HHS

Question 1

Hyperglycemic hyperosmolar syndrome (HHS) dx:
BG>:
mOsm>:
ketones:

Answer 1

severe hyperglycemia (>600 mg/dl)
350 hyperosmolality
no or minimal urine ketones

Question 2

Reduction of glomerular filtration rate (GFR) is essential. i.e.

The most important goals of therapy are:

how do fluids alone reduce BG levels via dilution and by

Prognosis for feline HHS patients is:
Dogs:

Answer 2

Renal failure and congestive heart failure are common

replace fluid deficits and SLOWLY decrease glucose concentration, thereby avoiding rapid intracranial shifts in osmolality and preventing cerebral edema

via dilution and increasing GFR

poor (12% long-term survival) -2 concurrent disease better px (62% discharged from hospital)

Question 3

HHS accounted for ___% cats __% dog DM emergencies

Answer 3

6.4% cats 5% dogs

Question 4

Hormonal Alterations MoA:

• relative or absolute lack of:
• increases in circulating levels of counterregulatory:
• counterregulatory elevated b/c:
• hepatic glycogenolysis and gluconeogenesis stimulated = diabetogenic hormones increase:

Pathogenesis of HHS is similar to DKA, except HHS is believed that small amounts of insulin and hepatic glucagon resistance inhibit:

Answer 4

insulin
glucagon, epinephrine, cortisol, and growth hormone concurrent disease
-protein catabolism, which in turn impairs insulin activity in muscle and provides amino acids for hepatic gluconeogenesis

lipolysis, thereby preventing ketosis and instead promoting HHSp

Question 5

Hyperglycemia promotes_____ diuresis
and _____ diuresis increases magnitude of:

vicious circle of progressive diuresis, dehydration, and hyperosmolality

Neurologic signs develop secondary:

Answer 5

osmotic
hyperglycemia

cerebral dehydration

Question 6

progressive dehydration, hypovolemia, and ultimately a reduction in____

severe hyperglycemia can ONLY occur in the presence of __

because:

Answer 6

GFR

reduced GFR

because no maximum rate of glucose loss via the kidney
ALL glucose that enters kidney in excess of the renal threshold will be excreted in the urine

Question 7

______correlation exists between GFR and serum glucose in diabetic humans

Answer 7

inverse

Question 8

Concurrent disease
initiating the hormonal changes associated with HHS:

predispose diseases include:

panc and HHS:

Answer 8

renal failure
congestive heart failure (CHF)
infection
neoplasia
endocrinopathies

panc and hepatic disease uncommon in cats with HHS
pancreatitis more common in dogs, 1/3 canine HHS

Question 9

Dx vet.:
Dx human:

humans with HHS may have small quantities of:

Dogs with HHS have been classified as being ketotic or nonketotic at the time of the hyperosmolar event

Glucose concentrations can reach:
index of suspicion bc VBG will not read

Answer 9

600 mg/dl, absence of urine ketones,>350 mOsm/
600 mg/dl, arterial pH >7.3 ,>HCO3 15 mmol/L, >320 mOsm/kg, AG <12 mmol/

quantities of urine and serum ketones, measured by the nitroprusside method. Dogs with HHS have been classified as being ketotic or nonketotic at the time of the hyperosmolar event.

1600 mg/d

Question 10

effective osmolality:
Na units
Gluc units

Answer 10

2(Na) + (Gluc/18)
mg/dl
mEq/L

Question 11

VBG to assess degree of acidemia
Is it possible to differentiate HHS from DKA in cats based on the degree of metabolic acidosis?

Dogs, low pH and HHS has been associated with:

Answer 11

No

poorer outcome

Question 12

HHS, metabolic acidosis is caused by

Answer 12

uremic acids and lactic acid

NOT ketones

Question 13

Sodium is measured in _____
glucose is measured in _____

This effect is nonlinear, however; mild hyperglycemia leads to smaller changes in plasma sodium concentration than more severe hyperglycemia

Answer 13

mEq/L

mg/dl

Question 14

Treatment
1. 
2.
3.
4.

Answer 14

1. replacing the fluid deficit, slowly
2. reducing serum glucose and Na levels slow
3. electrolyte abnormalities,
4. treating concurrent disease

Question 15

not to lower the serum:

Answer 15

glucose or sodium too rapidly

Question 16

In humans, fluid losses HHS are ___X DKA patients

vascular volume is anticipated to decrease when water moves to the interstitium and intracellular space as intravascular glucose and osmolality decline =

first goal of therapy is to replace vascular volume in those patients with signs of hypovolemia or hypovolemic
shock:

On its own, fluid therapy will start to reduce blood glucose levels via:

Answer 16

2X

insufficient fluid resuscitation can contribute to cardiovascular collapse and death

initial 20 ml/kg (cat) to 30 ml/kg (dog) bolus

dilution
increasing GFR
subsequent urinary glucose excretion

Question 17

How does isotonic saline (0.9% saline) preventing a rapid shift in osmolality?/why can you bolus?:

Answer 17

it both addresses the fluid deficits
and replaces glucose w. Na+ in extracellular space
preventing osmolality shifts

Question 18

dehydration deficits should be replaced more slowly with Na closer to current .:. seperate IV

Correct hypernatremia with free water formula:
no more than:

but first must corr. Na:

may be necessary to switch back to isotonic saline if the sodium is dropping to quickly or if there are problems maintaining vascular volume which should be anticipated why?:

In humans the fluid deficit is assumed:

Answer 18

24 hrs

Free water deficit: 0.6 x Kg x (currNa - norm Na/normNa)
1 mEq/L/hr

severe hypernatremia may be masked by a hyperglycemia-induced pseudohyponatremia

hyperglycemia is corrected and water moves out of the vascular space (osmoltic pull intracell. now)

12% to 15% of body weight

Question 19

insulin therapy is not as critical for reversal of HHS because much of the syndrome can be improved just by:

ketotic HHS patient, insulin may be needed somewhat sooner to:

insulin therapy should be instituted only after several hours of fluid therapy and only if:

Answer 19

improving GFR

reverse ketogenesis

potassium, magnesium, and phosphorus corrected

Question 20

HHS when is time for insulin?:

Answer 20

glucose concentrations are no longer adequately declining <50 mg/dl/hr

Question 21

goal is to decrease the glucose levels by no more than:

Answer 21

50 to 75 mg/dl/hr

or else decrease dose by 25% to 50%

Question 22

Insulin protocol is slower/lower than DKA:

__U/kg into 250 NaCl

Answer 22

Dilute 1 U/kg of regular insulin in 250 ml 0.9% NaCl. Start this solution at 10 ml/hr (then same chart)

Question 23

Monitoring 8):

Answer 23

1. Serial neurologic
2. BG <50-75mg/dl/hr
3. Na <1mEq/L/hr
4. hydration - expect osmotic shift and hypovolemia
5. PCV/TP, kg, UOP, USG
6. ELECTROLYTES
7. EKG signs-of-life monitor
8. ketones

Question 24

Px:
humans, the mortality rate 
children
dogs
cats

Answer 24

15% to 17%
72%
dogs better prognosis (62% discharged from hospital)
cats poor (12% long-term survival)