Introduction
Hyperosmolar Hyperglycaemic State is common in the elderly. This used to known as Hyperosmolar Non-Ketotic Syndrome (HONK) but as ketones are not uncommon its name was changed. It carries a high mortality of around 30%. Can develop in patients with otherwise undiagnosed type 2 diabetes. Ketonuria and acidosis are unusual. It is normally triggered by an acute intercurrent illness and has an onset of about a week. Patients are at an increased risk of VTE.
Presentation
Insidious onset of symptoms.
Can result in coma
Patients have severe hyperglycaemia (>50mmol/l)
Hyperosmolality (>320mOsmol/kg) with profound dehydration and prerenal uraemia
Investigation
Glucose
U&Es
Remember to correct Na+ for glucose level using the formula:
Na++1.6{(glucose-100)/100}
ABG (relatively normal)
Plasma osmolality
FBC
Amylase
Cholesterol (triglycerides are often raised)
ECG
CXR (? infection)
Urinalysis (and send for culture if nitrite/leucocyte positive)
Treatment
ABCDE
Phone endocrinology/diabetes Reg on-call (if out-of-hours call Reg A/B)
Correct hypoxaemia
IV access
Continuous monitoring +/- CVP
Fluid replacement
1 litre 0.9% saline over 1st hour
1 litre 0.9% saline with potassium every 2 hours for 4 hours
1 litre 0.9% saline with potassium 6 hourly until rehydrated
If serum sodium >155mmol/l use 0.45% saline
Target potassium is 4.0-5.0mmol/l
Insulin infusion starting at 3 units/hr
Recheck lab glucose hourly
Ensure a gradual reduction of glucose over the 1st 12-24 hours
Target glucose concentration for end of first day is 10-20mmol/l
If blood glucose falls below target then insulin can be reduced to 1unit/hr but SHOULD NOT BE STOPPED
Continue insulin until patient has eaten at least 2 meals.
Management of HHS, [StaffNet Source]
