Difference between revisions of "Hyperosmolar hyperglycemic state"

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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===
 
===Precipitants===
−
# Renal failure
+
*[[Pneumonia (Main)]]
−
# Pneumonia, Sepsis
+
*[[Urinary tract infection]]
−
# GI bleed
+
*Medication non-adherence
−
# MI
+
*[[Cocaine intoxication]]
−
# CVA, bleed/ischemic
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*Meds: [[Beta-blockers]], diuretics
−
# PE
+
*[[GI bleed]]
−
# Pancreatitis  
+
*[[Pancreatitis]]
−
# Burns
+
*[[Heat Emergencies|Heat related emergencies]]
−
# Heat Stroke
+
*[[Acute coronary syndrome]]
−
# Dialysis
+
*[[Stroke]]
−
# Recent Surgery
 
−
# Drugs, Meds: CCBs, Beta-blockers, carbamezapines, cimetidine, cocaine/alcohol, steroids, etc..
 
  
−
==Diagnosis==
+
==Clinical Features==
−
===History===
+
*[[Dehydration]]
−
# Fever
+
**[[Hypotension]]
−
# Thirst
+
*[[Seizure]] (15% of patients)
−
# Polyuria or Oliguria or Polydipsia
+
*[[Altered mental status]]
−
# Confusion
+
*Lethargy/[[coma]]
−
# Seizures (focal)
 
−
# Hallucinations
 
  
−
===Physical Exam===
+
==Differential Diagnosis==
−
# decrease consciousness
+
{{Hyperglycemia DDX}}
−
# tachy, hypotension
 
−
# fever
 
−
# focal seizures
 
−
# hemiparesis
 
−
# myoclonus
 
−
# quadriplegia
 
−
# nystagmus
 
  
−
==Work Up==
+
==Evaluation==
−
# CBC
+
===Work Up===
−
# UA
+
*Chemistry
−
# CXR
+
*Serum osm
−
# EKG
+
*[[Lactate]]
−
# cultures
+
*Serum ketones
−
# Head CT, LP if suspecting intracranial process
+
*CBC
 +
*Also consider:
 +
**Blood cultures
 +
**[[Urinalysis]]/Urine culture
 +
**[[LFTs]]
 +
**Lipase
 +
**[[Troponin]]
 +
**[[CXR]]
 +
**[[ECG]]
 +
**[[Head CT]]
  
−
* 50-65% have no history of diabetes
+
===Diagnosis===
−
* Chem-10: Glucose> 600mg/dl (often > 1000), BUN/Cr ratio  >30
+
*Glucose >600
−
* Acetone:  no ketosis (lactic acidosis +/- present)
+
*Osm >320
−
* Serum, Urine osmolarity: serum osmolarity > 320-350 mOsm/L
+
*Bicarb >15
−
* Creatinine Kinase: often elevated due to rhabdo
+
*pH >7.3
 +
*Serum ketones negative or mildly positive
 +
*Neurologic abnormalities frequently present (coma in 25-50% of cases)
  
−
==Treatment==
+
==Management==
−
# 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
+
#[[Fluid replacement]]
−
## ADA guidelines: 1/2 NS at 4-14 ml/kg/hr if corrected sodium normal or elevated
+
#*Average fluid deficit is 8-12L
−
## ADA guidelines: NS at 4-14 ml/kg/hr if low corrected sodium
+
#**50% should be replaced over the initial 12hr
−
# Add dextrose once glucose fall <=300 mg/dl
+
#**May have to replace slower if patient has cardiac/renal impairment
−
# Replace potassium (5-10 meq per h) when level available and OK UOP
+
#**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>
−
## if serum K <3.3 mEq/L add 40 mEq/L/hr
+
#[[Hypokalemia]]
−
## if serum K <5 mEq/L add 20 mEq to each liter of fluids
+
#*Must treat aggressively
−
## chemistry q1hr for first 4-6hrs of treatment
+
#*Once adequate urinary output has been established K+ replacement should begin
−
# Insulin: may be unnecessary in ED. Consider starting once hemodynamically stable and UOP is adequate
+
#[[Hyperglycemia]]
−
## consider 0.1 Unit/kg/hr IV and modify rate to lower glucose 50-75 dL/hour
+
#*Do not start insulin until K > 3.3 and adequate urinary output has been established
−
## once glucose is <=300 mg/dL, add D5 and decrease insulin to <= 0.5 Units/kg/hr
+
#[[Hypomagnesemia]]
−
# Empiric phosphate repletion, SC Heparin, Broad Spectrum PPx ABx may be needed
+
#*Repletion will help correct [[hypokalemia]]
−
# Avoid phenytoin for seizures since this agent inhibits the release of exogenous insulin and is associated with HHS 
+
#[[Hypophosphatemia]]
−
# Admit ICU, consider central line if underlying cardiac, or renal disease
+
#*Routine correction unnecessary unless phos <1.0
 +
[[File:HHS.jpg]]
 +
 
 +
==Disposition==
 +
*Most patients require ICU admission
 
   
 
   
 
==See Also==
 
==See Also==
−
Endo: DKA
+
*[[Diabetes mellitus (main)]]
−
 
+
*[[Diabetic ketoacidosis]]
−
Endo: Diabetes (Meds)
+
*[[Hypoglycemia]]
−
 
 
−
[[Hypoglycemia]]
 
−
 
 
−
==Source==
 
−
Sotelo 11/3/2009
 
  
−
[[Category:Endo]]
+
==References==
 +
<references/>
 +
[[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
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