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Year 3 > Hyperosmolar hyperglycaemic state (E&M) > Flashcards

Hyperosmolar hyperglycaemic state (E&M) Flashcards

1
Q

Define HHS.

A

Characterised by profound hyperglycaemia (>30mmol/L), hyperosmolarity (>320mOsm/kg) and volume depletion (dehydration) in the absence of significant ketoacidosis (pH>7.3 and bicarbonate>15mmol/L)

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2
Q

What is HHS also known as?

A

Non-ketotic hyperglycaemic hyperosmolar syndrome (NKHS)

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3
Q

How is ketogenesis avoided in HHS?

A

Small amounts of insulin still being secreted by pancreas

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4
Q

Which groups does HHS commonly affect? (2)

A
  • older people with T2DM
  • may be initial presentation of T2DM
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5
Q

What are the clinical features of HHS? (10)

A
  • acute cognitive impairment (recorded via GCS, due to hyponatraemia)
  • polyuria
  • polydipsia
  • weight loss
  • nausea and vomiting
  • weakness
  • dry mucous membranes + poor skin turgor (dehydration)
  • abdominal pain
  • focal neurological signs + seizures
  • more insidious onset (over days)
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6
Q

What might you see on examination of HHS?

A

Dehydration - dry mucous membranes, reduced skin turgor

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7
Q

When can coma occur in HHS?

A

Coma is rare and, if seen, is usually associated with a serum osmolarity >340mOsm/kg

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8
Q

What are some risk factors for HHS? (5)

A
  • infection (pneumonia, UTI, diabetic foot infection)
  • surgery
  • inadequate insulin therapy / non-adherence to diabetes medications
  • corticosteroids or antipsychotics
  • acute illness (MI, stroke, sepsis)
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9
Q

What do we measure in bloods for HHS and what would we see? (3)

A
  • blood glucose - markedly raised (>30mmol/L)
  • blood ketones - negative/low (<3mmol/L - distinguish HHS vs DKA)
  • VBG - none/mild acidosis (pH>7.3, bicarbonate>15mmol/L); lactic acidosis
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10
Q

What would serum osmolarity be like in HHS?

A

Significantly raised (>320mmol/L) due to hypovolaemia - key parameter to monitor

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11
Q

What would urinalysis show in HHS? (5)

A
  • renal impairment
  • hypo/hyperkalaemia
  • hypo/hypernatraemia
  • hypophosphataemia
  • hypomagnesaemia
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12
Q

What would FBC show in HHS?

A

Leukocytosis

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13
Q

What would ECG show in HHS? (2)

A
  • abnormal T or Q waves or ST-segment changes in MI
  • evidence of hypokalaemia (U waves) or hyperkalaemia (tall ‘peaked’ T waves)
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14
Q

What overall triad is seen in HHS?

A

Severe hyperglycaemia (>30) + hypotension + hyperosmolarity (>320)

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15
Q

What are some differential diagnoses for HHS? (8)

A
  • DKA
  • lactic acidosis
  • alcoholic ketoacidosis
  • ingestion of toxic substances
  • paracetamol OD
  • salicylate OD
  • seizures
  • stroke
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16
Q

What is the order of management in HHS?

A
  1. correct hypotension + electrolyte abnormalities
  2. correct hyperglycaemia - not done first as IV insulin can result in cerebral oedema due to quick shift in glucose
17
Q

How do we manage hypotension and dehydration in HHS?

A
  • fluid resuscitation with IV fluids - isotonic saline (1L 0.9% NaCl over 1h)
  • if SBP<90 give 500mL bolus saline - if no response give second bolus
  • if SBP>90/response to first bolus - start 0.9% NaCl
  • 500mL normal saline over 15-30min until SBP>100
  • use 0.45% saline if serum Na+>170
18
Q

What do we give for HHS if pH<6.9?

A

Give sodium bicarbonate

19
Q

What can excess infusion of NaCl cause? (2)

A
  • hyperchloraemic acidosis (hence Hartmann’s solution may be preferred when large volumes of fluid are needed)
  • excessive infusion of any IV fluid can cause pulmonary oedema and potentially cardiac failure
20
Q

How do we correct electrolyte disturbance in HHS?

A
  • add potassium (KCl) to saline solution infusion
  • serum potassium often high on admission despite total body potassium being low
  • potassium replacement needed as insulin drives K+ into cells
  • if rate of K+ infusion>20mmol/hr, cardiac monitoring may be required
21
Q

How do we correct hyperglycaemia in HHS?

A
  • corrected only if BGC stops falling while giving fluids
  • IV insulin (0.05 units/kg/hr)
  • if mixed DKA+HHS 0.1 units/kg/hr
  • if BGC falls <15mmol/L, infusion of 5% dextrose started
  • if capillary ketones<0.3, pH>7.3 or HCO3>18, use SC insulin instead - but there must be an overlap between IV and SC insulin for 1-2h
22
Q

What prophylaxis do we need for HHS and why?

A

VTE prophylaxis as patients at high risk due to dehydration

23
Q

What are some complications of HHS? (10)

A
  • insulin-related hypoglycaemia
  • treatment-related hypokalaemia
  • stroke
  • MI
  • PE
  • DIC
  • coma
  • mesenteric vessel thrombosis
  • cerebral oedema
  • central pontine myelinolysis
24
Q

Describe the prognosis of HHS.

A

Mortality ranges from 5-15% mostly as a consequence of older patient population that is affected by HHS + their comorbidities

Year 3 (148 decks)

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