Hyperosmolar hyperglycemic state

Background

Precipitants

1. Renal failure
2. Pneumonia, Sepsis
3. GI bleed
4. MI
5. CVA, bleed/ischemic
6. PE
7. Pancreatitis
8. Burns
9. Heat Stroke
10. Dialysis
11. Recent Surgery
12. Drugs, Meds: CCBs, Beta-blockers, carbamezapines, cimetidine, cocaine/alcohol, steroids, etc..

Diagnosis

History

1. Fever
2. Thirst
3. Polyuria or Oliguria or Polydipsia
4. Confusion
5. Seizures (focal)
6. Hallucinations

Physical Exam

1. decrease consciousness
2. tachy, hypotension
3. fever
4. focal seizures
5. hemiparesis
6. myoclonus
7. quadriplegia
8. nystagmus

Work Up

1. CBC
2. UA
3. CXR
4. EKG
5. cultures
6. 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

1. 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
   1. ADA guidelines: 1/2 NS at 4-14 ml/kg/hr if corrected sodium normal or elevated
   2. ADA guidelines: NS at 4-14 ml/kg/hr if low corrected sodium
2. Add dextrose once glucose fall <=300 mg/dl
3. Replace potassium (5-10 meq per h) when level available and OK UOP
   1. if serum K <3.3 mEq/L add 40 mEq/L/hr
   2. if serum K <5 mEq/L add 20 mEq to each liter of fluids
   3. chemistry q1hr for first 4-6hrs of treatment
4. Insulin: may be unnecessary in ED. Consider starting once hemodynamically stable and UOP is adequate
   1. consider 0.1 Unit/kg/hr IV and modify rate to lower glucose 50-75 dL/hour
   2. once glucose is <=300 mg/dL, add D5 and decrease insulin to <= 0.5 Units/kg/hr
5. Empiric phosphate repletion, SC Heparin, Broad Spectrum PPx ABx may be needed
6. Avoid phenytoin for seizures since this agent inhibits the release of exogenous insulin and is associated with HHS
7. Admit ICU, consider central line if underlying cardiac, or renal disease

See Also

Endo: DKA

Diabetes (Meds)

Hypoglycemia

Source

Sotelo 11/3/2009