Difference between revisions of "Hyperosmolar hyperglycemic state"

m (moved Hyperosmolar Hyperglycemic Nonketotic State (HHS) to Hyperosmolar Hyperglycemic State (HHS): The ADA terminology does not include the word nonketotic)
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==Background==
 
==Background==
 +
===Pathophysiology===
 +
#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)
 +
#Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O
 +
 
===Precipitants===
 
===Precipitants===
# Renal failure
+
#PNA
# Pneumonia, Sepsis
+
#UTI
# GI bleed
+
#Medication non-compliance
# MI
+
#Cocaine use
# CVA, bleed/ischemic
+
#Meds: Beta-blockers, diuretics
# PE
+
#GI hemorrhage
# Pancreatitis  
+
#Pancreatitis
# Burns
+
#Heat-related illness
# Heat Stroke
+
#ACS
# Dialysis
+
#CVA
# Recent Surgery
+
 
# Drugs, Meds: CCBs, Beta-blockers, carbamezapines, cimetidine, cocaine/alcohol, steroids, etc..
+
==Clinical Features==
 +
*Dehydration
 +
**Hypotension
 +
*Seizure (15% of pts)
 +
*ALOC
 +
*Lethargy/coma
  
 
==Diagnosis==
 
==Diagnosis==
===History===
+
*Glucose >600
# Fever
+
*Osm >315
# Thirst
+
*Bicarb >15
# Polyuria or Oliguria or Polydipsia
+
*pH >7.3
# Confusion
+
*Serum ketones negative or mildly positive
# Seizures (focal)
 
# Hallucinations
 
 
 
===Physical Exam===
 
# decrease consciousness
 
# tachy, hypotension
 
# fever
 
# focal seizures
 
# hemiparesis
 
# myoclonus
 
# quadriplegia
 
# nystagmus
 
  
 
==Work Up==
 
==Work Up==
# CBC
+
#Chem
# UA
+
##Hypokalemia must be aggressively treated
# CXR
+
#Osm
# EKG
+
#Lactate
# cultures
+
#Serum ketones
# Head CT, LP if suspecting intracranial process
+
#CBC
 +
#Also consider:
 +
##Blood cx
 +
##UA/UCx
 +
##LFTs
 +
##Lipase
 +
##Troponin
 +
##CXR
 +
##ECG
 +
##Head CT
  
* 50-65% have no history of diabetes
+
==Treatment==
* Chem-10: Glucose> 600mg/dl (often > 1000), BUN/Cr ratio  >30
+
[[File:HHS.jpg]]
* Acetone:  no ketosis (lactic acidosis +/- present)
 
* Serum, Urine osmolarity: serum osmolarity > 320-350 mOsm/L
 
* Creatinine Kinase: often elevated due to rhabdo
 
  
==Treatment==
 
# Fluids- mean deficit is 9L. Start IV NS until BP and UOP OK.  Then, change to 1/2 NS & replace 50% deficit over 12h, & 50% over next 12-24h
 
## ADA guidelines: 1/2 NS at 4-14 ml/kg/hr if corrected sodium normal or elevated
 
## ADA guidelines: NS at 4-14 ml/kg/hr if low corrected sodium
 
# Add dextrose once glucose fall <=300 mg/dl
 
# Replace potassium (5-10 meq per h) when level available and OK UOP
 
## if serum K <3.3 mEq/L add 40 mEq/L/hr
 
## if serum K <5 mEq/L add 20 mEq to each liter of fluids
 
## chemistry q1hr for first 4-6hrs of treatment
 
# Insulin: may be unnecessary in ED.  Consider starting once hemodynamically stable and UOP is adequate
 
## consider 0.1 Unit/kg/hr IV and modify rate to lower glucose 50-75 dL/hour
 
## once glucose is <=300 mg/dL, add D5 and decrease insulin to <= 0.5 Units/kg/hr
 
# Empiric phosphate repletion, SC Heparin, Broad Spectrum PPx ABx may be needed
 
# Avoid phenytoin for seizures since this agent inhibits the release of exogenous insulin and is associated with HHS 
 
# Admit ICU, consider central line if underlying cardiac, or renal disease
 
 
   
 
   
 
==See Also==
 
==See Also==
Endo: DKA
+
*[[DKA]]
 
+
*[[Diabetes (Meds)]]
[[Diabetes (Meds)]]
+
*[[Hypoglycemia]]
 
 
[[Hypoglycemia]]
 
  
 
==Source==
 
==Source==
Sotelo 11/3/2009
+
Tintinalli's
  
 
[[Category:Endo]]
 
[[Category:Endo]]

Revision as of 23:58, 27 September 2011

Background

Pathophysiology

  1. Occurs due to 3 factors:
    1. Insulin resistance or deficiency
    2. Increased hepatic gluconeogenesis and glycogenolysis
    3. Osmotic diuresis and dehydration followed by impaired renal excretion of glucose
      1. May result in TBW losses of 8-12L
  2. Ketosis usually absent (may be mild)
  3. Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O

Precipitants

  1. PNA
  2. UTI
  3. Medication non-compliance
  4. Cocaine use
  5. Meds: Beta-blockers, diuretics
  6. GI hemorrhage
  7. Pancreatitis
  8. Heat-related illness
  9. ACS
  10. CVA

Clinical Features

  • Dehydration
    • Hypotension
  • Seizure (15% of pts)
  • ALOC
  • Lethargy/coma

Diagnosis

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

Work Up

  1. Chem
    1. Hypokalemia must be aggressively treated
  2. Osm
  3. Lactate
  4. Serum ketones
  5. CBC
  6. Also consider:
    1. Blood cx
    2. UA/UCx
    3. LFTs
    4. Lipase
    5. Troponin
    6. CXR
    7. ECG
    8. Head CT

Treatment

HHS.jpg


See Also

Source

Tintinalli's