Difference between revisions of "Hyperosmolar hyperglycemic state"

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*Altered mental status
 
*Altered mental status
 
*Lethargy/coma
 
*Lethargy/coma
 +
 +
==Differential Diagnosis==
  
 
==Diagnosis==
 
==Diagnosis==
*Glucose >600
+
===Work Up===
*Osm >315
 
*Bicarb >15
 
*pH >7.3
 
*Serum ketones negative or mildly positive
 
 
 
==Work Up==
 
 
*Chem
 
*Chem
 
*Serum Osm
 
*Serum Osm
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**ECG
 
**ECG
 
**Head CT
 
**Head CT
 +
 +
===Evaluation===
 +
*Glucose >600
 +
*Osm >315
 +
*Bicarb >15
 +
*pH >7.3
 +
*Serum ketones negative or mildly positive
  
 
==Treatment==
 
==Treatment==
 +
[[File:HHS.jpg]]
 
*Fluid replacement
 
*Fluid replacement
 
**Average fluid deficit is 8-12L
 
**Average fluid deficit is 8-12L
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*Hypophosphatemia
 
*Hypophosphatemia
 
**Routine correction unnecessary unless phos <1.0
 
**Routine correction unnecessary unless phos <1.0
 
[[File:HHS.jpg]]
 
  
 
==Disposition==
 
==Disposition==

Revision as of 11:22, 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

Differential Diagnosis

Diagnosis

Work Up

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

Evaluation

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

Treatment

HHS.jpg

  • 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

Disposition

  • Most pts require ICU admission

See Also

References