Hyperosmolar hyperglycemic state: Difference between revisions

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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
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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===
*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==
*Glucose >600
{{Hyperglycemia DDX}}
*Osm >315
*Bicarb >15
*pH >7.3
*Serum ketones negative or mildly positive


==Work Up==
==Evaluation==
*Chem
===Work Up===
*Serum Osm
*Chemistry
*Lactate
*Serum osm
*[[Lactate]]
*Serum ketones
*Serum ketones
*CBC
*CBC
*Also consider:
*Also consider:
**Blood cx
**Blood cultures
**UA/UCx
**[[Urinalysis]]/Urine culture
**LFTs
**[[LFTs]]
**Lipase
**Lipase
**Troponin
**[[Troponin]]
**CXR
**[[CXR]]
**ECG
**[[ECG]]
**Head CT
**[[Head CT]]


==Treatment==
===Diagnosis===
*Fluid replacement
*Glucose >600
**Average fluid deficit is 8-12L
*Osm >320
***50% should be replaced over the initial 12hr
*Bicarb >15
***May have to replace slower if pt has cardiac/renal impairment
*pH >7.3
*Hypokalemia
*Serum ketones negative or mildly positive
**Must treat aggressively
*Neurologic abnormalities frequently present (coma in 25-50% of cases)
**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


==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]]
[[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]]


==References==
==References==
 
<references/>
[[Category:Endo]]
[[Category:Endocrinology]]

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