S17C222 - Hyperosmolar Hyperglycemic state

Question 1

HHS: overview

Answer 1

• hyperglycemia
• hyperosmolarity
• usually type2 DM
• often limited access to water and precipitating medical event
• higher mortality than DKA (just b/c of popn)

AKA: hyperosmotic, non-ketotic hyperglycemic and coma (HONC) however HHS syndrome does not include ketosis and coma

Question 2

HHS: pathophys

Answer 2

3 factors:

• insulin resistance/deficiency
• increased gluconeogenesis/glycogenolysis
• osmotic diuresis and dehydration and impaired excretion of glucose
• impaired use of glucose leads to increased glucose production from liver and hyperglycemia and as osmolality increases water moves from ICF into vessels and GFR increases, glucosuria occurs and osmotic diuresis occurs
• it pt has access to water they can replace thier losses
• as volume depletion occurs less glucose can be lost through the urine and hyperglycemia worsens
• can lose up to 12L of water
• ketoacidosis does not usually occur

Question 3

HHS: clinical picture

Answer 3

• usually elderly with comorbidities
• weakness, fatigue, dyspnea, anorexia, abdo pain, neuro complaint
• usually have T2DM and an acute illness or noncompliancd
• hypotension, dry mm

Question 4

HHS: Dx

Answer 4

• glucose >33
• pH >7.3
• serum bicarb >15
• none or small amt of ketones
• serum osmolarity >320
• anion gap

Question 5

HHS: Tx

Answer 5

• treat the hypokalemia (ensure urinary output first) - at 10-20mEq/h
• be cautious treating hypophosphatemia unless it is severe as treating it may cause hypocalcemia
• fluid resusc: in the elderly 50% of their body wt makes up their TBW and they may lose up to 25% of their TBW
• replace 1/2 of fluid deficity over first 12h then other 1/2 over next 24h, begin with NS, can change to 1/2NS
• treat precipitating cause
• ensure fluid resusc first then give insulin, infusion at 0.1unit/kg