
==References==
Endo: DKA
+
<references/>
 
+
[[Category:Endocrinology]]
Endo: Diabetes (Meds)
 
 
 
Endo: Hypoglycemia
 
 
 
 
 
 
==Source==
 
 
 
 
 
Sotelo 11/3/2009
 
 
 
 
 
 
 
 
 
[[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