Information
Editors
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 HASH(0x2f830d0) 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 HASH(0x2f830d0) 4 mmol/l, potassium is given 20-25 mmol/hour, monitoring the potassium concentration.