Difference between revisions of "Hyperosmolar hyperglycemic state"

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==Background==
 
==Background==
#Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O
+
*Prototypical pt is elderly pt w/ 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
##Increased hepatic gluconeogenesis and glycogenolysis
+
**Increased hepatic gluconeogenesis and glycogenolysis
##Osmotic diuresis and dehydration followed by impaired renal excretion of glucose
+
**Osmotic diuresis and dehydration followed by impaired renal excretion of glucose
###May result in TBW losses of 8-12L
+
***May result in TBW losses of 8-12L
#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)
  
 
===Precipitants===
 
===Precipitants===
#PNA
+
*PNA
#UTI
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*UTI
#Medication non-compliance
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*Medication non-compliance
#Cocaine use
+
*Cocaine use
#Meds: Beta-blockers, diuretics
+
*Meds: Beta-blockers, diuretics
#GI hemorrhage
+
*GI hemorrhage
#Pancreatitis
+
*Pancreatitis
#Heat-related illness
+
*Heat-related illness
#ACS
+
*ACS
#CVA
+
*CVA
  
 
==Clinical Features==
 
==Clinical Features==
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==Work Up==
 
==Work Up==
#Chem
+
*Chem
#Serum Osm
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*Serum Osm
#Lactate
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*Lactate
#Serum ketones
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*Serum ketones
#CBC
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*CBC
#Also consider:
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*Also consider:
##Blood cx
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**Blood cx
##UA/UCx
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**UA/UCx
##LFTs
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**LFTs
##Lipase
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**Lipase
##Troponin
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**Troponin
##CXR
+
**CXR
##ECG
+
**ECG
##Head CT
+
**Head CT
  
 
==Treatment==
 
==Treatment==
#Fluid replacement
+
*Fluid replacement
##Average fluid deficit is 8-12L
+
**Average fluid deficit is 8-12L
###50% should be replaced over the initial 12hr
+
***50% should be replaced over the initial 12hr
###May have to replace slower if pt has cardiac/renal impairment
+
***May have to replace slower if pt has cardiac/renal impairment
#Hypokalemia
+
*Hypokalemia
##Must treat aggressively
+
**Must treat aggressively
##Once adequate urinary output has been established K+ replacement should begin
+
**Once adequate urinary output has been established K+ replacement should begin
#Hyperglycemia
+
*Hyperglycemia
##Do not start insulin until K > 3.3 and adequate urinary output has been established
+
**Do not start insulin until K > 3.3 and adequate urinary output has been established
#Hypomagnesemia
+
*Hypomagnesemia
##Repletion will help correct hypokalemia
+
**Repletion will help correct hypokalemia
#Hypophosphatemia
+
*Hypophosphatemia
##Routine correction unnecessary unless phos <1.0
+
**Routine correction unnecessary unless phos <1.0
  
 
[[File:HHS.jpg]]
 
[[File:HHS.jpg]]
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*[[Hypoglycemia]]
 
*[[Hypoglycemia]]
  
==Source==
+
==References==
Tintinalli's
 
  
 
[[Category:Endo]]
 
[[Category:Endo]]

Revision as of 11:21, 20 July 2015

Background

  • Prototypical pt is elderly pt w/ 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)

Precipitants

  • PNA
  • UTI
  • Medication non-compliance
  • Cocaine use
  • Meds: Beta-blockers, diuretics
  • GI hemorrhage
  • Pancreatitis
  • Heat-related illness
  • ACS
  • CVA

Clinical Features

  • Dehydration
    • Hypotension
  • Seizure (15% of pts)
  • Altered mental status
  • Lethargy/coma

Diagnosis

  • Glucose >600
  • Osm >315
  • Bicarb >15
  • pH >7.3
  • Serum ketones negative or mildly positive

Work Up

  • Chem
  • Serum Osm
  • Lactate
  • Serum ketones
  • CBC
  • Also consider:
    • Blood cx
    • UA/UCx
    • LFTs
    • Lipase
    • Troponin
    • CXR
    • ECG
    • Head CT

Treatment

  • Fluid replacement
    • Average fluid deficit is 8-12L
      • 50% should be replaced over the initial 12hr
      • May have to replace slower if pt has cardiac/renal impairment
  • 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

HHS.jpg

Disposition

  • Most pts require ICU admission

See Also

References