Hyperosmolar Hyperglycemic State

 

Hyperosmolar hyperglycemic state is a life-threatening emergency manifested by marked elevation of blood glucose and hyperosmolarity with little or no ketosis. Although there are multiple precipitating causes, underlying infections are the most common. Other causes include certain medications, nonadherence to therapy, undiagnosed diabetes mellitus, substance abuse, and coexisting disease. In children and adolescents, hyperosmolar hyperglycemic state is often present when type 2 diabetes is diagnosed. Physical findings include profound dehydration and neurologic symptoms ranging from lethargy to coma. Treatment begins with intensive monitoring of the patient and laboratory values, especially glucose, sodium, and potassium levels. Vigorous correction of dehydration is critical, requiring an average of 9 L of 0.9% saline over 48 hours in adults. After urine output is established, potassium replacement should begin. Once dehydration is partially corrected, adults should receive an initial bolus of 0.1 units of intravenous insulin per kg of body weight, followed by a continuous infusion of 0.1 units per kg per hour (or a continuous infusion of 0.14 units per kg per hour without an initial bolus) until the blood glucose level decreases below 300 mg per dL. In children and adolescents, dehydration should be corrected at a rate of no more than 3 mOsm per hour to avoid cerebral edema. Identification and treatment of underlying and precipitating causes are necessary.

Hyperosmolar hyperglycemic state (HHS) is a life-threatening endocrine emergency that most commonly affects adults with type 2 diabetes mellitus.1,2 However, the incidence increased by 52.4% among children from 1997 to 2009.3 HHS occurs in patients with type 2 diabetes who can still produce insulin (as opposed to diabetic ketoacidosis [DKA], which occurs in persons with type 1 diabetes and some with type 2 diabetes). The hallmarks of HHS include profound dehydration, marked hyperglycemia, variable degrees of neurologic impairment, and mild or no ketosis. Although DKA and HHS have been described as distinct entities, one-third of patients exhibit findings of both.2 They may represent opposite ends of the decompensated diabetes spectrum, differing in time of onset, degree of dehydration, and severity of ketosis4 (depending on the degree of insulinopenia5 ). Table 1 compares laboratory findings of mild to severe DKA with those of HHS.6

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Fluid and electrolyte replacement should be initiated in patients with HHS based on recommendations from the American Diabetes Association (Figure 2).

C

6

Phosphate replacement should be considered in patients with HHS only if hypophosphatemia is severe (less than 1.0 mEq per L [1.0 mmol per L]) or if respiratory depression, anemia, or cardiac dysfunction is present.

C

6

Insulin therapy should be initiated in patients with HHS once fluid replacement has been started.

C

6

Patients should be assessed and treated for underlying causes of HHS.

C

6


HHS = hyperosmolar hyperglycemic state.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Fluid and electrolyte replacement should be initiated in patients with HHS based on recommendations from the American Diabetes Association (Figure 2).

C

6

Phosphate replacement should be considered in patients with HHS only if hypophosphatemia is severe (less than 1.0 mEq per L [1.0 mmol per L]) or if respiratory depression, anemia, or cardiac dysfunction is present.

C

6

Insulin therapy should be initiated in patients with HHS once fluid replacement has been started.

C

6

Patients should be assessed and treated for underlying causes of HHS.

C

6


HHS = hyperosmolar hyperglycemic state.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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Table 1.

Comparison of Diabetic Ketoacidosis with Hyperosmolar Hyperglycemic State

VariablesDiabetic ketoacidosis
Hyperosmolar hyperglycemic state
MildModerateSevere

Alternative sensoria in mental obtundation

Alert

Alert, drowsy

Stupor, coma

Stupor, coma

Anion gap

> 10

> 12

> 12

Variable

Arterial pH level

7.25 to 7.30

7.00 to 7.24

< 7.00

> 7.30

Effective serum osmolality (mOsm per kg)

Variable

Variable

Variable

> 320

Plasma glucose level (mg per dL [mmol per

The Author

GREGG D. STONER, MD, is a clinical professor of family medicine at the University of Illinois College of Medicine, Peoria.

Address correspondence to Gregg D. Stoner, MD, University of Illinois College of Medicine, 815 Main St., Ste. B, Peoria, IL 61602 (e-mail: gstoner@uic.edu). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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