Estado Hiperosmolar Hiperglucémico

Dr. Guillén Vargas Andrés R1 MI

HGZ20

Tijuana B.C. a 20 febrero del 2010.

Estado Hiperosmolar Hiperglucémico (EHH)

“ Hiperglucemia (glucosa sérica >600mg/dl) e hiperosmolaridad (>320mOsm/L) en

ausencia de cetonemia significativa y acidosis ”

Estado Hiperosmolar no cetósico

Coma Hiperosmolar

Estado Hiperosmolar Hiperglucémico (EHH)

Frecuencia DM2 > DM1. Edad media 65 años Debutan con EHH 30-40%. < 1% de admisiones por DM. Mortalidad de al menos 10%. Cetosis moderada es comun Coma <30%.

Estado Hiperosmolar Hiperglucémico (EHH)

Fisiopatología de EHH

Deficiencia de insulina y aumento de hormonas contrarreguladoras.

Diagnóstico EHH

Criterios diagnósticos EHH : a. Glucosa sérica >600 mg/dl

b. pH arterial >7.3

c. bicarbonato sérico >15 mEq/l

d. and mínima cetonuria and cetonemia.

Table 203.1 Diagnostic Criteria for DKA and HHS

  DKA  

  Mild Moderate Severe HHS

Diagnostic criteria and classification

       

Plasma glucose (mg/dL) >250 mg/dL

>250 mg/dL >250 mg/dL >600 mg/dL

Arterial pH 7.25–7.30

7.00 to <7.25 <7.00 >7.30

Serum bicarbonate (mEq/L) 15–18 10 to <15 <10 >15

Urine ketonea Positive Positive Positive Small

Serum ketonea Positive Positive Positive Small

Effective serum osmolalityb Variable Variable Variable >320 mOsm/kg

Anion gapc >10 >12 >12 <12

Mental status Alert Alert/drowsy Stupor/coma Stupor/comaDKA, diabetic ketoacidosis; HHS, hyperosmolar hyperglycemic state.

aNitroprusside reaction method.bCalculation of effective serum osmolality: 2[measured Na+ (mEq/L)] + [glucose (mg/dL)]/18.cCalculation of anion gap: (Na+) - [Cl- + HCO3

- (mEq/L)].

Source: Modified from Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2006;29:2739–2748.

EVALUACION EHH

ABC Historial de DM otras comorbilidades. Laboratorio. Gabinete.

Table 203.3 Typical admission biochemical data in patients who have hyperglycemic hyperosmolar syndrome and diabetic ketoacidosis

Laboratory Test HHS DKA

Glucose (mg/dL) 930 ± 83 616 ± 36

Na+ (mEq/L) 149 ± 3.2 134 ± 1.0

K+ (mEq/L) 3.9 ± 0.2 4.5 ± 0.13

BUN (mg/dL) 61 ± 11 32 ± 3

Creatinine (mg/dL) 1.4 ± 0.1 1.1 ± 0.1

pH 7.3 ± 0.03 7.12 ± 0.04

Bicarbonate (mEq/L) 18 ± 1.1 9.4 ± 1.4

BOHB (mmol/L) 1.0 ± 0.2 9.1 ± 0.85

Total osmolality (mOsm/kg)

380 ± 5.7 323 ± 2.5

Anion gap 11 17

Data are presented as mean ± SEM.Abbreviation: IRI, immuno reactive insulin, HHS, hyperglycemic hyperosmolar syndrome, DKA, diabetic ketoacidosis.Adapted from Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001;24:131–53.

Type of Deficit HHS DKA

Total water (l) 9 6

Water (mL/kg) 100–200 100

Na+ (mEq/kg) 5–13 7–10

Cl- (mEq/kg) 5–15 3–5

K+ (mEq/kg) 4–6 3–5

PO4 (mmol/kg) 3–7 5–7

Mg++ (mEq/kg) 1–2 1–2

Ca++ (mEq/kg) 1–2 1–2

Adapted from Ennis ED, Stahl EJVB, Kreisberg RA. The hyperosmolar hyperglycemic syndrome. Diabetes Rev 1994;2:115–126. and Kreisberg RA: Diabetic ketoacidosis: an update. Crit Care Clin 1987;3:817–834.

Resolucion EHH

Paciente alerta

Osmolaridad plasmática es < 315 mosmol/kg.

El paciente es capaz de comer.

BIBLIOGRAFIA

Harwood-Nuss’ Clinical Practice of Emergency Medicine.

UptoDate 7.1 2009.