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A. MLA Map Acute and Emergency > Hyperosmolar hyperglycaemic state > Flashcards

Hyperosmolar hyperglycaemic state Flashcards

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1
Q

What is a Hyperosmolar Hyperglycaemia State (HHS)?

1 - elevate osmolarity of electrolytes
2 - elevated glucose in the blood
3 - reduces glucose in the blood
4 - all of the above

A

2 - elevated glucose in the blood

  • blood glucose is high in blood
  • hyperosmolality state of glucose
  • associated with low or no insulin
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2
Q

Does Hyperosmolar Hyperglycaemia State (HHS) or diabetic ketoacidosis have a more rapid onset?

A
  • DKA = rapid onset (hours)
  • HHS = slow progressive (hours to days)
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3
Q

Is a Hyperosmolar Hyperglycaemia State (HHS) more common in T1DM or T2DM?

A
  • T2DM
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4
Q

Hyperosmolar Hyperglycaemia State (HHS) is where the blood glucose is high in blood, resulting in a hyperosmolality state, generally associated with low or no insulin. Glucose is a polar molecule so it cannot diffuse across cellular membranes. It also draws blood from intra to extracellular space. What affect does this have on urine?

1 - ketonameia
2 - polyuria
3 - dysuria
4 - glucosuria

A

2 - polyuria
- body tries to reduce fluid in blood vessels

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5
Q

Hyperosmolar Hyperglycaemia State (HHS) is where the blood glucose is high in blood, resulting in a hyperosmolality state, generally associated with low or no insulin. Glucose is a polar molecule so it cannot diffuse across cellular membranes. It also draws blood from intra to extracellular space. What affect does this have on cells of the body?

1 - dehydrates them
2 - induces cell lysis due to lack of fluid
3 - induces cell apoptosis
4 - all of the above

A

1 - dehydrates them

  • brain is specifically affected, causing mental issues such as confusion
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6
Q

A Hyperosmolar Hyperglycaemia State (HHS) is where the blood glucose is high in blood, resulting in a hyperosmolality state, generally associated with low or no insulin. How common is HHS in hospitalised diabetes patients?

1 - <1%
2 - <10%
3 - <30%
4 - >50%

A

1 - <1%
- 10-20% mortality

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7
Q

Insulin deficiency causes hyperglycaemia, which in turn can lead to increased glucose to be present in the urine, what is this called?

1 - glycosuria
2 - polyuria
3 - dysuria
4 - osmoluria

A

1 - glycosuria

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8
Q

Insulin deficiency causes hyperglycaemia, which in turn can lead to increased glucose to be present in the urine, called glycosuria. This can then lead to 2 major effects on the patient, both linked with 2 much fluid leaving the body as urine. What are these 2 effects?

1 - dehyrdation
2 - ketonaemia
3 - lipoaemia
4 - electrolyte losses

A

1 - dehyrdation

4 - electrolyte losses
- lost in urine
2 - electrolyte loss

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9
Q

Insulin deficiency causes hyperglycaemia, which in turn can lead to increased glucose to be present in the urine, called glycosuria. This can then lead to dehydration and electrolyte loss. How does hyperglycaemia cause electrolyte loss?

1 - hyperglycaemia induces hyponatraemia
2 - hyperglycaemia induces hypernatraemia
3 - hyperglycaemia induces hypokalaemia
4 - hyperglycaemia induces hyperkalaemia

A

1 - hyperglycaemia induces hyponatraemia

  • high blood glucose increases extracellular fluid due to osmosis
  • high extracellular fluid causes hyponatraemia
  • diuresis is increased to reduce extracellular fluid and glucose
  • electrolytes and glucose are lost
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10
Q

Insulin deficiency causes hyperglycaemia, which in turn can lead to increased glucose to be present in the urine, called glycosuria, which can then lead to dehydration and electrolyte loss. Long term what effect can this have on renal function?

1 - increased eGFR
2 - damaged renal tubules
3 - decreased eGFR
4 - no effect

A

2 - damaged renal tubules
- impaired renal function or even failure

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11
Q

The effects of insulin deficiency and hyperglycaemia can have a number of detrimental effects, culminating in a Hyperosmolar Hyperglycaemia State (HHS), as seen in the image. What does the ultimately lead to?

1 - liver damage
2 - shock and CV collapse
3 - brain damage
4 - renal failure

A

2 - shock and CV collapse
- most diabetic patients die of heart complications

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12
Q

A Hyperosmolar Hyperglycaemia State (HHS) is where the blood glucose is high in blood, resulting in a hyperosmolality state, which is associated with low or no insulin. Does lipolysis occur in HSS?

A
  • no
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13
Q

A Hyperosmolar Hyperglycaemia State (HHS) is where the blood glucose is high in blood, resulting in a hyperosmolality state, generally associated with low or no insulin. How many of the 4 diagnostic criteria for HSS are required to confirm a diagnosis of HSS?

1 - hypovolaemia
2 - hyperglycaemia >30 mmol/L
3 - no significant hyperketonaemia
4 - osmolality >320 mosmol/kg
5 - all of the above

A

5 - all of the above

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14
Q

Are ketones raised in Hyperosmolar Hyperglycaemia State (HHS)?

A
  • no
  • there is no switch to ketone metabolism
  • pH should also remain >7.3
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15
Q

To calculate osmolality we use the formula:

  • (2 x Na+ add K+) add urea add glucose

What is the normal range for osmolality?

