HHS

Question 1

what are the features of HHS?

Answer 1

hyperglycaemia
hypovalaemia
raised plasma osmolality

Question 2

what is HHS a complication of?

Answer 2

type 2 diabetes mellitus

Question 3

why does ketosis not occur in HHS?

Answer 3

presence of basal insulin secretion sufficient to prevent ketogenesis

Question 4

what can cause HHS?

Answer 4

anything that causes dehydration, most commonly infection but also being in hospital and having insufficient intake, drugs and alcohol, AKI etc
anything that causes raised BM eg cushing’s syndrome
MI and PE also can be triggers

Question 5

what is the presentation of HHS?

Answer 5

usually within days not hours
dehydration with marked thirst
marked drowsiness
convulsions, coma, focal neuro signs

Question 6

what are the diagnostic features of HHS?

Answer 6

hypovalaemia
marked hyperglycaemia (>30), without significant ketones
raised plasma osmolality >320.

Question 7

what are the bedside tests for HHS?

Answer 7

classic A-E
cap BM< -very raised
cap ketones -normal
urine dip -normal ketones, high glucose
12 lead ECG -?MI

Question 8

what are the blood tests for ?HHS?

Answer 8

plasma glucose
FBC -?infection
CRP-?infection
U+E
VBG
serum osmolality
cardiac enzymes -?MI
amylase -?pancreatitis
blood cultures ?sepsis
Mg2+ -usually low
CK -?rhabdo

Question 9

what do the U+Es look like in HHS?

Answer 9

Na+ can be low or high, usually high due to dehydration
K+ usually normal
creatinine -usually raised due to kidney dysfunction
urea -raised due to dehydration and kidney dysfunction

Question 10

what does the VBG look like in HHS?

Answer 10

usually mild metabolic acidosis, arterial pH usually >7.3
normal anion gap

Question 11

how do you calculate serum osmolality?

Answer 11

2(Na+ +K+) +glucose +urea

Question 12

what are the main treatment points for HHS?

Answer 12

fluid and electrolyte replacement
insulin
regular monitoring with VBGs
treat underlying cause eg infection
anticoagulation
consider HDU/ITU

Question 13

how do you do fluid replacement in HHS?

Answer 13

IV 0/9% NaCl
add K+ after first hour if needed just like DKA
aim for reduction in blood glucose of no more than 5mmol/h

Question 14

how do you use insulin to manage HHS?

Answer 14

fixed rate insulin infusion (FRIII) -0.05U/kg/h
aim for reduction in BM of no more than 5mmol/h
reassess once BM has stopped declining during initial treatment
need to wait an hour before giving insulin in kids just like DKA

Question 15

what anticoagulation should be used in HHS?

Answer 15

just need to make sure they’re on the admission one or give them the admission one -prophylactic LMWH

Question 16

what are some reasons to consider HDU/ITU in an HHS patient?

Answer 16

osmolality >350
Na+ >160
pH <7.1
all rest self explanatory -severe illness, severe K+, etc

Question 17

what are the potential complications of HHS?

Answer 17

clots due to hypercoagulability -MI, stroke, PE, DVT
renal failure
multi-organ failure
ARDS
DIC
rhabdo
cerebral oedema
central pontine myelinolysis
hypoglycaemia /heart failure due to overcorrection with insulin/fluids

Question 18

what happens in central pontine myelinolysis?

Answer 18

also called osmotic demyelination syndrome
happens after to rapid a correction of hyponetraemia, damage to myelin sheath of nerve cells in pons. sx=acute paralysis, dysphagia, dysarthria, other neuro sx.