Hyperosmolar hyperglycemic state: Difference between revisions

m (moved Hyperosmolar Hyperglycemic Nonketotic State (HHS) to Hyperosmolar Hyperglycemic State (HHS): The ADA terminology does not include the word nonketotic)
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==Background==
==Background==
===Pathophysiology===
#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)
#Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O
===Precipitants===
===Precipitants===
# Renal failure
#PNA
# Pneumonia, Sepsis
#UTI
# GI bleed
#Medication non-compliance
# MI
#Cocaine use
# CVA, bleed/ischemic
#Meds: Beta-blockers, diuretics
# PE
#GI hemorrhage
# Pancreatitis  
#Pancreatitis
# Burns
#Heat-related illness
# Heat Stroke
#ACS
# Dialysis
#CVA
# Recent Surgery
 
# Drugs, Meds: CCBs, Beta-blockers, carbamezapines, cimetidine, cocaine/alcohol, steroids, etc..
==Clinical Features==
*Dehydration
**Hypotension
*Seizure (15% of pts)
*ALOC
*Lethargy/coma


==Diagnosis==
==Diagnosis==
===History===
*Glucose >600
# Fever
*Osm >315
# Thirst
*Bicarb >15
# Polyuria or Oliguria or Polydipsia
*pH >7.3
# Confusion
*Serum ketones negative or mildly positive
# Seizures (focal)
# Hallucinations
 
===Physical Exam===
# decrease consciousness
# tachy, hypotension
# fever
# focal seizures
# hemiparesis
# myoclonus
# quadriplegia
# nystagmus


==Work Up==
==Work Up==
# CBC
#Chem
# UA
##Hypokalemia must be aggressively treated
# CXR
#Osm
# EKG
#Lactate
# cultures
#Serum ketones
# Head CT, LP if suspecting intracranial process
#CBC
#Also consider:
##Blood cx
##UA/UCx
##LFTs
##Lipase
##Troponin
##CXR
##ECG
##Head CT


* 50-65% have no history of diabetes
==Treatment==
* Chem-10: Glucose> 600mg/dl (often > 1000), BUN/Cr ratio  >30
[[File:HHS.jpg]]
* 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==
==See Also==
Endo: DKA
*[[DKA]]
 
*[[Diabetes (Meds)]]
[[Diabetes (Meds)]]
*[[Hypoglycemia]]
 
[[Hypoglycemia]]


==Source==
==Source==
Sotelo 11/3/2009
Tintinalli's


[[Category:Endo]]
[[Category:Endo]]

Revision as of 23:58, 27 September 2011

Background

Pathophysiology

  1. 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
  2. Ketosis usually absent (may be mild)
  3. Prototypical pt is elderly pt w/ uncontrolled type II DM without adequate access to H2O

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

HHS.jpg


See Also

Source

Tintinalli's

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