Difference between revisions of "Hyperosmolar hyperglycemic state"
m (Rossdonaldson1 moved page Hyperosmolar Hyperglycemic State (HHS) to Hyperosmolar hyperglycemic state) |
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| Line 1: | Line 1: | ||
==Background== | ==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=== | ===Precipitants=== | ||
| − | + | *PNA | |
| − | + | *UTI | |
| − | + | *Medication non-compliance | |
| − | + | *Cocaine use | |
| − | + | *Meds: Beta-blockers, diuretics | |
| − | + | *GI hemorrhage | |
| − | + | *Pancreatitis | |
| − | + | *Heat-related illness | |
| − | + | *ACS | |
| − | + | *CVA | |
==Clinical Features== | ==Clinical Features== | ||
| Line 36: | Line 36: | ||
==Work Up== | ==Work Up== | ||
| − | + | *Chem | |
| − | + | *Serum Osm | |
| − | + | *Lactate | |
| − | + | *Serum ketones | |
| − | + | *CBC | |
| − | + | *Also consider: | |
| − | + | **Blood cx | |
| − | + | **UA/UCx | |
| − | + | **LFTs | |
| − | + | **Lipase | |
| − | + | **Troponin | |
| − | + | **CXR | |
| − | + | **ECG | |
| − | + | **Head CT | |
==Treatment== | ==Treatment== | ||
| − | + | *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 | |
| − | + | *Hypokalemia | |
| − | + | **Must treat aggressively | |
| − | + | **Once adequate urinary output has been established K+ replacement should begin | |
| − | + | *Hyperglycemia | |
| − | + | **Do not start insulin until K > 3.3 and adequate urinary output has been established | |
| − | + | *Hypomagnesemia | |
| − | + | **Repletion will help correct hypokalemia | |
| − | + | *Hypophosphatemia | |
| − | + | **Routine correction unnecessary unless phos <1.0 | |
[[File:HHS.jpg]] | [[File:HHS.jpg]] | ||
| Line 76: | Line 76: | ||
*[[Hypoglycemia]] | *[[Hypoglycemia]] | ||
| − | == | + | ==References== |
| − | |||
[[Category:Endo]] | [[Category:Endo]] | ||
Revision as of 11:21, 20 July 2015
Contents
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
- PNA
- UTI
- Medication non-compliance
- Cocaine use
- Meds: Beta-blockers, diuretics
- GI hemorrhage
- Pancreatitis
- Heat-related illness
- ACS
- CVA
Clinical Features
- Dehydration
- Hypotension
- Seizure (15% of pts)
- Altered mental status
- Lethargy/coma
Diagnosis
- Glucose >600
- Osm >315
- Bicarb >15
- pH >7.3
- Serum ketones negative or mildly positive
Work Up
- Chem
- Serum Osm
- Lactate
- Serum ketones
- CBC
- Also consider:
- Blood cx
- UA/UCx
- LFTs
- Lipase
- Troponin
- CXR
- ECG
- Head CT
Treatment
- 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
- Average fluid deficit is 8-12L
- Hypokalemia
- Must treat aggressively
- Once adequate urinary output has been established K+ replacement should begin
- Hyperglycemia
- Do not start insulin until K > 3.3 and adequate urinary output has been established
- Hypomagnesemia
- Repletion will help correct hypokalemia
- Hypophosphatemia
- Routine correction unnecessary unless phos <1.0
Disposition
- Most pts require ICU admission