HHSHyperglycemic Hyperosmolar state

By:

Dr. Mohamed SaberMeeqat Hospital - Madinah

Def:

HHS is a metabolic emergenceyCharacterized by hyperglycemia andHyperosmolarity without ketoacidosis in aDM II patient

DKAHHS

>250> 600mg/dlPlasma Glucose

300-320≥ 320mosol/kgSr Osmolarity

3-6 L8-12 L + ↑ BUN and Cr.Dehydration

<15> 15HCO3

VariableSome alteration of consciousness

GCS

<7.30>7.30PH

125-135135-145Na+

Normal or highNormalK+

HighNormalAG

20-30NormalPCO2

Why HHS happens? Infection

Dialysis

Dehydration

TPN

Diuretics

Β-Bs

What happens?

Illness → ↓ insulin + ↑ Anti-insulin hormones → ↓ renal clearance and peripheral utilization of glucose → ↑ ↑

↑ Glucose → Hyperosmolarity→Severe Dehydration → Loss of water and Electrolytes

So we are Facing a patient like

this: DM II - Adult or Old Age

Symptoms of hyperglycemia

Severely dehydrated

↑↑↑ RBS

Acidosis?: maybe: it will be due to lactic acidosis (due

to hypoxia) rather than ketoacidosis

↑↑ Mortality rate

Neuro: ↓GCS, Delirium, Focal or generalized seizures, visual changes,Hemiparesis

DO not Underestimate HHS

It can be Fatal

Treatment Goals

1. REHYDRATE your patient

2. Correct electrolyte imbalance

3. Correct hyperglycemia

4. Treat underlying disease

5. Monitor and support CVS,

Pulmonary, Renal, and CNS

functions

What is your role?

Step 1: ABCD always First

Airway: may be compromised

due to decreased GCS

Breathing: may be tachypnic

due to Pneumonia

Circulation: may be

hypotensive

Disability: decreased GCS

:Step 2 Rapidly examine and asses

severity:

• Dehydrated: dry lips, skin, MM, loss of skin turgor

• Vitals:

oTachycardiac (Early dehydration and Shock)

oHypotensive (late)

• Systemic examination to rule out

other causes

What are the other causes?

Delerium for any reason

Alcoholic ketoacidosis

Dementia

Thyrotoxicosis (Fever, ↑RR, Dehydration)

Step 3:

Insert 2 wide-bore cannulae (16 or 18)

and start fluid resuscitation

Start 0.9% at 15-20 mL/kg or greater

= about 1-1.5 L in average –sized person

Then IVF at 200mL/hr

If hypernatremic start with 0.45%

You can increase the boluse and infusion

according to severity of dehydration but

Do not exceed 50mL/kg/first 4 hrs

Step 4:

Start Regular Insulin

Give 0.1 unit/kg as bolus

Then 0.1 unit/kg/hr as infusion

Never start insulin before Fluids

When RBS reaches 300 change fluid

type to D5 0.45%

Step 4:

Correct electrolytes

Summary

ABCD

Aggressively Rehydrate

Start insulin

Correct electrolytes

Add Antibiotics, Antipyretics

and Antiemetics

Thank you