Hyperosmolar hyperglycaemic state

Question 1

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

Answer 1

2 - elevated glucose in the blood

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

Question 2

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

Answer 2

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

Question 3

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

Answer 3

• T2DM

Question 4

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 (inside cells) to extracellular space (blood stream) in an attempt to dilute the glucose. What affect does this have on urine?

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

Answer 4

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

Question 5

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

Answer 5

1 - dehydrates them

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

Question 6

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%

Answer 6

1 - <1%
- 10-20% mortality

Question 7

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

Answer 7

1 - glycosuria

Question 8

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

Answer 8

1 - dehyrdation

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

Question 9

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

Answer 9

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

Question 10

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

Answer 10

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

Question 11

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

Answer 11

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

Question 12

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?

Answer 12

• no

Question 13

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

Answer 13

5 - all of the above

Question 14

Are ketones raised in Hyperosmolar Hyperglycaemia State (HHS)?

Answer 14

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

Question 15

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

Answer 15

2 - 275-295 mmol/kg

Question 16

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

Answer 16

4 - 374 mOsmol/kg

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

Question 17

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

Answer 17

9 - all of the above

Question 18

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

Answer 18

5 - all of the above

Question 19

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

Answer 19

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

Question 20

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

Answer 20

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

Question 21

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

Answer 21

3 - reduce the risk of cerebral oedema

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

Question 22

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

Answer 22

1 - ABC

Question 23

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?

Answer 23

• stop the insulin
• DO NOT STOP if patient is T1DM

Question 24

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

Answer 24

• yes
• infection could be a precipitating cause of HHS

Question 25

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

Answer 25

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

Question 26

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

Answer 26

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