estado hiperosmolar hiperglucémico
TRANSCRIPT
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Estado Hiperosmolar Hiperglucémico
Dr. Guillén Vargas Andrés R1 MI
HGZ20
Tijuana B.C. a 20 febrero del 2010.
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Estado Hiperosmolar Hiperglucémico (EHH)
“ Hiperglucemia (glucosa sérica >600mg/dl) e hiperosmolaridad (>320mOsm/L) en
ausencia de cetonemia significativa y acidosis ”
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Estado Hiperosmolar no cetósico
Coma Hiperosmolar
Estado Hiperosmolar Hiperglucémico (EHH)
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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)
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Fisiopatología de EHH
Deficiencia de insulina y aumento de hormonas contrarreguladoras.
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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.
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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.
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EVALUACION EHH
ABC Historial de DM otras comorbilidades. Laboratorio. Gabinete.
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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.
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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.
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Resolucion EHH
Paciente alerta
Osmolaridad plasmática es < 315 mosmol/kg.
El paciente es capaz de comer.
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BIBLIOGRAFIA
Harwood-Nuss’ Clinical Practice of Emergency Medicine.
UptoDate 7.1 2009.