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Potentially life-threatening emergency
Hyperosmolar hyperglycemic state
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Potentially life-threatening emergency

Hyperosmolar hyperglycemic state

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Contributors: Paritosh Prasad MD
Other Resources UpToDate PubMed

Synopsis

Hyperosmolar hyperglycemic state (HHS) is an acute metabolic complication of both diabetes mellitus type 1 and type 2. Although HHS accounts for only 1% of diabetic-related hospital admissions, HHS-related mortality is greater than that of diabetic ketoacidosis. This increased mortality is due to a greater severity of dehydration as well as the older age and concurrent comorbid conditions of patients with HHS.

The term "hyperosmolar hyperglycemic state" has replaced "hyperglycemic hyperosmolar nonketotic state" and "hyperglycemic hyperosmolar nonketotic coma," since the condition may present with varying degrees of ketosis and with altered mental status in the absence of coma.

HHS is due to ineffective action of insulin and elevated counter-regulatory hormones with increased hepatic glucose production and impaired peripheral utilization, resulting in dehydration and electrolyte abnormalities due to osmotic diuresis by glycosuria.

The most common precipitating factors for HHS are inadequate insulin therapy and the presence of infection. Other potential precipitants include acute coronary syndromes, drugs (steroids in particular), pulmonary embolism, stroke, and alcohol abuse.

HHS is marked by signs of dehydration and glucosuria (polydipsia, polyuria, decreased skin turgor, and tachycardia) and altered mental status (severity relates to degree of hyperosmolality). Coma may be present in 25%-50% of cases. Some patients with HHS may present with hemiparesis, hemianopsia, or even seizures.

Metabolic derangements include hyperglycemia, hyperosmolarity, hyponatremia, and hyperkalemia. Blood urea and creatinine may be elevated. Unlike diabetic ketoacidosis, bicarbonate is >20 mEq/L, pH is >7.3, and there are negative ketone bodies in urine and plasma.

Codes

ICD10CM:
E13.00 – Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E13.01 – Other specified diabetes mellitus with hyperosmolarity with coma

SNOMEDCT:
310505005 – Diabetic hyperosmolar non-ketotic state

Look For

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Diabetic ketoacidosis
  • Methanol or ethylene glycol intoxication – Marked serum hyperosmolarity in the absence of hyperglycemia should prompt evaluation for methanol or ethylene glycol intoxication.
  • Alcoholic ketoacidosis
  • Starvation ketosis
  • Lactic acidosis
  • Renal failure with uremic acidosis

Best Tests

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Management Pearls

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Therapy

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References

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Last Reviewed: 12/27/2016
Last Updated: 01/18/2017
Copyright © 2019 VisualDx®. All rights reserved.
Potentially life-threatening emergency
Hyperosmolar hyperglycemic state
Print 1 Images
Hyperosmolar hyperglycemic state : Hyperglycemia, Mental status alteration, Poor skin turgor, Urinary frequency, Xerostomia, Polydipsia, Dehydration signs
Copyright © 2019 VisualDx®. All rights reserved.