Title:Hyperglycemic Hyperosmolar State: A Pragmatic Approach to Properly Manage Sodium Derangements
VOLUME: 14 ISSUE: 6
Author(s):Marco Baldrighi, Pier P. Sainaghi, Mattia Bellan, Ettore Bartoli and Luigi M. Castello*
Affiliation:Department of Translational Medicine, Universita del Piemonte Orientale, Novara, Department of Translational Medicine, Universita del Piemonte Orientale, Novara, Department of Translational Medicine, Universita del Piemonte Orientale, Novara, Department of Translational Medicine, Universita del Piemonte Orientale, Novara, Department of Translational Medicine, Universita del Piemonte Orientale, Novara
Keywords:Hyperglycemic hyperosmolar state, hyponatremia, hypernatremia, cerebral edema, osmotic demyelination syndrome,
fluid therapy.
Abstract:Introduction: Although hypovolemia remains the most relevant problem during acute decompensated
diabetes in its clinical manifestations (diabetic ketoacidosis, DKA, and hyperglycemic
hyperosmolar state, HHS), the electrolyte derangements caused by the global hydroelectrolytic imbalance
usually complicate the clinical picture at presentation and may be worsened by the treatment itself.
Aim: This review article is focused on the management of dysnatremias during hyperglycemic hyperosmolar
state with the aim of providing clinicians a useful tool to early identify the sodium derangement
in order to address properly its treatment.
Discussion: The plasma sodium concentration is modified by most of the therapeutic measures commonly
required in such patients and the physician needs to consider these interactions when treating
HHS. Moreover, an improper management of plasma sodium concentration (PNa+) and plasma osmolality
during treatment has been associated with two rare potentially life-threatening complications
(cerebral edema and osmotic demyelination syndrome). Identifying the correct composition of the fluids
that need to be infused to restore volume losses is crucial to prevent complications.
Conclusion: A quantitative approach based on the comparison between the measured PNa+ (PNa+
M)
and the PNa+ expected in the presence of an exclusive water shift (PNa+
G) may provide more thorough
information about the true hydroelectrolytic status of the patient and may therefore, guide the physician
in the initial management of HHS. On the basis of data derived from our previous studies, we propose
a 7-step algorithm to compute an accurate estimate of PNa+
G.
