hyperglycemic hyperosmolar state hhs
TRANSCRIPT
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HHSHyperglycemic Hyperosmolar state
By:
Dr. Mohamed SaberMeeqat Hospital - Madinah
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Def:
HHS is a metabolic emergenceyCharacterized by hyperglycemia andHyperosmolarity without ketoacidosis in aDM II patient
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DKAHHS
>250> 600mg/dlPlasma Glucose
300-320≥ 320mosol/kgSr Osmolarity
3-6 L8-12 L + ↑ BUN and Cr.Dehydration
<15> 15HCO3
VariableSome alteration of consciousness
GCS
<7.30>7.30PH
125-135135-145Na+
Normal or highNormalK+
HighNormalAG
20-30NormalPCO2
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Why HHS happens? Infection
Dialysis
Dehydration
TPN
Diuretics
Β-Bs
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What happens?
Illness → ↓ insulin + ↑ Anti-insulin hormones → ↓ renal clearance and peripheral utilization of glucose → ↑ ↑
↑ Glucose → Hyperosmolarity→Severe Dehydration → Loss of water and Electrolytes
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So we are Facing a patient like
this: DM II - Adult or Old Age
Symptoms of hyperglycemia
Severely dehydrated
↑↑↑ RBS
Acidosis?: maybe: it will be due to lactic acidosis (due
to hypoxia) rather than ketoacidosis
↑↑ Mortality rate
Neuro: ↓GCS, Delirium, Focal or generalized seizures, visual changes,Hemiparesis
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DO not Underestimate HHS
It can be Fatal
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Treatment Goals
1. REHYDRATE your patient
2. Correct electrolyte imbalance
3. Correct hyperglycemia
4. Treat underlying disease
5. Monitor and support CVS,
Pulmonary, Renal, and CNS
functions
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What is your role?
Step 1: ABCD always First
Airway: may be compromised
due to decreased GCS
Breathing: may be tachypnic
due to Pneumonia
Circulation: may be
hypotensive
Disability: decreased GCS
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:Step 2 Rapidly examine and asses
severity:
• Dehydrated: dry lips, skin, MM, loss of skin turgor
• Vitals:
oTachycardiac (Early dehydration and Shock)
oHypotensive (late)
• Systemic examination to rule out
other causes
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What are the other causes?
Delerium for any reason
Alcoholic ketoacidosis
Dementia
Thyrotoxicosis (Fever, ↑RR, Dehydration)
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Step 3:
Insert 2 wide-bore cannulae (16 or 18)
and start fluid resuscitation
Start 0.9% at 15-20 mL/kg or greater
= about 1-1.5 L in average –sized person
Then IVF at 200mL/hr
If hypernatremic start with 0.45%
You can increase the boluse and infusion
according to severity of dehydration but
Do not exceed 50mL/kg/first 4 hrs
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Step 4:
Start Regular Insulin
Give 0.1 unit/kg as bolus
Then 0.1 unit/kg/hr as infusion
Never start insulin before Fluids
When RBS reaches 300 change fluid
type to D5 0.45%
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Step 4:
Correct electrolytes
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Summary
ABCD
Aggressively Rehydrate
Start insulin
Correct electrolytes
Add Antibiotics, Antipyretics
and Antiemetics
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Thank you