Hyperosmolar hyperglycemic state

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
  • 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

HHS.jpg

Disposition

  • Most pts require ICU admission

See Also

References