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.