Difference between revisions of "Hyperosmolar hyperglycemic state"

(Work Up)
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==Work Up==
 
==Work Up==
 
#Chem
 
#Chem
##Hypokalemia must be aggressively treated
+
#Serum Osm
#Osm
 
 
#Lactate
 
#Lactate
 
#Serum ketones
 
#Serum ketones

Revision as of 00:20, 28 September 2011

Background

  1. Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O
  2. 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
  3. Ketosis usually absent (may be mild)
  4. Cerebral edema is uncommon complication (case reports)

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
  2. Serum 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

  1. Fluid replacement
    1. Average fluid deficit is 8-12L
      1. 50% should be replaced over the initial 12hr
      2. May have to replace slower if pt has cardiac/renal impairment
  2. Hypokalemia
    1. Must treat aggressively
    2. Once adequate urinary output has been established K+ replacement should begin
  3. Hyperglycemia
    1. Do not start insulin until K > 3.3 and adequate urinary output has been established
  4. Hypomagnesemia
    1. Repletion will help correct hypokalemia
  5. Hypophosphatemia
    1. Routine correction unnecessary unless phos <1.0

HHS.jpg

Disposition

  • Most pts require ICU admission

See Also

Source

Tintinalli's