HYPEROSMOLAR

HYPERGLYCAEMIC
STATE
TUAN MOHD AMIRUL HASBI BIN TUAN PAIL
012009100131
 INTRODUCTION
 Life threatening emergency
 Less severe than DKA
 Previously known as HHNKC
 infection is the most common precipitating factor
 Characterised by
 Hyperglycaemia
 Hyperosmolar
 Dehydration
 Without ketoacidosis
 DIAGNOSTIC FEATURES
PARAMETERS VALUES
Plasma Gluc Level >600ml
Serum osmolality >320mOsm/kg
Profound dehydration >9L
pH >7.3
Bicarbonate conc. >15 mEq/L
Small ketonuria
Some alteration in consciousness
 AETIOLOGY
 Patient DM2 prone to develop it  DRUGS:
 Old age
 Thiazide
 Living alone  Steroids
 No access to medical treatment  Atypical antipsychotic
 Acute infection, burns, and trauma  Antiarrythmics

 CVA, MI  Antiepileptic
 Antihypertensive: CCB,
 Alcohol excess
Thiazide, Diuretics.
 Recurrent vomiting/diarrhea
PATHOPHYSIOLOGY
 SYMPTOMS
 Confuse
 Weakness
 Polyuria, polydipsia, polyphagia
 Vomitting
 Dry skin
 Seizure
 fever
 Physical examinations
1. Assessment of vital signs
tachycardia-hypotension-tachypnea
hyperthermia/hypothermia
head to toe examination for signs of dehydration
2.Evaluation of DM
presence of fingerpricks
ecchymoses on abdomen, thigh and arm
obesity
acanthosis nigrican

diabetic dermopathy

tooth decay

thrush

moon face

Retinopathy, premature, cataract

3. Assessment of dehydration

every 1L body fluids loss, there is 1kg of wt loss

skin turgor

dryness of skin

Dry, sticky mouth

Lethargy
 COMPLICATION
 Cerebral edema

 Acute respiratory distress syndrome

 Vascular complication

 Hypoglycaemia

 hyperglycaemia
 DD(x)
 Diabetes insipidus

 Diabetic ketoacidosis

 Myocardial infarction

 Pulmunory embolism
INVESTIGATIONS
 MANAGEMENT
GOAL:

1. Fluid replacement to correct dehydration

2. To correct hyperglycaemia by insulin
3. Correction of electrolytes
4. Treat underlying disease
5. Monitor CVS, CNS, renal, RS function.
 Fluid Replacement
 Rapid infusion of large amount of fluid to correct circulation and
to reestablish adequate urine flow
 Fluid deficit in HHS is 11-12L- large
 Isotonic 0.9% saline is used - 2L within 2hour
 Then change to 0.45% isotonic saline
 When the glucose level approach normal after the hydration and
insulin therapy, then 5% dextrose is given as the vehicle for free
water.
 Fluid deficit should correct estimated deficit within 24 hour.
 in patient with renal/cardiac compromise, CVP monitoring and
serum osmolality is mandatory while the infusion to avoid fluid
overload.
 INSULIN THERAPY
 Regular insulin by continuous IV infusion is the treatment of
choice.
 Exclude hypokalemia
 IV bolus of regular insulin (0.15 u/kg)
 Followed by 0.1 u/kg/ hour
 Until blood gluc falls to 300mg/dl
 Then, reduce to 0.05 u/kg/hour plus 5% dextrose
 Target: blood gluc below 250mg/dl
 When the patient is concious, ask to take orally for
maintenance of blood sugar.
 Potassium Replacement
 Mild to moderate hyperkalemia is not uncommon in
HHS
 Insulin therapy and volume expansion decreased the
K+ concentration, hence K+ replacement is needed.
 Once renal function is assured, K+ may be given to
prevent hypokalaemia
 When IV fluids infusion, monitor serum potassium
level. When it falls below 5 mEq/L, and urine output is
good, 20-30 mEq/L of postassium may be given.
 Treat the cause
 Identify and treat the underlying problem.