Skip to Main Content

++

Acute medical emergency seen in type 2 DM characterized by:

++

  • Impaired mental status
  • Hyperglycemia (plasma glucose >600 mg/dL)
  • Hyperosmolality (serum osmolality >320 mOsm/kg)
  • Dehydration
  • pH >7.30
  • HCO3 >15 mEq/L
  • No ketoacidosis or severe ketosis

++

Initial presentation of DM in 20% of patients.

++

Mortality 30–50%.

++

Precipitating factors are:

++

  • Acute infection 30–40% (pneumonia, UTI, sepsis)
  • CVA
  • MI
  • Acute pancreatitis
  • Renal failure
  • Thrombosis
  • Severe burns
  • Hypothermia
  • Trauma
  • Subdural hematoma
  • Endocrine (acromegaly, thyrotoxicosis, Cushing syndrome)
  • Drugs (β-blockers, calcium channel blockers, diuretics, steroids, and TPN)

++ ++

Ketone production is minimal as pancreas still retains ability to secrete insulin to prevent fatty acid lipolysis.

++
++

  • Elderly individual with type 2 DM
  • Nausea/vomiting
  • Muscle weakness and cramps
  • Polyuria, and then oliguria
  • Slight hyperthermia common; if >38°C, suspect infection
  • Confusion, lethargy, seizures, hemiparesis, and coma

++

  • Extreme hyperglycemia (>1,000 mg/dL) is sufficient for diagnosis
  • Serum osmolality >320 mOsm/kg with higher osmolality leading to worse impairment of mental status. (Osmotic concentration is referred to as osmolality when expressed in milliosmoles/kilogram of solvent and as osmolarity when expressed in milliosmoles/liter of solvent.)
  • Effective serum osmolality calculated as:
    • 2(Na+ + K+) + (mg/dL of glucose/18) + (BUN/2.8) can give a quick assessment
  • Urine ketones are absent, which distinguishes from DKA
  • Serum Na+ concentration is usually normal or elevated because of severe dehydration
  • Serum K+ concentration is initially frequently high and goes down with treatment
  • Wide anion gap due to mild metabolic acidosis (multifactorial but HCO3- >15 mEq/L)
  • Prerenal renal insufficiency

++

  • Overall mortality ranges from 10% to 20%
  • Mortality rate increases with age and higher levels of osmolality
  • Mortality directly associated with age: 10% in patients <75 years and 35% in patients >75 years
  • Degree of dehydration should be assessed with decrease in body weight, tachycardia, oliguria, and hypotension
  • A complete neurological assessment with subsequent frequent assessments should be done

++

  • Goals of treatment include aggressive intravascular fluid replacement, correction of hyperglycemia, electrolyte replacement, and supportive care
  • Fluid replacement should always precede insulin replacement
  • Care should be taken to avoid pitfalls. Insulin infusion should not be begun before adequate correction of fluid status or with K+ <3.5 mEq/dL or hypophosphatemia
  • Also care should be maintained not to lower glucose by >100 mg/dL/h for risk of osmotic encephalopathy
  • Adequate subcutaneous insulin should be given before stopping insulin infusion

++

Management of hyperosmolar hyperglycemic state (HHS):

++
Table Graphic Jump Location
Favorite Table | Download (.pdf) | Print
Management of Hyperosmolar Hyperglycemic State (HHS)
Fluid replacementCorrection of hyperglycemiaElectrolyte management
Initial management
  • NS 15–20 mL/kg/h initially, until BP and organ perfusion normalize
  • Then, subsequent fluid management should focus on free water replacement
  • Total body water deficit may be as high as ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.