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MinnaKoivikko

Hyperglycaemic Hyperosmolar Syndrome

Essentials

  • Manage an acutely ill patient with hyperglycaemia before he/she enters coma.
  • Do not confuse this condition with ketoacidosis Diabetic Ketoacidosis.
  • The condition is associated with significant mortality (20-50%)

Predisposing factors

  • 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

Symptoms and findings

  • 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

Laboratory findings

  • 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.

Treatment

  • 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.

Implementing fluid and insulin therapy

  • 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.