Hyperosmolar hyperglycaemic state

Question 1

What is it?

Answer 1

When hyperglycaemia results in osmotic diuresis, severe dehydration and electrolyte deficiencies
Insulin levels reduced but still high enough to stop hepatic ketogenesis but low enough so that there is still hepatic glucose production

Question 2

What DM is it associated w ?

Answer 2

T2DM

Question 3

What are RFs?

Answer 3

Infection - particularly pneumonia
Consumption of glucose rich fluids
concurrent meds e.g. thiazide diuretics or steroids

Question 4

how does it present?

Answer 4

Severe dehydration due to osmotic diuresis
Decreased consciousness - due to elevated plasma osmolality
Hyperglycaemia
Hyperosmolality - predisposes to

Question 5

Why is there an increased risk of occlusive events? How is this prevented?

Answer 5

hyperosmolality predisposes to stroke, MI or arterial insufficiency of lower limbs
Give LMWH

Question 6

What would indicate a diagnosis?

Answer 6

Hypovolaemia
Hyperglycaemia 30 or more,
No hyperketonaemia <3mmol/L or acidosis pH >7.3, bicarb >15mmol/L
Osmolality >320

Question 7

What is the management?

Answer 7

LMWH prophylaxis
Rehydrate slowly - 0.9% saline over 48hr
Replace K+ when urine starts to flow
Insulin if BM not falling by 5mmol/L/h w rehydration or if ketonaemia
Keep BM 10-15mmol/L for first 24 hrs to avoid cerebral oedema