Makindo Medical Notes.com

Related Subjects: Type 1 DM | Type 2 DM | Diabetes in Pregnancy | HbA1c | Diabetic Ketoacidosis (DKA) Adults | Hyperglycaemic Hyperosmolar State (HHS) | Diabetic Nephropathy | Diabetic Retinopathy | Diabetic Neuropathy | Diabetic Amyotrophy | Maturity Onset Diabetes of the Young (MODY) | Diabetes: Complications |

Calculated Osmolality is 2 x (Na + K) + Urea + Glucose. Often asked in medical student exams. You should calculate it in HHS

Goals of Treatment

• Normalise the osmolality, replace fluid, electrolytes and Normalise blood glucose (fluids may do that)
• There is severe water loss, but the Na may be normal as glucose osmotically pulls water into the circulation.
• Once glucose falls then Na rises. Don't allow osmolality in terms of glucose to fall < 14 mmol/L. Boost it with 10% glucose if it falls below this.
• Start 10% Glucose when CBG<14 mmol/L. Run 10% Dextrose 1 litre 125 mls/hr 8 hours IV as well as 0.9% Saline. Run both Saline and Dextrose regime in 2 separate lines at the SAME time.
• When to start Insulin: Not always needed with HHS. Only start when blood glucose is no longer falling with IV fluids alone. If there is significant ketonaemia (3-hydroxy butyrate > 1 mmol/L or urine ketones greater than 2+).

Clinical

• Comatose, profoundly dehydrated, hypotensive
• Tachycardic, no Kussmaul breathing, no acetone breath

Differential

• Shock, MI, Sepsis
• Diabetic ketoacidosis
• Diabetes insipidus

Investigation

• FBC, U&E, LFTs, Glucose, Lactate
• Venous blood gas unless low SaO₂ and needs ABG
• Blood cultures, urine culture, CXR if signs/symptoms

Management: Fluids, IV insulin may be needed. Establish cause

Fluids (70 kg man) 6L in first 18 hrs

• 1L NS (0.9% Normal-Saline) over 1st hour
• 1L NS with KCL over 2 hours x 2
• 1L NS with KCL over 4 hours x 2
• 1L NS with KCL over 6 hours
• Consider 0.45% Saline if osmolality not falling
• Caution
  • Overhydration in Elderly
  • Cardiac/Renal failure
  • Other serious co-morbidities.
  • Low body mass - adjust
• Re-assessment of cardiovascular status at 12 hours is mandatory, further fluid may be required

Insulin (given at 0.05 Units/kg/hr )

• Glucose will fall with rehydration but if despite initial fluids the reasons to start IV insulin are
  • Significant ketonaemia blood ketones >1.0 mmol/L
  • Ketonuria (urine ketones >2+)
  • Glucose not falling (Target is to fall but by less than 5 mmol/L per hour)
• Continue subcutaneous intermediate* or basal insulin
• Start Fixed rate IV insulin infusion based on estimated weight in Kg with an infusion pump with 50 U Actrapid in 50ml with 0.9%NS. I unit per ml and infuse Insulin IV at 0.05 unit/kg/hr x Wt in Kg
• Give bolus (stat) dose of IM insulin (0.1 unit/kg x weight in Kg) if delay in setting up a FRIII. Continue any Lantus, Levemir or Tresiba SC at usual dose and time.

IV Dextrose

• Start 10% Glucose when CBG<14 mmol/L.
• Run 10% Dextrose 1 litre 125 mls/hr 8 hours IV as well as 0.9% Saline.
• Give both Saline and Dextrose regime in 2 separate lines at the SAME time.
• Ensure Glucose Falls by less than 5 mmol/L/hr

Monitor to ensure

• Ensure Na falls by less than 10 mmol/L/day
• Ensure Glucose Falls by less than 5 mmol/L/hr

Determine cause

• Infection screen: CXR, urine and blood culture
• Swab any potentially infected site
• ECG (look for silent infarct)
• Give Antibiotics if sepsis

References

• The management of the hyperosmolar hyperglycaemic state (HHS) in adults with diabetes Joint British Diabetes Societies Inpatient Care Group August 2012