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Hyperosmolar Hyperglycaemic State (Symptoms (Bicarbonate is NOT LOWERED,…
Hyperosmolar Hyperglycaemic State
Symptoms
Bicarbonate is NOT LOWERED
Stupor or coma
No ketones in blood or urine
Hyperosmolality - which may predispose to stroke, MI or arterial insufficiency of the lower limbs
Hyperglycaemia
Pathophysiology
A life threatening emergency characterised by marked hyperglycaemia, hyperosmolality and mild or no ketosis
This is the metabolic emergency characteristic of uncontrolled type 2 diabetes mellitus
Endogenous insulin levels are reduced but are still sufficient to inhibit hepatic ketogenesis but insufficient to inhibit hepatic glucose production
Investigations
Hyperlgycaemia - 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
Treatment Plan
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
Epidemiology
Patients present in middle or later life often with previously undiagnosed diabetes
Signs
Decreased level of consciousness - which is directly related to the elevation of plasma osmolality
Severe dehydration (secondary to osmotic diuresis)
Risk factors
Consumption of glucose rich fluids
Concurrent medication such as thiazide diuretics or steroids
Infection - most common precipitating cause (particularly pneumonia)