Title: Pediatric HHS: Becoming More Frequent
题目：儿童高血糖高渗状态（HHS）－会越来越常见

Emergency Physicians should be aware that hyperglycemic hyperosmolar state occurs in children and that HHS is likely to become more common given the increasing incidence of childhood obesity and type 2 DM (1). Furthermore, HHS, although classically associated with type 2 DM, has also been reported increasingly with type 1 DM.
急诊医师应该知道，高血糖高渗状态（HHS）可以发生在儿童，并且HHS可能因儿童肥胖和2型糖尿病发病率越来越高而更常见。此外，典型的HHS虽然与2型糖尿病相关，也有越来越多的与1型糖尿病相关的报道。
Correctly differentiating HHS vs. DKA is crucial as treatment principles are different.
正确区分HHS与糖尿病酮症酸中毒（DKA）是至关重要的，因为它们的治疗原则是不同的。
Clinically, HHS and DKA differ by the severity of dehydration and whether or not ketosis and metabolic acidosis are present.
临床上，HHS和DKA脱水的轻重不同，是否存在酮症及代谢性酸中毒。
HHS is characterized by the triad of hyperglycemia (typically > 600 mg/dL), hyperosmolality (serum osmolality > 320mOsm/L), and absence of significant acidosis or ketosis.
HHS的特点是三联症：高血糖（通常> 600毫克/分升），高渗（血浆渗透压>320mOsm/ L），和无显着的酸中毒或酮症。
Fluid therapy is the cornerstone of management of pediatric HHS. Initial bolus of NaCl 20 mL/kg should be given and can be repeated until peripheral circulation/perfusion is established. Fluid deficits should then be gradually corrected over 48 h. Fluid administration alone results in a substantial decline in serum glucose.
液体疗法是治疗小儿HHS的主要措施。最初要快速静注20毫升/公斤的生理盐水并可以反复进行，直至末梢循环/灌注重新建立。然后将全部的流体赤字在48 小时内逐步纠正。单靠输液就可导致血糖大幅下降。
Severe dehydration, electrolyte disturbance, and hypertonicity are far more frequent causes of death in HHS than is cerebral edema; therefore, concerns about cerebral edema should not deter the clinician from administering the necessary amount of fluid to restore adequate hydration and perfusion.
HHS的严重脱水，电解质紊乱，高渗要比脑水肿更多的造成死亡，因此，对脑水肿的担忧不应该拖延医生给予必要的液体量，以恢复充足的水分和灌注。
In general, insulin administration should be considered only when serum glucose concentrations are no longer declining adequately (< 50 mg/dL/h) with fluid administration alone or in children with significant ketosis and acidosis.
在一般情况下，只有在充分补液后血糖浓度不再明显下降（<50毫克/dL/h）或有明显酮症或酸中毒时才应考虑给胰岛素。
Unlike DKA, insulin therapy is usually not necessary for resolution of ketosis in HHS. Of note, some children with type 1 DM may have features of HHS (i.e. severe hyperglycemia), if high-carbohydrate-containing beverages have been used to quench thirst before presentation (1,2).

与DKA不同的是，HHS酮症的改善通常不需要胰岛素 。值得注意的是，如果1型糖尿病儿童在就诊前喝了大量的高碳水化合物的饮料可以出现HHS的特征（如严重的高血糖）。

References参考文献:
(1) Arora R, Chiwane S, Hartwig E, et al. A Child with Altered Sensorium, Hyperglycemia, and Elevated Troponins[J]. J Emerg Med, Epub July, 2013.

(2) McDonnell CM, Pedreira CC, Vadamalayan B, et al. Diabetic ketoacidosis, hyperosmolarity and hypernatremia: are high-carbohydrate drinks worsening initial presentation?[J]. Pediatr Diabetes, 2005;6:90-94.

(3) Zeitler P, Haqq A, Rosenbloom A, et al. Hyperglycemic hyperosmolar syndrome in children: pathophysiological considerations and suggested guidelines for treatment[J]. J Pediatr, 2011,158:9-14.