Hyperglycemic hyperosmolar state (high glucose)

Chest | Endocrinology and Metabolism | Hyperglycemic hyperosmolar state (high glucose) (Disease)


Hyperosmolar hyperglycemic state (HHS) is 1 of 2 serious metabolic derangements that occurs in patients with diabetes mellitus (DM) and can be a life-threatening emergency. It is less common than the other acute complication of diabetes, diabetic ketoacidosis (DKA). HHS was previously termed hyperosmolar hyperglycemic nonketotic coma; however, the terminology was changed because coma is found in fewer than 20% of patients with HHS.

HHS is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis. Most patients present with severe dehydration and focal or global neurologic deficits.

Causes and Risk factors

HHS most commonly occurs in patients with type 2 DM who have some concomitant illness that leads to reduced fluid intake. Infection is the most common preceding illness, but many other conditions can cause altered mentation, dehydration, or both. Once HHS has developed, it may be difficult to differentiate it from the antecedent illness. The concomitant illness may not be identifiable. HHS has also been reported in patients with type 1 DM, in whom DKA is more common.

HHS usually presents in older patients with type 2 DM and carries a higher mortality than DKA, estimated at approximately 10-20%. (See Epidemiology. )

Diagnosis and Treatment

Detection and treatment of an underlying illness are critical. Standard care for dehydration and altered mental status is appropriate, including airway management, intravenous access, crystalloid administration, and any medications routinely given to coma patients. Although many patients with HHS respond to fluids alone, IV insulin in dosages similar to those used in DKA can facilitate correction of hyperglycemia. Insulin used without concomitant vigorous fluid replacement increases the risk of shock. ...