Hyperosmolar hyperglycemic state

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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

Endo: Diabetes (Meds)

Endo: Hypoglycemia


Source

Sotelo 11/3/2009