Hyperosmolar hyperglycemic state

Last reviewed: 25 Aug 2022
Last updated: 12 Apr 2022



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 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.

Peer reviewers

Daniel Morganstein, MBBS, MA (Cantab), MRCP, PhD

Consultant Diabetologist

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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