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Pathology
Hyperosmolar hyperglycaemia with dehydration and haemoconcentration. Counter-regulatory hormone excess with relative insulin deficit (able to switch off ketogenesis but not to control hyperglycaemia)
Aetiology
Elderly with intercurrent infections, intake of drinks with high sugar content, myocardial infarction, drugs (e.g. steroids, thiazide diuretics), non-compliance with diabetes medications, first presentation of type 2 diabetes
Signs
Dehydration, confusion, coma, polyuria, slurred speech, seizures and signs of stroke.
Symptoms
Lethargy, confusion, altered consciousness, neurological symptoms
Investigations
Bloods: Glucose (>40 mmol/l), serum electrolytes, serum osmolality
>350mosmol/kg), ketones, septic screen
Venous Blood Gas: pH and bicarbonate
ECG: Rule out ischaemia or infarction
MSU: Screen for infection
Chest X-Ray: Screen for infection
Treatment
IV Fluids: 8-10 litre deficit to be corrected slowly as risk of cerebral oedema
Insulin: 3-5 units/hr to reduce glucose ~ 5mmol/L/hr. Monitor potassium.
VTE prophylaxis: Hypercoagulable state
Prognosis
Mortality up to 50% especially in elderly
Venous thromboembolism, permanent neurological sequelae
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Key References
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