Emergency Strategy - How to treat hyperglycemic hyperosmolar states
Emergency Strategy - How to treat hyperglycemic hyperosmolar state
Hyperglycemic hyperosmolar state is a form of hyperglcemia due to relative insufficiency of the insulin. Hyperglycemic hyperosmolar is different from diabetic ketoacidosis , there is no or minimal ketone formation.
Hyperglycemic hyperosmolar state is common in elderly patient. It is associated with lactic acidosis with invariable form of severe dehydration. Hyperglycemic hyperosmolar will be the first initial presentation of diabetic especially diabetes mellitus type 2. Mortality rate is high.
Precipitating factors of hyperglycemic hyperosmolar states are stress, stroke, myocardial infarction, surgery , trauma or infection.
The pH > 7.3 with concentration of bicarbonate > 18 mmol/l. Blood glucose level is more than 33 mmol/l. Serum effective osmolality ( 2 * sodium’s concentration + glucose > 330 mmol/l) and serum total osmolality ( 2 * concentration of sodium + glucose + urea> 330 mmol/l. There is an absence of ketone in the urine.
After evaluating the patient, identify and treat any precipitating factors. Establish IV line and consider 1 liter of 0.9% of NACI per hour. If the patient is hypotensive consider colloid or 0.9% of NACI . In cases of normotensive consider 0.9% of NACI if low concentration of sodium and 0.45% of NACI if high or normal concentration of sodium. IV bolus of insulin 0.15 U/kg is given followed by IV insulin infusion 0.1U/kg/hr. The infusion rates should be double if blood glucose level does not fall by 3- 4 mmol/l. If potassium is less than 3 mmol/l, consider 40 mmol/l of potassium. If potassium is 3- 5 mmol/l consider 20 - 30 mmol/l of potassium per liter of IV fluid. If potassium is more than 5 mmol/l check potassium level every 2 hours and hold potassium administration.
If blood glucose level less than 15 mmol/l the insulin infusion rate is half and switch to IV 5% dextrose containing fluid. The blood glucose level is maintained a 12- 16 mmol/l. Subcutaneous insulin is considered if there is an improvement in serum osmolality < 315 mmol/l and improvement in conscious level . 1 hour after subcutaneous insulin injection, IV insulin is discontinued. Arterial and venous thrombosis are prevented by considering heparinization of the patient for 2- 3 days.
Severe dehydration are more common in hyperglycemic hyperosmolar states than diabetic ketoacidosis. Due to elderly patient commonly affected by hyperglycemic hyperosmolar state, fluid regimens shoudl be less vigorous and less rapid. Central nervous pressure line is important in aiding fluid replacement. Oral hypoglycemic agent is considered after hyperglycemic hyperosmolar states and acute stress has resolved.
Hyperglycemic hyperosmolar state is a form of hyperglcemia due to relative insufficiency of the insulin. Hyperglycemic hyperosmolar is different from diabetic ketoacidosis , there is no or minimal ketone formation.
Hyperglycemic hyperosmolar state is common in elderly patient. It is associated with lactic acidosis with invariable form of severe dehydration. Hyperglycemic hyperosmolar will be the first initial presentation of diabetic especially diabetes mellitus type 2. Mortality rate is high.
Precipitating factors of hyperglycemic hyperosmolar states are stress, stroke, myocardial infarction, surgery , trauma or infection.
The pH > 7.3 with concentration of bicarbonate > 18 mmol/l. Blood glucose level is more than 33 mmol/l. Serum effective osmolality ( 2 * sodium’s concentration + glucose > 330 mmol/l) and serum total osmolality ( 2 * concentration of sodium + glucose + urea> 330 mmol/l. There is an absence of ketone in the urine.
After evaluating the patient, identify and treat any precipitating factors. Establish IV line and consider 1 liter of 0.9% of NACI per hour. If the patient is hypotensive consider colloid or 0.9% of NACI . In cases of normotensive consider 0.9% of NACI if low concentration of sodium and 0.45% of NACI if high or normal concentration of sodium. IV bolus of insulin 0.15 U/kg is given followed by IV insulin infusion 0.1U/kg/hr. The infusion rates should be double if blood glucose level does not fall by 3- 4 mmol/l. If potassium is less than 3 mmol/l, consider 40 mmol/l of potassium. If potassium is 3- 5 mmol/l consider 20 - 30 mmol/l of potassium per liter of IV fluid. If potassium is more than 5 mmol/l check potassium level every 2 hours and hold potassium administration.
If blood glucose level less than 15 mmol/l the insulin infusion rate is half and switch to IV 5% dextrose containing fluid. The blood glucose level is maintained a 12- 16 mmol/l. Subcutaneous insulin is considered if there is an improvement in serum osmolality < 315 mmol/l and improvement in conscious level . 1 hour after subcutaneous insulin injection, IV insulin is discontinued. Arterial and venous thrombosis are prevented by considering heparinization of the patient for 2- 3 days.
Severe dehydration are more common in hyperglycemic hyperosmolar states than diabetic ketoacidosis. Due to elderly patient commonly affected by hyperglycemic hyperosmolar state, fluid regimens shoudl be less vigorous and less rapid. Central nervous pressure line is important in aiding fluid replacement. Oral hypoglycemic agent is considered after hyperglycemic hyperosmolar states and acute stress has resolved.