Management of Hyperglycemic Hyperosmolar Syndrome
Hyperglycemic Hyperosmolar Syndrome (HHS) is a critical complication of diabetes mellitus that requires immediate diagnosis and treatment. Patients with this syndrome present with hyperglycemia, hyperosmolality and significant dehydration that are often a
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Elaine C. Fajardo
Case Presentation A 68 year old woman with a past medical history of alcohol abuse status post detoxification, chronic kidney disease and type 2 diabetes mellitus was brought into the Emergency Department (ED) by ambulance for slurred speech. She was on the phone with her daughter when she developed the dysarthria. Unable to speak effectively, she got off the phone and went to a neighbor’s apartment. The neighbor reported an episode of shaking, lasting approximately 10 s, prior to paramedic arrival. En route to the hospital, the patient became combative, confused and incontinent of stool and urine. She was hypertensive with blood pressure of 226/97 mmHg, tachycardic with heart rate of 109 bpm, and hyperglycemic with capillary blood glucose “critically high”. Upon arrival to the ED, a stroke alert was initiated. NIH Stroke Scale was calculated to be 18, with points for level of consciousness, motor drift, language aphasia, and dysarthria. Neurological exam revealed a lethargic patient, not following commands, with reduced withdrawal to noxious stimuli in the right upper and lower extremities. There was an upgoing Babinski sign on the right. Non-contrast CT scan of the head did not
E.C. Fajardo Internal Medicine Department, Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA e-mail: [email protected]
show acute intracranial hemorrhage, mass shift or trauma. MRI/MRA of the brain revealed no sign of acute cerebral vascular infarct or cerebroarterial abnormality. Laboratory results were significant for: Sodium = 132 mmol/L, Potassium = 3.6 mmol/L, Bicarbonate = 18.6 mmol/L, Anion gap = 20 mmol/L, Urea 38 = mg/dL, Creatinine = 2.1 mg/dL (baseline 1.3), Glucose = 769, and Serum Osmolality = 331 Osm/kg. The WBC was 3.6 ×1000/ul without neutrophilic predominance. Point of Care lactate was 3.2 mmol/L and Point of Care pH was 7.30. The serum beta-hydroxy-butyrate level was not checked. Urine ketones were negative. Question What is the most appropriate intervention for the patient’s neurological symptoms? Answer Intravenous (IV) Fluid Therapy This patient presented with focal neurological findings and grand mal seizure without evidence of cerebral vascular accident or other culprit lesion on MRI. She did not have fever, infectious prodrome or elevated WBC that would indicate a CNS infection. With serum glucose >320 mg/dL, serum osmolality >320 mOsm/kg, pH >7.30 and negative urine ketones, she met the diagnostic criteria for Hyperosmolar Hyperglycemic Syndrome (HHS), and her neurological signs are likely due to the hyperosmolar state. The most common admitting diagnosis in patients with HHS is acute stroke [1, 2]. In patients presenting with seizures and stroke-
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_50
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like symptoms secondary to HHS, their neurological exams return to normal with appropriate management of HHS [3]. T
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