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
- 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
- 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
Guillermo Umpierrez, MD
Professor of Medicine
Emory University School of Medicine
GU is partly supported by research grants from the National Center for Advancing Translational Sciences of the National Institutes of Health, under Award Number UL1TR002378, from the Clinical and Translational Science Award program, and a National Institutes of Health (NIH) grant U30, P30DK11102. GU has also received research grant support to Emory University for investigator-initiated studies from Novo Nordisk, Astra Zeneca, and Dexcom. GU is an author of a number of references cited in this topic.
Daniel Morganstein, MBBS, MA (Cantab), MRCP, PhD
Beta Cell Unit
Chelsea and Westminster NHS Trust
DM declares that he has no competing interests.
M. Cecilia Lansang, MD
Department of Medicine
Division of Endocrinology and Metabolism
University of Florida
MCL has received speaker fees from Sanofi-Aventis and Novo Nordisk, makers of insulin products.
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