Hyperosmolar hyperglycaemic state

Question 1

If a patient with known type 2 diabetes comes in with polyuria, polydipsia, weight loss, lethargy and vomiting, what is at the top of the differentials?

Answer 1

hyperosmolar hypoglycaemic state

Question 2

List 5 common symptoms of HHS

Answer 2

Polydipsia
Polyuria
Weight loss
Lethargy
Vomiting
Confusion
Tachycardia
Dry mucous membranes
Weakness

Question 3

What are the first 6 investigations you would order in a patient with suspected HHS?

Answer 3

blood glucose
blood ketones
VBG
U&Es
FBC
ECG

Question 4

In a patient with HHS, what is the serum osmolality usually above?

Answer 4

320mOsm/kg

Question 5

In a patient with HHS, what would you expect to be the potassium level?

Answer 5

Low unless AKI

Question 6

In a patient with HHS, what is the threshold for leukocytosis requiring further investigation?

Answer 6

25 x109/L

Question 7

What would the blood ketone concentration be in a patient with HHS?

Answer 7

<3mmol/L

Question 8

What is the first step in management for a patient with HHS?

Answer 8

IV fluid - 1L of 0.9% NaCl over 1 hour

Question 9

What are the thresholds for senior or critical care support for HHS?

Serum osmolality
Na+
pH
K+
GCS
O2
systolic BP
pulse
urine output
creatinine

which 3 other things to look out for?

Answer 9

• Serum osmolality is >350 mOsm/kg (>350 mmol/kg)
• Serum sodium is >160 mmol/L (>160 mEq/L)
• Venous/arterial pH is <7.1
• Serum potassium is <3.5 mmol/L (<3.5 mEq/L) or >6 mmol/L (>6 mEq/L) on admission
• Glasgow Coma Scale (GCS) score is <12 or AVPU (Alert, Voice, Pain, Unresponsive) scale score is abnormal[Glasgow Coma Scale ]
• Oxygen saturation is <92% on air (assuming normal baseline respiratory function)
• Systolic blood pressure is <90 mmHg
• Pulse is >100 or <60 bpm
• Urine output is <0.5 mL/kg/hour
• Serum creatinine is >200 micromol/L (>2.3 mg/dL)
• The patient is hypothermic
• The patient has a concurrent macrovascular event such as myocardial infarction or stroke, or other significant comorbidity.
  
  • In practice, heart failure and significant renal impairment (chronic kidney disease and/or acute kidney injury, particularly if eGFR <30 mL/minute/1.73 m²) should also warrant senior or critical care support.

Question 10

When should a potassium infusion solution be given in a patient with HHS?

Answer 10

If potassium is <5.5mmol/L

Question 11

List 3 common causes of HHS

Answer 11

Myocardial infarction
Stroke
Sepsis

Question 12

In HHS if there is significant ketonaemia, what should be given?

Answer 12

Fixed-rate IV insulin infusion at 0.05units/kg/hour

Question 13

What counts as significant ketonaemia in HHS?

Answer 13

beta-hydroxybutyrate >1 mmol/L

Question 14

Should a urinary catheter be places in HHS treatment?

Answer 14

Yes - because fluid balance chart needed