Difference between revisions of "Hyperosmolar hyperglycemic state"

(Background)
(Text replacement - " pts" to " patients")
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*Dehydration
 
*Dehydration
 
**Hypotension
 
**Hypotension
*Seizure (15% of pts)
+
*Seizure (15% of patients)
 
*Altered mental status
 
*Altered mental status
 
*Lethargy/coma
 
*Lethargy/coma
Line 73: Line 73:
  
 
==Disposition==
 
==Disposition==
*Most pts require ICU admission
+
*Most patients require ICU admission
 
   
 
   
 
==See Also==
 
==See Also==

Revision as of 16:49, 21 June 2016

Background

  • Prototypical patient is elderly with 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 patients)
  • 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
      • Aggressiveness of fluid replacement must be weighed against the risk of cerebral edema, which increases with younger age[1]
  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 patients require ICU admission

See Also

References

  1. Stoner GD. Hyperosmolar Hyperglycemic State. Am Fam Physician. 2005 May 1;71(9):1723-1730. http://www.aafp.org/afp/2005/0501/p1723.html