Aggressive Fluid Resuscitation in Severe Pediatric Hyperglycemic Hyperosmolar Syndrome: A Case Report

Diagnosis and Acute Management of Hyperglycemic Hyperosmolar Syndrome in Children and Adolescents

ABSTRACT

Hyperglycemic hyperosmolar syndrome (HHS) is an indolent process characterized by significantly increased levels of serum glucose, high osmolality, and electrolyte abnormalities. The incidence of HHS has steadily risen in the pediatric population over the past several years. Patients with HHS often present with profound dehydration, fatigue, and early mental status changes. Primary emergency management of HHS involves fluid replacement, hemodynamic support, correcting electrolyte derangements, and addressing complications and underlying illnesses. Insulin is not an initial therapy in HHS and should be considered only after the patient's fluids and electrolytes have been repleted. Unlike in diabetic ketoacidosis, HHS patients are not acidotic, although children may present with mixed HHS/diabetic ketoacidosis syndromes. Complications of HHS include thrombosis, rhabdomyolysis, and, rarely, malignant hyperthermia.

The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications

In hyperglycemia, hypertonicity results from solute (glucose) gain and loss of water in excess of sodium plus potassium through osmotic diuresis. Patients with stage 5 chronic kidney disease (CKD) and hyperglycemia have minimal or no osmotic diuresis; patients with preserved renal function and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) have often large osmotic diuresis. Hypertonicity from glucose gain is reversed with normalization of serum glucose ([Glu]); hypertonicity due to osmotic diuresis requires infusion of hypotonic solutions. Prediction of the serum sodium after [Glu] normalization (the corrected [Na]) estimates the part of hypertonicity caused by osmotic diuresis. Theoretical methods calculating the corrected [Na] and clinical reports allowing its calculation were reviewed. Corrected [Na] was computed separately in reports of DKA, HHS and hyperglycemia in CKD stage 5. The theoretical prediction of [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu] in most clinical settings, except in extreme hyperglycemia or profound hypervolemia, was supported by studies of hyperglycemia in CKD stage 5 treated only with insulin. Mean corrected [Na] was 139.0 mmol/L in 772 hyperglycemic episodes in CKD stage 5 patients. In patients with preserved renal function, mean corrected [Na] was within the eunatremic range (141.1 mmol/L) in 7,812 DKA cases, and in the range of severe hypernatremia (160.8 mmol/L) in 755 cases of HHS. However, in DKA corrected [Na] was in the hypernatremic range in several reports and rose during treatment with adverse neurological consequences in other reports. The corrected [Na], computed as [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu], provides a reasonable estimate of the degree of hypertonicity due to losses of hypotonic fluids through osmotic diuresis at presentation of DKH or HHS and should guide the tonicity of replacement solutions. However, the corrected [Na] may change during treatment because of ongoing fluid losses and should be monitored during treatment.

Severe complications after initial management of hyperglycemic hyperosmolar syndrome and diabetic ketoacidosis with a standard diabetic ketoacidosis protocol

Hyperglycemic hyperosmolar syndrome (HHS) is a clinical entity not identical to diabetic ketoacidosis (DKA), and with a markedly higher mortality. Children with HHS can also present with concomitant DKA. Patients with HHS (with or without DKA) are profoundly dehydrated but often receive inadequate fluid resuscitation as well as intravenous insulin therapy based on traditional DKA protocols, and this can lead to devastating consequences. In this article, we briefly review HHS along with a report of an adolescent who presented with HHS and DKA and was initially managed as DKA. She went into hypotensive shock and developed severe, multiorgan failure. A thorough understanding of the pathophysiology of HHS and its differences from DKA in terms of initial management is crucial to guide management and improve outcomes. Additionally, fluid therapy in amounts concordant with the degree of dehydration remains the mainstay therapy.

Two case reports of severe pediatric hyperosmolar hyperglycemia and diabetic ketoacidosis accompanied with rhabdomyolysis and acute renal failure

OBJECTIVE

This report describes two adolescent males in China who suffered from type 2 diabetes mellitus (T2DM) and hyperglycemic hyperosmolar syndrome (HHS) complicated by rhabdomyolysis (RM). After sufficient fluid administration, both patients recovered.

DESIGN

Case report.

RESULTS

These two obese patients suffered from T2DM, DKA and HHS. Because of insufficient fluid administration, these patients became aggravated and suffered from RM. After aggressive fluid resuscitation and insulin injection, the conditions of the two patients improved. Insulin administration was ceased after approximately 1 month of subcutaneous injections. The two patients attained good glucose control with diet management.

CONCLUSIONS

HHS is one of the most severe complications of T2DM. RM is a sign that the condition of a patient with HHS may worsen. Although management strategies are undefined, effective fluid infusion was shown to be helpful. Thus, the early signs of HHS and RM should be recognized so as to avoid severe complications.