Hyperosmolar hyperglycemic state: Difference between revisions
m (Rossdonaldson1 moved page Hyperosmolar Hyperglycemic State (HHS) to Hyperosmolar hyperglycemic state) |
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==Background== | ==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=== | ===Precipitants=== | ||
*PNA | |||
*UTI | |||
*Medication non-compliance | |||
*Cocaine use | |||
*Meds: Beta-blockers, diuretics | |||
*GI hemorrhage | |||
*Pancreatitis | |||
*Heat-related illness | |||
*ACS | |||
*CVA | |||
==Clinical Features== | ==Clinical Features== | ||
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==Work Up== | ==Work Up== | ||
*Chem | |||
*Serum Osm | |||
*Lactate | |||
*Serum ketones | |||
*CBC | |||
*Also consider: | |||
**Blood cx | |||
**UA/UCx | |||
**LFTs | |||
**Lipase | |||
**Troponin | |||
**CXR | |||
**ECG | |||
**Head CT | |||
==Treatment== | ==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 | |||
[[File:HHS.jpg]] | [[File:HHS.jpg]] | ||
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*[[Hypoglycemia]] | *[[Hypoglycemia]] | ||
== | ==References== | ||
[[Category:Endo]] | [[Category:Endo]] | ||
Revision as of 11:21, 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
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
- 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