Hyperosmolar hyperglycaemic state

Occurs most commonly in older people with type 2 diabetes. Contributes to less than 1% of all diabetes-related admissions. However, mortality is high (5% to 15%).

Presents with polyuria, polydipsia, weakness, weight loss, tachycardia, dry mucous membranes, poor skin turgor, hypotension, and, in severe cases, shock.

Altered sensorium (lethargy, disorientation, stupor) is common and correlates best with effective serum osmolality. Coma is rare and, if seen, is usually associated with a serum osmolality >340 mmol/kg (>340 mOsm/kg)

Treatment includes correction of fluid deficit and electrolyte abnormalities, and intravenous insulin.

Hyperosmolar hyperglycaemic state (HHS), also known as non-ketotic hyperglycaemic hyperosmolar syndrome (NKHS), is characterised by profound hyperglycaemia (glucose >33.3 mmol/L [>600 mg/dL]), hyperosmolality (effective serum osmolality ≥320 mmol/kg [≥320 mOsm/kg]), and volume depletion in the absence of significant ketoacidosis (pH >7.3 and HCO3 >15 mmol/L [>15 mEq/L]), and is a serious complication of diabetes. HHS may be the first presentation of type 2 diabetes.[1]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan;24(1):131-53. http://care.diabetesjournals.org/content/24/1/131.long http://www.ncbi.nlm.nih.gov/pubmed/11194218?tool=bestpractice.com [2]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009 Jul;32(7):1335-43. http://care.diabetesjournals.org/content/32/7/1335.long http://www.ncbi.nlm.nih.gov/pubmed/19564476?tool=bestpractice.com Although both HHS and diabetic ketoacidosis (DKA) are often discussed as distinct entities, they represent 2 points on the spectrum of metabolic derangements in diabetes.[3]Bhattacharyya OK, Estey EA, Cheng AY. Update on the Canadian Diabetes Association 2008 clinical practice guidelines. Can Fam Physician. 2009 Jan;55(1):39-43. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628826/ http://www.ncbi.nlm.nih.gov/pubmed/19155364?tool=bestpractice.com Both HHS and DKA are characterised by relative or absolute insulin deficiency combined with increased counter-regulatory hormones.[1]Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. 2001 Jan;24(1):131-53. http://care.diabetesjournals.org/content/24/1/131.long http://www.ncbi.nlm.nih.gov/pubmed/11194218?tool=bestpractice.com [4]Wolfsdorf JI, Allgrove J, Craig ME, et al; International Society for Pediatric and Adolescent Diabetes. ISPAD clinical practice consensus guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2014 Sep;15(suppl 20):154-79. http://c.ymcdn.com/sites/www.ispad.org/resource/resmgr/Docs/CPCG_2014_CHAP_11.pdf http://www.ncbi.nlm.nih.gov/pubmed/25041509?tool=bestpractice.com Approximately 33% of patients with hyperglycaemic crises present with a mixed picture of DKA and HHS.[5]Wachtel TJ, Tetu-Mouradjian LM, Goldman DL, et al. Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island. J Gen Intern Med. 1991 Nov-Dec;6(6):495-502. http://www.ncbi.nlm.nih.gov/pubmed/1765864?tool=bestpractice.com