HHS

Question 1

HHS Definition

Answer 1

Precise definition does not exist but there are characteristic features

• Hypovolaemia
• Marked hyperglycaemia without significant hyperketonaemia
• Osmolality usually 320 mosmol/kg or more
• Mixed picture HHS/DKA may occur

Question 2

HHS Epidemiology

Answer 2

• Affects mostly elderly people, also presenting in younger adults
• Type 2 diabetics

Question 3

HHS Presentation

Answer 3

• Patients become ill very quickly
• Usually manifests as acutely unwell patient showing signs of gross dehydration
• Patients notice early signs of general weakness, leg cramps, visual impairment
• N/V can occur less common than in DKA
• Focal neurological symptoms may occur, seizures are present in up to 25% of cases
• Coma is rare; represents progression to severe states

Question 4

HHS Signs

Answer 4

General
-Ill appearance, disorientation/confusion, dehydration
Vital signs
-Tachycardia, hypotension, increased RR, pyrexia/hypothermia, low sats
Skin
-Careful examination of entire skin surface is needed looking for rashes and localised sepsis, reduced turgor
Head
-Sunken eyes, dry mouth, on cranial nerve examination may reveal visual field deficits, nystagmus, other palsies
Neck
-Lymph enlargement, signs of meningitis
Cardiac
-HF
Abdominal
-Acute abdomen, paralytic ileus may occur
Neurological
-Check orientation and higher functions and Kernig’s sign

Question 5

HHS Differentials

Answer 5

Diagnosis is usually clear

• Older patients present with delirium
• Acute poisoning
• Lactic acidosis or other causes of metabolic acidosis

Question 6

HHS Ix

Answer 6

• Urinalysis (marked glycosuria with normal or only slightly elevated ketones)
• Capillary glucose markedly elevated
• Serum osmolality >320
• U/Es (pre-renal AKI)
• FBS, CRP
• Cultures if any site of possible infection
• ABG (pH usually>7.3
• CK and cardiac enzymes as MI can cause
• ECG and CXR

Question 7

HHS Initial Management

Answer 7

Treat cause, replace fluids/electrolytes, normalise blood glucose

• Prevent complications eg ulceration
• ABC, monitoring, IV access, catheterise, alert acute medical/diabetic team (!)

Question 8

HHS Management

Answer 8

• Measure and calculate osmolality to monitor response
• Use 0.9% saline switch to 0.45% if osmolality is not declining despite adequate fluid balance
• Blood glucose should fall by no more than 5 per hour, low dose insulin if glucose is no longer falling with IV fluids alone
• Assess for complications
• Prophylactic anticoagulation required

Question 9

HHS Complications

Answer 9

Mortality is high (15-20%)

• Ischaemia or infarction
• VTE
• ARDS
• DIC
• Rhabdomyolisis