Difference between revisions of "Hyperosmolar hyperglycemic state"
Neil.m.young (talk | contribs) (Text replacement - " pt " to " patient ") |
ClaireLewis (talk | contribs) |
||
| (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- | + | *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}} | ||
| − | == | + | ==Evaluation== |
===Work Up=== | ===Work Up=== | ||
| − | * | + | *Chemistry |
| − | *Serum | + | *Serum osm |
| − | *Lactate | + | *[[Lactate]] |
*Serum ketones | *Serum ketones | ||
*CBC | *CBC | ||
*Also consider: | *Also consider: | ||
| − | **Blood | + | **Blood cultures |
| − | ** | + | **[[Urinalysis]]/Urine culture |
| − | **LFTs | + | **[[LFTs]] |
**Lipase | **Lipase | ||
| − | **Troponin | + | **[[Troponin]] |
| − | **CXR | + | **[[CXR]] |
| − | **ECG | + | **[[ECG]] |
| − | **Head CT | + | **[[Head CT]] |
| − | === | + | ===Diagnosis=== |
*Glucose >600 | *Glucose >600 | ||
| − | *Osm > | + | *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) | ||
| − | == | + | ==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
Contents
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
- Pneumonia (Main)
- Urinary tract infection
- Medication non-adherence
- Cocaine intoxication
- Meds: Beta-blockers, diuretics
- GI bleed
- Pancreatitis
- Heat related emergencies
- Acute coronary syndrome
- Stroke
Clinical Features
- Dehydration
- Seizure (15% of patients)
- Altered mental status
- Lethargy/coma
Differential Diagnosis
Hyperglycemia
- Physiologic stress response (rarely causes glucose >200 mg/dL)
- Diabetes mellitus (main)
- Hemochromatosis
- Iron toxicity
- Sepsis
Evaluation
Work Up
- Chemistry
- Serum osm
- Lactate
- Serum ketones
- CBC
- Also consider:
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[2]
- Average fluid deficit is 8-12L
- 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
Disposition
- Most patients require ICU admission
See Also
References
- ↑ Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care. 2014; 37(11):3124-31.
- ↑ Stoner GD. Hyperosmolar Hyperglycemic State. Am Fam Physician. 2005 May 1;71(9):1723-1730. http://www.aafp.org/afp/2005/0501/p1723.html