Hyperosmolar hyperglycemic state: Difference between revisions
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*Altered mental status | *Altered mental status | ||
*Lethargy/coma | *Lethargy/coma | ||
==Differential Diagnosis== | |||
==Diagnosis== | ==Diagnosis== | ||
===Work Up=== | |||
==Work Up== | |||
*Chem | *Chem | ||
*Serum Osm | *Serum Osm | ||
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**ECG | **ECG | ||
**Head CT | **Head CT | ||
===Evaluation=== | |||
*Glucose >600 | |||
*Osm >315 | |||
*Bicarb >15 | |||
*pH >7.3 | |||
*Serum ketones negative or mildly positive | |||
==Treatment== | ==Treatment== | ||
[[File:HHS.jpg]] | |||
*Fluid replacement | *Fluid replacement | ||
**Average fluid deficit is 8-12L | **Average fluid deficit is 8-12L | ||
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*Hypophosphatemia | *Hypophosphatemia | ||
**Routine correction unnecessary unless phos <1.0 | **Routine correction unnecessary unless phos <1.0 | ||
==Disposition== | ==Disposition== | ||
Revision as of 11:22, 20 July 2015
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
Differential Diagnosis
Diagnosis
Work Up
- Chem
- Serum Osm
- Lactate
- Serum ketones
- CBC
- Also consider:
- Blood cx
- UA/UCx
- LFTs
- Lipase
- Troponin
- CXR
- ECG
- Head CT
Evaluation
- Glucose >600
- Osm >315
- Bicarb >15
- pH >7.3
- Serum ketones negative or mildly positive
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
- Average fluid deficit is 8-12L
- 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
Disposition
- Most pts require ICU admission