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12-1 Diabetic Emergencies-HHS PDF

The document provides guidelines for the management of hyperglycaemic hyperosmolar state (HHS). HHS is characterized by extreme dehydration, hyperglycemia, and hyperosmolality without significant ketosis or acidosis. Immediate management involves intravenous hydration with 0.9% saline, monitoring of serum osmolality to prevent rapid changes, and low dose insulin to gradually lower blood glucose levels while avoiding precipitous drops. Prophylactic low molecular weight heparin and correction of electrolyte abnormalities are also recommended. The goals of treatment are to safely normalize osmolality and glucose levels while replacing fluid and electrolyte losses.

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132 views12 pages

12-1 Diabetic Emergencies-HHS PDF

The document provides guidelines for the management of hyperglycaemic hyperosmolar state (HHS). HHS is characterized by extreme dehydration, hyperglycemia, and hyperosmolality without significant ketosis or acidosis. Immediate management involves intravenous hydration with 0.9% saline, monitoring of serum osmolality to prevent rapid changes, and low dose insulin to gradually lower blood glucose levels while avoiding precipitous drops. Prophylactic low molecular weight heparin and correction of electrolyte abnormalities are also recommended. The goals of treatment are to safely normalize osmolality and glucose levels while replacing fluid and electrolyte losses.

Uploaded by

Oana Dumitru
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Clinical Practice Guidelines:

Management of
Type 2 Diabetes Mellitus
th
(5 Edition) 2015
Management of diabetic emergencies:
Hyperglycaemic Hyperosmolar State
Hyperglycaemic Hyperosmolar State (HHS)
• Prompt diagnosis is important.

• Intensive management in high-dependency units or


equivalent level of care.

• Common presentation in the young adults and elderly


with multiple comorbidities.

• Higher mortality than DKA.


Hyperglycaemic Hyperosmolar State (HHS)
• Common: vascular complications such as myocardial
infarction, stroke or peripheral arterial thrombosis.

• Uncommon: seizures, cerebral oedema and osmotic


demyelination syndrome.

• Rapid changes in osmolality during treatment may also


be the precipitant of osmotic demyelination syndrome.

• Progresses over many days dehydration and metabolic


disturbances are more extreme
Diagnostic Criteria of HHS

• Hypovolaemia

• Marked hyperglycaemia (BG >30 mmol/L)

• Osmolality >320 mosmol/kg


Other Important Clinical Features
• There is NO significant hyperketonaemia (<3.0 mmol/L) or
acidosis (pH >7.3, bicarbonate >15 mmol/L).

• When acidosis is present, causes of acidosis such as lactic


acid and toxicology screen need to be investigated.

• The presence of acute cognitive impairment may be


associated with:
• cerebral oedema in severe cases or
• significant electrolyte disturbances,
• hyperosmolality (>330 mosmol/kg),
• sudden drop in osmolality,
• severe dehydration,
• infection and sepsis,
• hypoglycaemia during treatment
• renal failure.
Dehydration in HHS

• Clinical features of dehydration in the patient with HHS


can be deceptive and may not be reflective of the
seriousness of the fluid depletion.

• This is because hypertonicity leads to preservation of


intravascular volume, causing movement of water from
intracellular to extracellular space.
Precipitating Factors For HHS

a) Infections and sepsis

b) Thrombotic stroke

c) Intracranial haemorrhage

d) Silent myocardial infarction

e) Pulmonary embolism
Management

The goals of treatment of HHS are to treat the underlying


cause as well as to gradually and safely:

• Normalise the osmolality

• Replace fluid and electrolyte losses

• Normalise blood glucose

• Prevention of complications
What is the immediate management?
• Hydration: Intravenous (IV) 0.9% saline solution.

• Monitor serum osmolality regularly - prevent harmful rapid


changes in osmolality.

• The rate of rehydration - assessing the combination of initial


severity and any pre-existing comorbidities. Rapid
rehydration - heart failure. Insufficient rehydration - fail to
reverse acute kidney injury.

• An initial rise in sodium is expected and is not in itself an


indication for hypotonic fluids. Thereafter, the rate of fall of
plasma sodium should not exceed 10 mmol/L in 24 hours.
What is the immediate management?
• The fall in blood glucose should be no more than 5
mmol/L/hr.

• Low dose IV insulin (0.05 units/kg/hr) commenced once


blood glucose is no longer falling with IV fluids alone or
immediately if there is significant ketonaemia (β-hydroxy
butyrate >3 mmol/L).

• Prophylactic low molecular weight heparin (LMWH) is


recommended unless contraindicated.

• Electrolytes: Hyperkalaemia, hypokalaemia,


hypophosphataemia and hypomagnesaemia are common
and should be corrected accordingly.
What is the immediate management?

• In acutely ill patients, pyrexia may not be present. If sepsis


is highly suspicious, the source of infection should be
sought and treated.

• Discharge planning includes diabetes education, dietitian


referral, education on medication and insulin administration
(if patient is on insulin) to reduce the risk of recurrence and
prevent long-term complications.

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