Difference between revisions of "Hyperosmolar hyperglycemic state"
Line 1: Line 1:
 
==Background==
 
==Background==
 
===Pathophysiology===
 
===Pathophysiology===
 +
#Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O
 
#Occurs due to 3 factors:
 
#Occurs due to 3 factors:
 
##Insulin resistance or deficiency
 
##Insulin resistance or deficiency
Line 7: Line 8:
 
###May result in TBW losses of 8-12L
 
###May result in TBW losses of 8-12L
 
#Ketosis usually absent (may be mild)
 
#Ketosis usually absent (may be mild)
−
#Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O
+
#Cerebral edema is uncommon complication (case reports)
  
 
===Precipitants===
 
===Precipitants===
Line 53: Line 54:
  
 
==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]]
  
 +
==Disposition==
 +
*Most pts require ICU admission
 
   
 
   
 
==See Also==
 
==See Also==

Revision as of 00:19, 28 September 2011

Background

Pathophysiology

  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
    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

  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

Retrieved from "https://www.wikem.org/w/index.php?title=Hyperosmolar_hyperglycemic_state&oldid=5916"