高渗性高血糖状态（HHS）是与高死亡率相关的医疗紧急情况。它的发生频率低于糖尿病酮症酸中毒（DKA），影响已存在/新的2型糖尿病患者，并越来越多地影响儿童/年轻人。混合DKA/HHS可能发生。JBDSHHS护理路径包括3个主题(临床评估和监测，干预措施，评估和预防伤害)和5个阶段的治疗(0-60分钟，1-6、6-12、12-24和24-72小时）。HHS的临床特征包括明显的低血容量,渗透压≥320mOsm/kg，使用[(2×Na+)+葡萄糖+尿素]，显著高血糖≥30mmol/L，无显著酮症（≤3.0mmol/L），无明显酸中毒（pH>7.3）和碳酸氢盐≥15mmol/L治疗的目的是改善临床状态/24小时替换液体损失，渗透压逐渐下降（3.0-8.0mOsm/kg/h，以最大程度地减少神经系统并发症的风险），前24小时血糖10-15mmol/L，预防低血糖/低钾血症并预防伤害(VTE，渗透性脱髓鞘,流体过载,足部溃疡）。必须识别和处理潜在的沉淀物。干预措施包括：（1）静脉注射（IV）0.9％的氯化钠以恢复循环量（液体损失100-220ml/kg，老年人的谨慎)，（2）一旦渗透压随着补液而停止下降，应开始固定速率静脉内胰岛素输注（FRIII），除非有酮症（FRIII应与IV液体同时开始）。（3）一旦葡萄糖<14mmol/L，应开始葡萄糖输注（5％或10％）；（4）根据钾水平进行钾替代。HHS分辨率标准为:渗透压<300mOsm/kg,纠正低血容量（尿量≥0.5ml/kg/h），认知状态恢复至病前状态，血糖<15mmol/L。
Hyperosmolar Hyperglycaemic State (
HHS) is a medical emergency associated with high mortality. It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre-existing/new type 2 diabetes mellitus and increasingly affecting children/younger adults. Mixed DKA/
HHS may occur. The JBDS
HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6, 6-12, 12-24 and 24-72 h). Clinical features of
HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg using [(2×Na+ ) + glucose+urea], marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L. Aims of the therapy are to improve clinical status/replace fluid losses by 24 h, gradual decline in osmolality (3.0-8.0 mOsm/kg/h to minimise the risk of neurological complications), blood glucose 10-15 mmol/L in the first 24 h, prevent hypoglycaemia/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose <14 mmol/L and (4) potassium replacement according to potassium levels.
HHS resolution criteria are: osmolality <300 mOsm/kg, hypovolaemia corrected (urine output ≥0.5 ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.
PDF(Pubmed)