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ALL / Endocrinology

Hyperosmolar hyperglycaemic state

Hyperosmolar hyperglycaemic state

Hyperosmolar hyperglycaemic state (HHS) is a medical emergency that can be difficult to manage and has a significant associated mortality (up to 20%). Hyperglycaemia results in osmotic diuresis, severe dehydration, and electrolyte deficiencies. HHS typically presents in the elderly with type 2 diabetes mellitus (T2DM).

Pathophysiology
  • hyperglycaemia → ↑ serum osmolality → osmotic diuresis → severe volume depletion

Precipitating factors
  • intercurrent illness
  • dementia
  • sedative drugs

Clinical features
  • whilst DKA presents within hours of onset, HHS comes on over many days, and consequently, the dehydration and metabolic disturbances may be more extreme
  • consequences of volume loss
    • clinical signs of dehydration
    • polyuria
    • polydipsia
  • systemic
    • lethargy
    • nausea and vomiting
  • neurological
    • altered level of consciousness
    • focal neurological deficits
  • haematological
    • hyperviscosity (may result in myocardial infarctions, stroke and peripheral arterial thrombosis)

There are no precise diagnostic criteria but the following are typically seen
  • hypovolaemia
  • marked hyperglycaemia (>30 mmol/L)
  • significantly raised serum osmolarity (> 320 mosmol/kg)
    • can be calculated by: 2 * Na+ + glucose + urea
  • no significant hyperketonaemia (<3 mmol/L)
  • no significant acidosis (bicarbonate > 15 mmol/l or pH > 7.3 - acidosis can occur due to lactic acidosis or renal impairment)

Management
  • fluid replacement
    • fluid losses in HHS are estimated to be between 100 - 220 ml/kg
    • IV 0.9% sodium chloride solution
    • typically given at 0.5 - 1 L/hour depending on clinical assessment
    • potassium levels should be monitored and added to fluids depending on the level
  • insulin
    • should not be given unless blood glucose stops falling while giving IV fluids
  • venous thromboembolism prophylaxis
    • patients are at risk of thrombosis due to hyperviscosity

Complications
  • vascular complications may occur due to hyperviscosity:
    • such as myocardial infarction
    • stroke
+PassMedicine Notes

Hyperosmolar hyperglycaemic state (HHS) is a medical emergency that can be difficult to manage and has a significant associated mortality (up to 20%). Hyperglycaemia results in osmotic diuresis, severe dehydration, and electrolyte deficiencies. HHS typically presents in the elderly with type 2 diabetes mellitus (T2DM).

Pathophysiology
  • hyperglycaemia --> ↑ serum osmolality --> osmotic diuresis --> severe volume depletion
Precipitating factors
  • intercurrent illness
  • dementia
  • sedative drugs
Clinical features
  • whilst DKA presents within hours of onset, HHS comes on over many days, and consequently, the dehydration and metabolic disturbances may be more extreme
  • consequences of volume loss
    • clinical signs of dehydration
    • polyuria
    • polydipsia
  • systemic
    • lethargy
    • nausea and vomiting
  • neurological
    • altered level of consciousness
    • focal neurological deficits
  • haematological
    • hyperviscosity (may result in myocardial infarctions, stroke and peripheral arterial thrombosis)
There are no precise diagnostic criteria but the following are typically seen
  • hypovolaemia
  • marked hyperglycaemia (>30 mmol/L)
  • significantly raised serum osmolarity (> 320 mosmol/kg)
    • can be calculated by: 2 * Na+ + glucose + urea
  • no significant hyperketonaemia ( 15 mmol/l or pH > 7.3 - acidosis can occur due to lactic acidosis or renal impairment)
Management
  • fluid replacement
    • fluid losses in HHS are estimated to be between 100 - 220 ml/kg
    • IV 0.9% sodium chloride solution
    • typically given at 0.5 - 1 L/hour depending on clinical assessment
    • potassium levels should be monitored and added to fluids depending on the level
  • insulin
    • should not be given unless blood glucose stops falling while giving IV fluids
  • venous thromboembolism prophylaxis
    • patients are at risk of thrombosis due to hyperviscosity
Complications
  • vascular complications may occur due to hyperviscosity:
    • such as myocardial infarction
    • stroke


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