Hyperosmolar hyperglycemic state: Difference between revisions
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Endo: DKA | Endo: DKA | ||
[[Diabetes (Meds)]] | |||
[[Hypoglycemia]] | [[Hypoglycemia]] |
Revision as of 03:44, 4 August 2011
Background
Precipitants
- Renal failure
- Pneumonia, Sepsis
- GI bleed
- MI
- CVA, bleed/ischemic
- PE
- Pancreatitis
- Burns
- Heat Stroke
- Dialysis
- Recent Surgery
- Drugs, Meds: CCBs, Beta-blockers, carbamezapines, cimetidine, cocaine/alcohol, steroids, etc..
Diagnosis
History
- Fever
- Thirst
- Polyuria or Oliguria or Polydipsia
- Confusion
- Seizures (focal)
- Hallucinations
Physical Exam
- decrease consciousness
- tachy, hypotension
- fever
- focal seizures
- hemiparesis
- myoclonus
- quadriplegia
- nystagmus
Work Up
- CBC
- UA
- CXR
- EKG
- cultures
- Head CT, LP if suspecting intracranial process
- 50-65% have no history of diabetes
- Chem-10: Glucose> 600mg/dl (often > 1000), BUN/Cr ratio >30
- 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
Endo: DKA
Source
Sotelo 11/3/2009