Hyperosmolar Hyperglycaemic State

Question 1

Epidemiology

Answer 1

Patients present in middle or later life with previously undiagnosed diabetes
Average presentation age = 60
Usually it is precipitated by infection (MC = PNEUMONIA)

Question 2

Pathophysiology

Answer 2

Endogenous insulin levels are reduced but are still sufficient to inhibit hepatic ketogenesis but insufficient to inhibit excessive hepatic glucose production via gluconeogensis
glucose = osmotically active = excessive glucose = hyperosmolar blood

Question 3

Risk factors

Answer 3

Infection
Inadequate insulin or oral anti diabetic therapy
Nursing home residents
Post operative state
TPN

Question 4

Diagnosis

Answer 4

FIRST LINE =
Glucose, urea + electrolytes blood tests
- hyperglycaemia >30 mmol/L = increased plasma osmolality
- without hyper-ketonaemia (<3mmol/L)
- without acidosis (pH >7.3, bicarbonate > 15 mmol/L)
Urine dipstick = Heavy glycosuria

Question 5

Treatment

Answer 5

FIRST LINE = INSULIN (+ K+ and glucose)
then IV fluids - 0.9% saline
LMWH - enoxaparin - decrease risk of thromboembolism

Question 6

! COMPLICATIONS - macrovascular and microvascular

Answer 6

macrovascular -
- cardiovascular = MI
- cerebrovascular = ischaemic stroke
- Peripheral arterial = PVD
microvascular
- retinopathy
- neuropathy (diabetic foot)
- nephropathy (nephrotic syndrome, CKD)

Question 7

SIGNS AND SYMPTOMS

Answer 7

HEIGHTENED T2DM SYMPTOMS
DECREASED CONSCIOUSNESS