Hyperosmolar Hyperglycaemic State
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Transcript of Hyperosmolar Hyperglycaemic State
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HYPEROSMOLAR HYPERGLYCAEMIC
STATE
TUAN MOHD AMIRUL HASBI BIN TUAN PAIL012009100131
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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
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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
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AETIOLOGY
Patient DM2 prone to develop it
Old age
Living alone
No access to medical treatment
Acute infection, burns, and trauma
CVA, MI
Alcohol excess
Recurrent vomiting/diarrhea
DRUGS:
Thiazide
Steroids
Atypical antipsychotic
Antiarrythmics
Antiepileptic
Antihypertensive: CCB, Thiazide, Diuretics.
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PATHOPHYSIOLOGY
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SYMPTOMS
Confuse
Weakness
Polyuria, polydipsia, polyphagia
Vomitting
Dry skin
Seizure
fever
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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
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acanthosis nigrican
diabetic dermopathy
tooth decay
thrush
moon face
Retinopathy, premature, cataract
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3. Assessment of dehydration
every 1L body fluids loss, there is 1kg of wt loss
skin turgor
dryness of skin
Dry, sticky mouth
Lethargy
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COMPLICATION
Cerebral edema
Acute respiratory distress syndrome
Vascular complication
Hypoglycaemia
hyperglycaemia
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DD(x)
Diabetes insipidus
Diabetic ketoacidosis
Myocardial infarction
Pulmunory embolism
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INVESTIGATIONS
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MANAGEMENT
GOAL:
1.Fluid replacement to correct dehydration
2.To correct hyperglycaemia by insulin3.Correction of electrolytes 4.Treat underlying disease5.Monitor CVS, CNS, renal, RS function.
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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.
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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.
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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.
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Treat the cause
Identify and treat the underlying problem.