Hyperosmolar Hyperglycemic State (previously known as “Hyperosmolar Hyperglycemic Nonketotic Syndrome” and, before that, “Hyperosmolar Hyperglycemic Nonketotic Coma”) is a bit of a slippery animal. Despite being redefined several times, the precise definition remains elusive. This may cause it to be over-diagnosed in anyone with severe hyperglycemia. The treatment likewise remains a bit controversial, with different guidelines recommending opposing strategies. Consequently, we may need to rely on a sound understanding of the physiology and some common sense to navigate the confusion of this diagnosis.
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The IBCC chapter is located here.
- The podcast & comments are below.
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Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.
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Nice, thanks for doing this.. however I feel like this chapters missing an “ending.” Can you also talk about “transitioning.” Like DKA you monitor until the gap closes then transition them. What about for HHNK? Are you monitoring serial serum osms? How do you know when you’re done and how do you suggest transitioning. Thanks
hm….
Great, as always.
The UK guidelines talk about using different measures of osmolality/tonicity to monitor and guide response to fluid and insulin therapy. The 3-8mOsm per hour seems pretty aggressive – at the upper end this could be a reduction in osmolality of nearly 200 over 24 hours – and I can’t see how they arrived at this?
The only thing I’d add to your chapter is the importance of VTE prophylaxis (some places still advocating therapeutic doses of LMW heparin?) and watching for pressure sores. Thanks again!
D
By administering insulin, we are decreasing serum osmolality and tonicity and increasing intracellular osmolality and tonicity… leading to tissue swelling?