Hyperglycemic Hyperosmolar State

I.  Diagnosis of Hyperglycemic Hyperosmolar State:

a. Defined by a serum glucose >600, increased serum osmolality (>320 mosm), ph>7.30 and mild or no ketones

b. Mild AG can occur (10-12), but higher AG should suggest a second process, such as lactic acidosis, etc.

c. Mortality from HHS is 10-50% (much higher than in DKA, likely due to comorbid conditions in patients who develop HHS)

d. Precipitating triggers:

i. Infections, most commonly PNA, gram neg infxns, UTI (triggers in >50% of HHS)

ii. Medications: non-compliance with DM meds (approx 20% of cases) or other new medications (steroids, diuretics, certain antipsychotic agents, TPN)

iii. Undiagnosed DM

iv. Acute MI

v. Renal Failure

vi. PE

vii. CVA

viii. Cushing’s syndrome

ix. Substance abuse (etoh or cocaine)

x. + others (think of almost any body stressor)

II. Management of Hyperglycemic Hyperosmolar State*:   

a.  IV Fluids:

i. Pts with HHS are very volume depleted (often up to 8-9L) due to the osmotic dieresis; start with a 1L bolus of NS

ii. If the patient is in hypovolemic shock, continue IVF boluses/volume expanders

iii. If the patient has a normal BP or is mildly hypotensive, start maintenance fluids, based on the corrected Na (Na +1.6 (serum glucose-100/100)

1. If corrected Na is normal or high, start with 1/2 NS at a rate of 4-14ml/kg/hr, depending on degree of dehydration

2. If corrected Na is low, start with NS at a similar rate

3. Once serum glucose <300, add D5 to the IVF

iv. If the patient is in cardiogenic shock, avoid IVF and treat underlying cardiac physiology first

 

b. Insulin:

i. Start with a bolus of IV regular insulin (0.15 units/kg, usually around 10 units)

ii. Start an insulin gtt at 0.1 units/kg/hr; if serum glucose does not fall by 50-75mg/dL every hour, double the drip rate hourly until achieved

iii. Once the glucose is <300, decrease the drip to 0.05-0.1 units/hr

iv.  If the patient is able to eat, transition SC insulin (see attached slides), otherwise continue insulin drip with D5

v.  Assess metabolic panel Q2 hrs for electrolyte abnl

c.  Potassium

i. If initial serum K is <3.3, hold insulin and give KCl 40 meq (preferably a combination of KCl and KPhos) until K>3.3meq/L

ii. If initial serum K is >5.0, do not give potassium, but recheck serum K every 2 hrs

iii. If initial serum K is between 3.3 and 5.0, add 20-30meq/L to the IVF, with goal K between 4 and 5

(Victoria Kelly MD, 2/22/11)