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Hyperosmotic Hyperglycaemic Syndrome (HHS) 8/12/10 PY Mindmaps FANZCA Part II Notes E-medicine (2009) SP Notes - three times less frequent than DKA - deaths often due to co-morbid conditions (MI) - higher mortality rate than DKA PATHOPHYSIOLOGY - triggers: infection, MI, surgery, omission of normal medications - decreased insulin or resistance -> decreased glucose utilisation in skeletal muscle, increased fat and muscle breakdown -> increased hepatic gluconeogenesis -> increase in glucagon, cortisol, catecholamines -> increased BSL -> glycosuria + osmotic diuresis -> just enough insulin to prevent lipolysis and ketone production HISTORY - polydipsia polyuria weight loss weakness slow onset progressive dehydration coma - causes: MI, infection, diuretics, CVA, PE Risk factors - elderly type II DM mental obtundation/dementia physical impairment limiting access to H2O renal dysfunction inappropriate diuretic use steroids beta-blockers phenytoin EXAMINATION CVS – tachycardia, decreased skin turgor, sunken eyes, dry mouth RESP – tachypnoea Jeremy Fernando (2010) CNS – drowsy, delirium, coma, focal or generalised seizures, visual changes, hemiparesis INVESTIGATIONS - very high osmolarity (> 320mosmol/kg) - very high glucose - little or no ketonuria (beta-hydroxybutyrate) - hyponatraemia (or pseudohyponatraemia -> hyperglycaemia draws water out of cells) or hypernatraemia - hypokalaemia - hypomagnesaemia - normal anion gap - ABG: pH normally > 7.3 (metabolic acidosis is not severe) - normal level of ketones - renal dysfunction commonly present Diagnostic Criteria - serum osmolarity > 320mosmol/L serum glucose > 33mmol/L profound dehydration (elevated urea:creatinine ratio) no ketoacidosis Investigations for cause - CXR: chest infection compliance with medication ECG + TNT: MI FBC CRP blood cultures urine MANAGEMENT Goals (1) (2) (3) (4) correct dehydration (often 6-9 L of H2O loss) provide insulin replace electrolytes correct metabolic acidosis Resuscitation A – may require intubation if comatosed and not protecting airway B – mechanical ventilation can minimise WOB and manage possible metabolic acidosis C – resuscitate with isotonic fluid until patient has a normal heart rate and BP (see below for H2O replacement) or can use colloids. Treatment Jeremy Fernando (2010) Specific (1) Calculate corrected Na+ - if hypernatraemic, the corrected Na+ = measured Na+ + glucose/3 - monitor this as Na+ changes for glucose (2) Calculate H2O deficit - H2O deficit = 0.6 x premorbid weight x (1 – 140/corrected Na+) (3) Fluid management in first 24 hours - maintenance as D5W at standard rate - if hypernatraemic: replace half the H2O deficit over 24 hours using ½ normal saline. (4) Monitor Na+ closely – should not change more than 10mmol in 24 hours (5) Replace other electrolytes as required - K+ (often require aggressive replacement – 10-20mmol/hr, make sure not anuric) Mg2+ PO43 Ca2+ (6) Fluid management in second 24 hours - when glucose < 15mmol/L -> use D5W @ 100-250mL/hr AND saline - keep Na+ between 140-150mmol/L - the metabolic acidosis rarely requires specific treatment as responds to volume expansion and insulin therapy. General - insulin at 0.1U/kg/hr do not allow blood glucose to drop by more than 3mmol/L/hr once glucose <15mmol/L and corrected Na+ <150 mmol/L -> 10% dextrose thromboprophylaxis (SCD’s, clexane, TEDS) -> high risk of VTE diagnose cause and treat: infection, compliance, MI, CVA Disposition - needs management in ICU - endocrine/general medical referral - family informed Complication Management - delirium -> coma cerebral oedema (prevent by resuscitation with isotonic fluid and slow correction of glucose) seizures (focal and generalized) severe dehydration and shock Jeremy Fernando (2010) - renal failure - thrombotic complications: VTE, stroke, AMI - intercurrent events: sepsis, MI, aspiration - occlusive events: focal CNS signs, chorea, DIC, leg ischaemia, rhabdomyolysis - fluid overload and congestive heart failure - metabolic derangement: hypokalaemia, hypophosphataemia, hypomagnesaemia, hypoglycaemia, hyperchloraemia with NAGMA Jeremy Fernando (2010)