1 - 200-250 mmol/kg
2 - 275-295 mmol/kg
3 - 300-350 mmol/kg
4 - >400 mmol/kg

A

2 - 275-295 mmol/kg

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16
Q

A patient with HHS has his blood tests and gives the following results:

Hb 134 g/L, WBC 12 x109/L
Na+ 154 mmol/L, K+ 4.0 mmol/L, creatinine 180 μmol/L, Urea 18 mmol/L, Glucose 40 mmol/L, LFTs normal and CRP 65 mg/L.

Which is the best estimate of his serum osmolality?

1 - 352 mOsmol/kg
2 - 356 mOsmol/kg
3 - 366 mOsmol/kg
4 - 374 mOsmol/kg
5 - 421 mOsmol/kg

A

4 - 374 mOsmol/kg

  • 2 x Na+ K+ = (154 + 4) x 2 = 316
  • Urea = 18
  • Glucose = 40
    = 374 mOsmol/kg
17
Q

A Hyperosmolar Hyperglycaemia State (HHS) is where the blood glucose is high in blood, resulting in a hyperosmolality state, generally associated with low or no insulin. Which of the following are the main clinical symptoms of HHS?

1 - insidious onset (slow gradual onset)
2 - polyuria
3 - polydipsia (excessive thirst)
4 - muscle weakness
5 - blurred vision
6 - hallucinations/confusion
7 - coma
8 - clinical signs of dehydration
9 - all of the above

A

9 - all of the above

18
Q

A Hyperosmolar Hyperglycaemia State (HHS) is where the blood glucose is high in blood, resulting in a hyperosmolality state, generally associated with low or no insulin. Which of the following are precipitations for HHS?

1 - infection
2 - myocardial infarction
3 - high dose steroid therapy
4 - cocaine
5 - all of the above

A

5 - all of the above

19
Q

A Hyperosmolar Hyperglycaemia State (HHS) is where the blood glucose is high in blood, resulting in a hyperosmolality state, generally associated with low or no insulin. The first step in treating HHS is to rehydrate the patient. Patients should be given 0.9% saline slowly via IV over 48 hours at what volumes?

1 - 50 - 100ml/kg
2 - 100 - 150ml/kg
3 - 110 - 220ml/kg
4 - 150 - 250ml/kg

A

3 - 110 - 220ml/kg
- 70kg patient =
(110 x 70)/1000 or (220 x 70)/1000 = 7.7 - 15.4L or 8-15L

  • replace fluid loss
  • correct electrolytes and osmolality (measure frequently)
  • reduce glucose
  • treat underlying precipitant
  • prevent complications
20
Q

A Hyperosmolar Hyperglycaemia State (HHS) is where the blood glucose is high in blood, resulting in a hyperosmolality state, generally associated with low or no insulin. When would insulin be given to a patient with HHS?

1 - never
2 - if blood glucose does not reduce at all
3 - if glucose does not fall by 10-15mmol/L in 1st 24 hours
4 - if glucose is not falling 5mmol/L/h

A

4 - if glucose is not falling 5mmol/L/h
- whilst rehydrating
- if ketones are present

21
Q

A Hyperosmolar Hyperglycaemia State (HHS) is where the blood glucose is high in blood, resulting in a hyperosmolality state, generally associated with low or no insulin. Why do we want to aim to keep the patients blood glucose between 10-15mmol/L for the 1st 24 hours?

1 - to reduce the risk of HHS reoccurrence
2 - reduce the risk of DKA
3 - reduce the risk of cerebral oedema
4 - reduce the risk of renal failure

A

3 - reduce the risk of cerebral oedema

We need to treat the patient slowly, due to the risk of cerebral oedema and heart failure

22
Q

If a diabetic patient is suspected of being Hyperosmolar Hyperglycaemia State (HHS) and arrives at hospital, which of the following is most important to check initially?

1 - ABC
2 - capillary blood glucose
3 - ABG/VBG
4 - all of the above

A

1 - ABC

23
Q

If a patient is confirmed as being Hyperosmolar Hyperglycaemia State (HHS) and they are taking insulin, would we continue with the insulin or stop it?

A
  • stop the insulin
  • DO NOT STOP if patient is T1DM
24
Q

When managing a patient with Hyperosmolar Hyperglycaemia State (HHS), would we need to do a blood culture?

A
  • yes
  • infection could be a precipitating cause of HHS
25
Q

When treating a patient with Hyperosmolar Hyperglycaemia State (HHS). Should K+ be added straight away?

A
  • no
  • only give once urine begins to flow
  • DO NOT GIVE WITH 1ST BAG OF FLUIDS
26
Q

In a patient with ‘Hyperosmolar Hyperglycaemic State’, which is the most appropriate initial treatment?

1 - Start broad-spectrum antibiotics
2 - Start intravenous insulin infusion 0.05 units/kg/hour
3 - Start intravenous insulin infusion 0.1 units/kg/hour
4 - Start intravenous 0.9% saline 1L 12 hourly
5 - Start intravenous 0.9% saline 1L over 1st hour

A

5 - Start intravenous 0.9% saline 1L over 1st hour
- adjust based on patients SBP

Insulin will be given eventually, but rehydration is the most important thing to do

Aim is to gradually reduce the osmolality

A. MLA Map Acute and Emergency (42 decks)

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