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MinnaKoivikko

Hyperglycaemic Hyperosmolar Syndrome

Hyperglycaemia-inducing medication (diuretics, glucocorticoids)
Operations and comparable stress-creating situations, e.g. myocardial or cerebral infarction, burns
Acute severe infections
- Pneumonia
- Diabetic gangrene
- Pyelonephritis
- Sepsis
- Gastroenteritis leading to dehydration
Chronic diseases and excessive diuretics
- Renal failure
- Heart failure
Low fluid intake and dehydration because of various underlying causes
Neglecting the treatment of diabetes
Acromegaly or Cushing's syndrome

The patient usually has type 2 diabetes. Hyperglycaemic hyperosmolar syndrome (HHS) may sometimes be the first manifestation of diabetes.
Fever is a common finding. The cause is usually an infection but remember that an infected patient may often be non-febrile.
Signs of dehydration
Thirst, polyuria, fatigue, decreased level of consciousness and other neurological symptoms, for example convulsions, aphasia, hemiparesis

Plasma glucose usually > 25 mmol/l
No ketoacidosis, pH > 7.30 and bicarbonate concentration > 15 mmol/l (blood gas analysis)
Only mild ketonuria or ketonaemia
Haemoglobin, hematocrit, leukocyte count and plasma creatinine are usually elevated, associated with dehydration.

Febrile hyperglycaemia can be treated in primary care while HHS requires intensive care.
Principles of therapy
- Recognize the condition immediately.
- Provide sufficient (re)hydration with Ringer solution.
- Manage the electrolyte imbalance.
- Correct hyperglycaemia with rapid-acting insulin.
- Treat infection effectively after samples have been obtained (urine and blood cultures, etc).
- Prophylactic therapy for thombosis with low-molecular-weight heparin is often indicated.

Water deficiency is considerable (6-10 l) and its treatment should be started before insulin therapy
- Ringer solution 2 000 ml within the first 1.5-2 hours
- Thereafter, based on corrected sodium concentration, Ringer solution, 0.45% NaCl solution or 0.9% NaCl solution 500 ml/hour until plasma glucose ≤ 15 mmol/l
- 5% glucose solution until dehydration has resolved
Insulin (primarily as intravenous infusion)
- Starting dose of rapid-acting insulin 0.15 units/kg i.v. or 20 units i.m.
- 0.1 units/kg/h as an i.v. infusion or 0.1 units/kg i.m. at 1-hour intervals. The dosage is adjusted according to the results of glucose monitoring.
- When plasma glucose is < 15 mmol/l add long-acting insulin. Infusion should still be continued for about 4 hours after administering the long-acting insulin.
- Later the patient may be managed by oral medication or even with a controlled diet only.
Potassium
- When diuresis starts and plasma potassium concentration is ≤ 4 mmol/l, potassium is given 20-25 mmol/hour, monitoring the potassium concentration.