Hyperosmolar Hyperglycaemic State

Question 1

what the the definition of hyperosmolar hyperglycaemic state?

Answer 1

This is a life-threatening emergency characterised by marked hyperglycaemia, hyperosmolality and mild or no ketosis

Question 2

what is the epidemiology of hyperosmolar hyperglycaemic state?

Answer 2

Patients present in middle or later life often with previously undiagnosed diabetes

Question 3

what is the aetiology of hyperosmolar hyperglycaemic state?

Answer 3

Characteristic of uncontrolled type 2 diabetes

Question 4

what are the risk factors of hyperosmolar hyperglycaemic state?

Answer 4

• Infection - most common precipitating cause - particularly pneumonia
• Consumption of glucose rich fluids
• Concurrent mediation such as thiazide diuretics or steroids

Question 5

what is the brief pathophysiology of hyperosmolar hyperglycaemic state?

Answer 5

Endogenous insulin levels are reduced but are still sufficient to inhibit hepatic ketogenesis but insufficient to inhibit hepatic glucose production

Question 6

wha are the key presentations of hyperosmolar hyperglycaemic state?

Answer 6

• Severe dehydration (secondary to osmotic diuresis)
• Decreased level of consciousness - which is directly related to the elevation
  of plasma osmolality
• Hyperglycaemia
• Hyperosmolality - which may predispose to stroke, MI or arterial
  insufficiency of the lower limbs
• No ketones in blood or urine
• Stupor or coma
• Bicarbonate is NOT LOWERED

Question 7

what are the signs of hyperosmolar hyperglycaemic state?

Answer 7

• Hyperglycaemia - blood glucose > 11mmol/L
• Urine stick testing shows heavy glycosuria
• Plasma osmolality is extremely high
• Total body K+ is low as a result of osmotic diuresis - but serum K+ is often raised due to the absence of insulin which allows K+ to shift out of cells

Question 8

what are the symptoms of hyperosmolar hyperglycaemic state?

Answer 8

Thirst, dry mouth, urinating often, confusion, dizziness, nausea, disorientation, dry skin

Question 9

what is the 1st line investigation for hyperosmolar hyperglycaemic state?

Answer 9

blood glucose level test

Question 10

what are the gold standard investigations for hyperosmolar hyperglycaemic state?

Answer 10

urine stick test, plasma osmolality test

Question 11

what other tests could be done for hyperosmolar hyperglycaemic state?

Answer 11

total body K+ levels

Question 12

what are the differential diagnoses for hyperosmolar hyperglycaemic state?

Answer 12

• Diabetes Insipidus
• Diabetic Ketoacidosis
• Myocardial Infarction
• Pulmonary Embolism

Question 13

how is hyperosmolar hyperglycaemic state managed?

Answer 13

• These patients are more sensitive to insulin so give a lower rate of infusion
• Fluid replacement with 0.9% saline
• Low molecular weight heparin e.g. SC ENOXAPARIN to reduce risk of thromboembolism, MI, stroke and arterial thrombosis which patient is at increased risk of due to hyperosmolality
• Restore electrolyte loss (K+)
• Risk of cerebral oedema - from rapid lowering of blood glucose (with insulin
• that they are extremely sensitive to) and thus osmolality of blood

Question 14

how is hyperosmolar hyperglycaemic state monitored?

Answer 14

Calculate corrected sodium levels, adjust isotonic saline replacement

Question 15

what are the complications of hyperosmolar hyperglycaemic state?

Answer 15

• Shock
• Blood clot formation
• Brain swelling (cerebral oedema)
• Increased blood acid level (lactic acidosis)

Question 16

what is the prognosis of hyperosmolar hyperglycaemic state?

Answer 16

• 5-20% mortality
• is usually due to the underlying illness that caused the hyperglycemic crisis. Prognosis is worse for elderly patients and patients in whom coma and hypotension are found