Hyperosmolar hyperglycaemic state

Question 1

What is hyperosmolar hyperglycaemic state?

Answer 1

Severe hyperglycaemia without significant ketosis; the characteristic metabolic emergency of T2DM

Question 2

Who is HHS most common in?

Answer 2

People present in middle or later life, often with previously undiagnosed diabetes

Question 3

What are some precipitants of HHS?

Answer 3

• Infection
• Stroke or MRI
• Trauma or compromised water intake (Elderly)
• Hyperthyroidism, acromegaly or hypercortisolism
• Iatrogenic (steroids)
• Non-compliance
• Newly diagnosed diabetes

Question 4

Why does HHS occur (And DKA doesn’t) in T2DM?

Answer 4

• Pathophysiology is similar to DKA, but HHS, there are stillsmall amounts of insulinbeing secreted by the pancreas
• This is sufficient toprevent DKA by suppressing lipolysis and, in turn, ketogenesis, but level is not high enough to lower blood glucose to a safe level

Question 5

How does HHS present?

Answer 5

• Dehydration due to polyuria
• Polydipsia
• Nausea and vomiting
• Stupor/coma (Impaired consciousness is directly related to degree of osmolarity)

Question 6

What glucose level defines HHS?

Answer 6

Profound hyperglycaemia (glucose >33.3mmol/L)

Question 7

What serum osmolarity defines HHS?

Answer 7

Hyperosmolality (serum osmolarity >320mmol/kg)

Question 8

What are some investigation findings in HHS?

Answer 8

• Profound hyperglycaemia
• Hyperosmolarity
• Significant renal impairment
• Hypernatraemia (Or high end of normal)

Question 9

What are some management options in HHS?

Answer 9

1. 0.9% saline for fluid replacement (No insulin)
2. Monitor BG, osmolarity and sodium
3. Start low dose insulin only if significant ketones

Question 10

What are some managements of co-morbidities in HHS?

Answer 10

• Screen for vascular event e.g. silent MI
• LMWH for all patients (unless contraindicated)
• High risk of feet complications

Question 11

How does HHS differ from DKA?

Answer 11