Hyperglycaemic Hyperosmolar state

Question 1

Define Hyperglycaemic hyperosmolar state

Answer 1

Osmolarity >320mOsm, BM >30 mmol/L in a patient who is severely dehydrate and unwell (with pH >7.3)

Question 2

Aetiology of HHS

Answer 2

Hyperglycaemia but no ketonaemia as still some insulin to suppress ketogenesis
Dehydration causes increased osmolality

Precipitating factors:
- Infection e.g. UTI, pneumonia
- Stroke
- MI
- Surgery
- Trauma
- Elderly patients who are bed-ridden + compromised access to water
- Hyperthyroidism, acromegaly
- Non-adherence to medication
- Medication: Corticosteroids, thiazide diuretics, beta-blockers, and didanosine

Question 3

Symptoms of HHS

Answer 3

Acute cognitive impairment (confusion, collapse)
Polyuria, polydipsia
Weight loss
Nausea and vomiting
Weakness

Question 4

Signs of HHS

Answer 4

Obs
- Tachycardia
- Hypotension
- Hypothermia
General
- Dry mucous membranes
- Poor skin turgor
- Kussmaul breathing
- confusion

Question 5

Differentials for HHS

Answer 5

DKA
Lactic acidosis
Alcoholic ketoacidosis
Paracetamol/salicylate overdose

Question 6

Investigations for HHS

Answer 6

capillary BG
Urine ketones
Urinalysis and culture (?UTI)
ECG (?MI)

Glucose: >40mmol/L
Osmolality: >320 mosm/kg or more
VBG: pH >7.3 or bicarb >15
Ketones:<3mmol/L (exclude DKA)
U&Es: ?K+, renal impairment
FBC: leucocytosis
Blood culture: (?Infection)
LFTs: (?hepatic precipitant)

CXR: (?pneumonia)

Question 7

Management of HHS

Answer 7

Consider the need for admission to a high-dependency unit
Inform specialist diabetes team + early senior review

1. 0.9% sodium chloride bolus 1L/1 hour (switch to 0.45% NaCl if osmolality is not declining)
2. Consider potassium replacement if <3,5 with 40mmol/L
3. Glucose <14 → 5/10% dextrose at 125ml/hr
4. Consider changing flow rate of NaCl according to osmolality
5. Insert urinary catheter to monitor urine output + calculate fluid balance
6. Once BMs are no longer dropping with IV fluids OR ketones start to rise: Insulin, bolus of 0.1units/kg, followed by a fixed rate insulin infusion at 0.1units/kg/hour.
7. Prophylactic LMWH
8. Treat underlying cause e.g. Abx for infection

Once stable, convert to SC insulin regimen and encourage early mobilisation
Measure daily U&Es
D/C with SC insulin and switch to oral hypoglycaemic once stable (weeks/months)

Question 8

Complications of HHS

Answer 8

Myocardial infarction
Stroke
Pulmonary embolism
Disseminated intravascular coagulation
Mesenteric vessel thrombosis
Coma

Question 9

Prognosis for HHS

Answer 9

Mortality ranges from 5-15%, usually seen in elderly patients with comorbid conditions
Mortality is usually caused by the underlying illness that precipitated the metabolic complications