Hyperosmolar Hyperglycaemic State

HYPEROSMOLAR HYPERGLYCAEMIC

STATE

TUAN MOHD AMIRUL HASBI BIN TUAN PAIL012009100131

INTRODUCTION

Life threatening emergency

Less severe than DKA

Previously known as HHNKC

infection is the most common precipitating factor

Characterised by

Hyperglycaemia

Hyperosmolar

Dehydration

Without ketoacidosis

DIAGNOSTIC FEATURES

PARAMETERS VALUES

Plasma Gluc Level >600ml

Serum osmolality >320mOsm/kg

Profound dehydration >9L

pH >7.3

Bicarbonate conc. >15 mEq/L

Small ketonuria

Some alteration in consciousness

AETIOLOGY

Patient DM2 prone to develop it

Old age

Living alone

No access to medical treatment

Acute infection, burns, and trauma

CVA, MI

Alcohol excess

Recurrent vomiting/diarrhea

DRUGS:

Thiazide

Steroids

Atypical antipsychotic

Antiarrythmics

Antiepileptic

Antihypertensive: CCB, Thiazide, Diuretics.

PATHOPHYSIOLOGY

SYMPTOMS

Confuse

Weakness

Polyuria, polydipsia, polyphagia

Vomitting

Dry skin

Seizure

fever

Physical examinations

1. Assessment of vital signs

tachycardia-hypotension-tachypnea

hyperthermia/hypothermia

head to toe examination for signs of dehydration

2.Evaluation of DM

presence of fingerpricks

ecchymoses on abdomen, thigh and arm

obesity

acanthosis nigrican

diabetic dermopathy

tooth decay

thrush

moon face

Retinopathy, premature, cataract

3. Assessment of dehydration

every 1L body fluids loss, there is 1kg of wt loss

skin turgor

dryness of skin

Dry, sticky mouth

Lethargy

COMPLICATION

Cerebral edema

Acute respiratory distress syndrome

Vascular complication

Hypoglycaemia

hyperglycaemia

DD(x)

Diabetes insipidus

Diabetic ketoacidosis

Myocardial infarction

Pulmunory embolism

INVESTIGATIONS

MANAGEMENT

GOAL:

1.Fluid replacement to correct dehydration

2.To correct hyperglycaemia by insulin3.Correction of electrolytes 4.Treat underlying disease5.Monitor CVS, CNS, renal, RS function.

Fluid Replacement

Rapid infusion of large amount of fluid to correct circulation and to reestablish adequate urine flow

Fluid deficit in HHS is 11-12L- large

Isotonic 0.9% saline is used - 2L within 2hour

Then change to 0.45% isotonic saline

When the glucose level approach normal after the hydration and insulin therapy, then 5% dextrose is given as the vehicle for free water.

Fluid deficit should correct estimated deficit within 24 hour.

in patient with renal/cardiac compromise, CVP monitoring and serum osmolality is mandatory while the infusion to avoid fluid overload.

INSULIN THERAPY

Regular insulin by continuous IV infusion is the treatment of choice.

Exclude hypokalemia

IV bolus of regular insulin (0.15 u/kg)

Followed by 0.1 u/kg/ hour

Until blood gluc falls to 300mg/dl

Then, reduce to 0.05 u/kg/hour plus 5% dextrose

Target: blood gluc below 250mg/dl

When the patient is concious, ask to take orally for maintenance of blood sugar.

Potassium Replacement

Mild to moderate hyperkalemia is not uncommon in HHS

Insulin therapy and volume expansion decreased the K+ concentration, hence K+ replacement is needed.

Once renal function is assured, K+ may be given to prevent hypokalaemia

When IV fluids infusion, monitor serum potassium level. When it falls below 5 mEq/L, and urine output is good, 20-30 mEq/L of postassium may be given.

Treat the cause

Identify and treat the underlying problem.