DKA isn& #39;t the only hyperglycemic emergency in peds patients.

Check out this peer review https://tinyurl.com/y5ldx5bh ">https://tinyurl.com/y5ldx5bh&... & follow this thread exploring the patho, clinical recognition, & mgmt of #HHS

#EmoryACPNP2020 @brownam130

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#HHS or Hyperglycemic Hyperosmolar State usually affects adults with #T2DM

-Growing incidence in peds population d/t increased rates of childhood obesity
-Mixed features of #HHS and #DKA can also occur in #T1DM

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#HHS is characterized by https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> serum glucose, https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> serum osmolality, & https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben"> hypertonic dehydration WITHOUT ketosis

Check out this quick overview of the patho of HHS

3/

Guideline criteria from @ispad_org for HHS:

-BG>600, arterial pH >7.30, bicarb >15
-Serum osmolality >320
- 0-minimal ketonuria & ketonemia
-And altered mental status

4/

Clinical Presentation similar to #DKA
-polyuria, polydipsia, abd pain, N/V, dehydration, & AMS

So why is #HHS so serious?

Dehydration progresses over days-week w/ few clinical signs. Hypertonicity preserves intravascular space despite extreme fluid & electrolyte losses

5/

Fluid losses in #HHS are DOUBLE https://abs.twimg.com/emoji/v2/... draggable="false" alt="😲" title="Erstauntes Gesicht" aria-label="Emoji: Erstauntes Gesicht"> that in #DKA. Cornerstones of mgmt include:

-Aggressive fluid resuscitation
-Electrolyte correction
-Maintaining renal perfusion
-Conservative insulin administration

Lets talk specifics!

6/

Fluid Resuscitation:

-20ml/kg of NS repeated to restore perfusion followed by
-0.45-0.75% NS over the next 24-48hrs for 12-15% of body weight
-slow Na correction at 0.5mmol/L/hr
-& replacement fluids of urinary losses

7/

Early insulin therapy NOT recommended. Fluids alone=marked decrease in BG

-Initiate insulin @ 0.025-0.05 U/kg/hr once glucose is no longer declining @ > 50mg/hr with fluids alone
-Monitor glucose hourly

8/

Profound K, Mg, & phos depletion in #HHS

-Add K to IVF prior to insulin initiation when serum K < 5.5
-may consider mag and phosphate repletion as well
-Bicarb is contraindicated https://abs.twimg.com/emoji/v2/... draggable="false" alt="🙅‍♀️" title="Frau gestikuliert „Nicht OK“" aria-label="Emoji: Frau gestikuliert „Nicht OK“"> d/t risk for hypokalemia
-Check serum electrolytes Q2-3h

9/

Complications in children with HHS include:

-Rhabdomyolysis
-Malignant hyperthermia
-Compartment syndrome
-Ventricular arrhythmias
-AKI & venous thrombosis
-Cerebral edema is less common in #HHS

What are your clinical pearls for managing #HHS? Let& #39;s Discuss!

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