Complications

Complications table
ComplicationTimeframeLikelihood

insulin-related hypoglycemia

short termhigh

This iatrogenic complication can occur with excessive high-dose insulin therapy.

It can be prevented by following treatment protocols with frequent monitoring of plasma glucose and use of glucose-containing intravenous fluids.[1][63] Treatment-related severe hypoglycemia is associated with increased mortality.[6]

treatment-related hypokalemia

short termhigh

This iatrogenic complication can occur with excessive high-dose insulin therapy, inadequate potassium replacement, and bicarbonate therapy. Treatment-related severe hypokalemia is associated with increased mortality.[6]

It can be prevented by following treatment protocols with frequent monitoring of potassium levels and appropriate replacement.[1][64]

stroke

short termlow

Reported as a complication of HHS. Predisposing factors include volume depletion with increased viscosity, hyperfibrinogenemia, and elevated levels of plasma plasminogen activator inhibitor (PAI-1).[15][65]

Aggressive early hydration is helpful in reducing the incidence of these complications to approximately 2%.[15] There is no evidence for full anticoagulation. Prophylactic treatment is based on clinical evaluation of risk factors for thromboembolic events.[9]

myocardial infarction

short termlow

Reported as a complication of HHS. Predisposing factors include volume depletion with increased viscosity, hyperfibrinogenemia, and elevated levels of plasma PAI-1.[15][65]

Aggressive early hydration is helpful in reducing the incidence of these complications to approximately 2%.[15] There is no evidence for full anticoagulation. Prophylactic treatment is based on clinical evaluation of risk factors for thromboembolic events.[9]

pulmonary embolism

short termlow

Reported as a complication of HHS. Predisposing factors include volume depletion with increased viscosity, hyperfibrinogenemia, and elevated levels of plasma PAI-1.[15][65]

Aggressive early hydration is helpful in reducing the incidence of these complications to approximately 2%.[15] There is no evidence for full anticoagulation. Prophylactic treatment is based on clinical evaluation of risk factors for thromboembolic events.[9]

disseminated intravascular coagulation

short termlow

Reported as a rare complication of HHS. Predisposing factors include volume depletion with increased viscosity, hyperfibrinogenemia, and elevated levels of plasma PAI-1.[15][65]

Aggressive early hydration is helpful in reducing the incidence of these complications to approximately 2%.[15] There is no evidence for full anticoagulation. Prophylactic treatment is based on clinical evaluation of risk factors for thromboembolic events.[9]

mesenteric vessel thrombosis

short termlow

Reported as a rare complication of HHS. Predisposing factors include volume depletion with increased viscosity, hyperfibrinogenemia, and elevated levels of plasma PAI-1.[15][65]

Aggressive early hydration is helpful in reducing the incidence of these complications to approximately 2%.[15] There is no evidence for full anticoagulation. Prophylactic treatment is based on clinical evaluation of risk factors for thromboembolic events.[9]

cerebral edema

short termlow

This is rare in adults with HHS. It presents with headache, lethargy, papillary changes, and seizure. Mortality is high.

Mannitol infusion and mechanical ventilation should be used. Cerebral edema can be prevented by avoiding a reduction in plasma osmolality of more than 3 mOsm/kg/hour. This can be achieved by monitoring plasma osmolality, adding dextrose to intravenous fluids once plasma glucose falls below 250 to 300 mg/dL, and selecting the correct concentration of intravenous saline.[14][46][66][67]

coma

short termlow

Usually associated with serum osmolality levels >330 to 340 mOsm/kg and is most often more hypernatremic than hyperglycemic in nature.[8][9]

Intensive care unit admission, close monitoring, and aggressive fluid and insulin therapy are necessary. Many patients may require airway protection and mechanical ventilation.

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