Hyperosmolar hyperglycemic state

Last reviewed: 5 Jan 2023
Last updated: 24 Jan 2023



History and exam

Key diagnostic factors

  • altered mental status
More key diagnostic factors

Other diagnostic factors

  • polyuria
  • polydipsia
  • weight loss
  • weakness
  • dry mucus membranes
  • poor skin turgor
  • tachycardia
  • hypotension
  • seizures
  • hypothermia
  • shock
  • abdominal pain
  • focal neurologic signs
Other diagnostic factors

Risk factors

  • infection
  • 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
  • hyperthyroidism
  • acromegaly
More risk factors

Diagnostic investigations

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
  • urinalysis
  • liver function tests
  • CBC
More 1st investigations to order

Investigations to consider

  • chest x-ray
  • ECG
  • cardiac biomarkers
  • blood, urine, or sputum cultures
More investigations to consider

Treatment algorithm


all patients


HHS resolved and patient able to tolerate oral intake



Guillermo Umpierrez, MD

Professor of Medicine

Emory University School of Medicine




GU has received research grants from Astra Zeneca, Dexcom, and Bayer. GU is an author of a number of references cited in this topic.

Peer reviewers

William B. Horton, MD, MSc, FACP

Assistant Professor of Medicine

University of Virginia School of Medicine




WBH has been a principal investigator for several grants from nonprofit funding sources including the National Institutes of Health, the Juvenile Diabetes Research Foundation, and the American Heart Association. WBH was a contributor to the Diabetes Textbook: Clinical principles, patient management and public health issues, Springer Nature Switzerland AG 2019, having written a chapter about inpatient management of diabetes and hyperglycemia for which he received no fee.

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