Difference between revisions of "Hyperosmolar hyperglycemic state"

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===Precipitants===
 
===Precipitants===
*PNA
+
*[[Pneumonia (Main)]]
*UTI
+
*[[Urinary tract infection]]
 
*Medication non-compliance
 
*Medication non-compliance
*Cocaine use
+
*[[Cocaine intoxication]]
 
*Meds: Beta-blockers, diuretics
 
*Meds: Beta-blockers, diuretics
*GI hemorrhage
+
*[[GI bleed]]
*Pancreatitis
+
*[[Pancreatitis]]
*Heat-related illness
+
*[[Heat Emergencies|Heat related emergencies]]
*ACS
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*[[Acute coronary syndrome]]
*CVA
+
*[[Stroke]]
  
 
==Clinical Features==
 
==Clinical Features==

Revision as of 00:32, 30 August 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

Clinical Features

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

Differential Diagnosis

Hyperglycemia

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

  1. 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
  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 pts require ICU admission

See Also

References