Difference between revisions of "Hyperosmolar hyperglycemic state"

(Text replacement - " pt " to " patient ")
 
(15 intermediate revisions by 5 users not shown)
Line 1: Line 1:
 
==Background==
 
==Background==
*Prototypical patient is elderly with 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
Line 8: Line 8:
 
*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===
 
*[[Pneumonia (Main)]]
 
*[[Pneumonia (Main)]]
 
*[[Urinary tract infection]]
 
*[[Urinary tract infection]]
*Medication non-compliance
+
*Medication non-adherence
 
*[[Cocaine intoxication]]
 
*[[Cocaine intoxication]]
*Meds: Beta-blockers, diuretics
+
*Meds: [[Beta-blockers]], diuretics
 
*[[GI bleed]]
 
*[[GI bleed]]
 
*[[Pancreatitis]]
 
*[[Pancreatitis]]
Line 22: Line 25:
  
 
==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==
 
{{Hyperglycemia DDX}}
 
{{Hyperglycemia DDX}}
  
==Diagnosis==
+
==Evaluation==
 
===Work Up===
 
===Work Up===
*Chem
+
*Chemistry
*Serum Osm
+
*Serum osm
*Lactate
+
*[[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]]
  
===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)
  
==Treatment==
+
==Management==
 
#[[Fluid replacement]]
 
#[[Fluid replacement]]
 
#*Average fluid deficit is 8-12L
 
#*Average fluid deficit is 8-12L

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