38 - HHS Case Study

Question 1

What are the signs and symptoms of hyperosmolar hyperglycemic syndrome (HHS)?

Answer 1

a. Abdominal pain
b. Nausea and vomiting
c. Mental status change
d. Weight loss

Question 2

What is the rate of mortality compared to DKA?

Answer 2

a. HHS mortality is higher than DKA
b. DKA is often more severe, but we can rescue them easier
c. Higher mortality comes from older age, comorbidities

Question 3

What is the difference in pH in HHS and DKA?

Answer 3

a. pH in HHS is relatively normal, not much ketone difference
b. pH will be low in DKA

Question 4

Who is at risk for HHS?

Answer 4

a. Uncontrolled type 2 diabetics
b. Higher age, more comorbidities
c. Precipitating stress can act as a trigger

Question 5

What is the diagnostic criteria for HHS?

Answer 5

a. Greater than 600 for glucose
b. Greater than 320 for osmolality
c. Presence of abnormal creatinine (?)
d. pH of 7.3 or higher in HHS, not a huge acidosis
i. Usually in DKA they are 6.9 or 7.0, so not that low in HHS
e. Bicarb usually 15
f. Usually have a mental status change (more common in older)
g. Dehydration
h. Ketonuria (ketones in the urine) with no or small ketonemia (ketones in the blood)

Question 6

What is the A1c value associated with a DM diagnosis?

Answer 6

6.5% for DM

Question 7

What is the A1c value associated with IGT (increased glucose tolerance)?

Answer 7

5.7-6.4% for increased glucose intolerance

Question 8

What does the A1c tell you?

Answer 8

Will let you know how long… If it is high it has been going on for at least 3 months

Question 9

What is the treatment for HHS?

Answer 9

a. Fluids***
b. Replace potassium
c. Give insulin after fluids and potassium
d. Go slow on insulin
e. Sugar will come down a lot from just giving so much fluid

Question 10

How much fluids will you give to HHS patinets?

Answer 10

• About 1 L/hour
• Want to drop the glucose about 75-100 per hour
• Average fluid deficit is 9 L ***
• Need to be much slower in fluids in elderly

Question 11

What do you need to monitor very closely in HHS?

Answer 11

Electrolytes need to be monitored every few hours

• Potassium and sodium
• Sodium is usually high (need to dilute)
• Potassium is usually low (need to replace)

Vitals and neuro checks need to be done frequently as well

Question 12

What do we need to be concerned about when treating HHS?

Answer 12

Brain swelling

• Don’t lower the sodium (dilute them) too quickly
• If you do that, the brain can’t keep up due to BBB and there will be high sodium in brain, low sodium outside of brain
• Water will rush in cause brain swelling

Question 13

What are some further meds you can give to the patient if needed?

Answer 13

• Antibiotics
• Tylenol
• Anti-nausea

Question 14

What types of medications and medical situations can increase glucose?

Answer 14

a. Decreased sensitivity to insulin
b. Decreased insulin levels
c. Acute stress, this is the body’s response,
d. Changing hormone levels with pregnancy
e. Infection, sepsis
f. MI, stroke
g. Dehydration
h. Meds: hydrochlorothiazide (diuretic), antipsychotics, steroids** (steroids will really increase the glucose) **

Question 15

What likely brought on the HHS in this patient?

Answer 15

a. The acute stress of miscarriage

b. Type 2 diabetes

Question 16

What do you do with a patiet in this condition?

Answer 16

a. Admit

b. HHS because she has been sick for 3 weeks, rather than DKA, who are sick for 2 days

Question 17

Compare HHS and DKA

Answer 17

• HHS comes on slower
• Higher mortality (10-20%) in HHS, especially when they are elderly
• Mental status change is common in HHS
• This is how diabetes is diagnosed in 30-40% of type 2 diabetics
• Acid base imbalances are not as severe in HHS as they are in DKA
• Potassium is more of an issue in HHS due to fluid replacement and vomiting
• Like DKA, there is often times a precipitating stress associated with onset