Hyperosmolar hyperglycemic state occurs most commonly in older patients with type 2 diabetes. Contributes to less than 1% of all diabetes-related admissions. However, mortality is high (5% to 20%).
Presents with polyuria, polydipsia, weakness, weight loss, tachycardia, dry mucus 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 mOsm/kg.
Treatment includes correction of fluid deficit and electrolyte abnormalities, and intravenous insulin.
Hyperosmolar hyperglycemic state (HHS), also known as non-ketotic hyperglycemic hyperosmolar syndrome, is characterized by profound hyperglycemia (glucose >600 mg/dL), hyperosmolality (effective serum osmolality ≥320 mOsm/kg), and volume depletion in the absence of significant ketoacidosis (pH >7.3 and HCO3 >15 mEq/L), and is a serious complication of diabetes. HHS may be the first presentation of type 2 diabetes.
HHS and DKA are characterized by relative or absolute insulin deficiency combined with increased counter-regulatory hormones. Approximately one third of patients with hyperglycemic crises present with a mixed picture of DKA and HHS. Infection is the most common precipitant.
History and exam
Key diagnostic factors
- altered mental status
Other diagnostic factors
- weight loss
- dry mucus membranes
- poor skin turgor
- abdominal pain
- focal neurologic signs
- inadequate insulin or oral antidiabetic therapy
- acute illness in a known patient with diabetes
- nursing home residents
- failure to detect hyperglycemia
- postoperative state
- precipitating medications
- total parenteral nutrition (TPN)
- Cushing syndrome
1st investigations to order
- plasma glucose level
- serum or urinary ketone level
- serum BUN level
- serum creatinine level
- serum sodium level
- serum potassium level
- serum chloride level
- serum magnesium level
- serum calcium level
- serum phosphate level
- serum osmolality
- anion gap calculation
- serum lactate level
- blood gas
- liver function tests
Investigations to consider
- chest x-ray
- cardiac biomarkers
- blood, urine, or sputum cultures
HHS resolved and patient able to tolerate oral intake
- Diabetic ketoacidosis (DKA)
- Lactic acidosis
- Alcohol ketoacidosis
- Standards of medical care in diabetes - 2022
- Diabetic ketoacidosis and hyperglycemic hyperosmolar state
Diabetes: what is it?
Diabetes type 2: should I take insulin?More Patient leaflets
Tracheal intubation: animated demonstration
Bag-valve-mask ventilation: animated demonstrationMore videos
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer