Hyperosmolar hyperglycemic state

Last updated

Hyperosmolar hyperglycemic state
Other namesHyperosmolar hyperglycemic nonketotic coma (HHNC), hyperosmolar non-ketotic coma (HONK), nonketotic hyperosmolar coma, hyperosmolar hyperglycemic nonketotic syndrome (HHNS) [1]
Specialty Endocrinology
Symptoms Signs of dehydration, altered level of consciousness [2]
Complications Disseminated intravascular coagulopathy, mesenteric artery occlusion, rhabdomyolysis [2]
Usual onsetDays to weeks [3]
DurationFew days [3]
Risk factors Infections, stroke, trauma, certain medications, heart attacks [4]
Diagnostic method Blood tests [2]
Differential diagnosis Diabetic ketoacidosis [2]
Treatment Intravenous fluids, insulin, low molecular weight heparin, antibiotics [3]
Prognosis ~15% risk of death [4]
FrequencyRelatively common [2]

Hyperosmolar hyperglycemic state (HHS), also known as hyperosmolar non-ketotic state (HONK), is a complication of diabetes mellitus in which high blood sugar results in high osmolarity without significant ketoacidosis. [4] [5] Symptoms include signs of dehydration, weakness, leg cramps, vision problems, and an altered level of consciousness. [2] Onset is typically over days to weeks. [3] Complications may include seizures, disseminated intravascular coagulopathy, mesenteric artery occlusion, or rhabdomyolysis. [2]

Contents

The main risk factor is a history of diabetes mellitus type 2. [4] Occasionally it may occur in those without a prior history of diabetes or those with diabetes mellitus type 1. [3] [4] Triggers include infections, stroke, trauma, certain medications, and heart attacks. [4] Diagnosis is based on blood tests finding a blood sugar greater than 30 mmol/L (600 mg/dL), osmolarity greater than 320 mOsm/kg, and a pH above 7.3. [2] [3]

Initial treatment generally consists of intravenous fluids to manage dehydration, intravenous insulin in those with significant ketones, low molecular weight heparin to decrease the risk of blood clotting, and antibiotics among those in whom there are concerns of infection. [3] The goal is a slow decline in blood sugar levels. [3] Potassium replacement is often required as the metabolic problems are corrected. [3] Efforts to prevent diabetic foot ulcers are also important. [3] It typically takes a few days for the person to return to baseline. [3]

While the exact frequency of the condition is unknown, it is relatively common. [2] [4] Older people are most commonly affected. [4] The risk of death among those affected is about 15%. [4] It was first described in the 1880s. [4]

Signs and symptoms

Symptoms of high blood sugar including increased thirst (polydipsia), increased volume of urination (polyuria), and increased hunger (polyphagia). [6]

Symptoms of HHS include:

Cause

The main risk factor is a history of diabetes mellitus type 2. [4] Occasionally it may occur in those without a prior history of diabetes or those with diabetes mellitus type 1. [3] [4] Triggers include infections, stroke, trauma, certain medications, and heart attacks. [4]

Other risk factors:

Pathophysiology

HHS is usually precipitated by an infection, [7] myocardial infarction, stroke or another acute illness. A relative insulin deficiency leads to a serum glucose that is usually higher than 33 mmol/L (600 mg/dL), and a resulting serum osmolarity that is greater than 320 mOsm. This leads to excessive urination (more specifically an osmotic diuresis), which, in turn, leads to volume depletion and hemoconcentration that causes a further increase in blood glucose level. Ketosis is absent because the presence of some insulin inhibits hormone-sensitive lipase-mediated fat tissue breakdown.[ citation needed ]

Diagnosis

Criteria

According to the American Diabetes Association, diagnostic features include: [8] [9]

Imaging

Cranial imaging is not used for diagnosis of this condition. However, if MRI is performed, it may show cortical restricted diffusion with unusual characteristics of reversible T2 hypointensity in the subcortical white matter. [10]

Differential diagnosis

The major differential diagnosis is diabetic ketoacidosis (DKA). In contrast to DKA, serum glucose levels in HHS are extremely high, usually greater than 40-50 mmol/L (600 mg/dL). [6] Metabolic acidosis is absent or mild. [6] A temporary state of confusion (delirium) is also more common in HHS than DKA. HHS also tends to affect older people more. DKA may have fruity breath, and rapid and deep breathing. [6]

DKA often has serum glucose level greater than 300 mg/dL (HHS is >600 mg/dL). [6] DKA usually occurs in type 1 diabetics whereas HHS is more common in type 2 diabetics. [6] DKA is characterized by a rapid onset, and HHS occurs gradually over a few days. [6] DKA also is characterized by ketosis due to the breakdown of fat for energy. [6]

Both DKA and HHS may show symptoms of dehydration, increased thirst, increased urination, increased hunger, weight loss, nausea, vomiting, abdominal pain, blurred vision, headaches, weakness, and low blood pressure with standing. [6]

Management

Phases and timelines

The JBDS HHS care pathway [11] comprises 3 main themes to consider when managing a patient with HHS:

To streamline management, there are 5 phases of therapy from the time of recognition of the condition to resolution:

  1. 0–60 min
  2. 1–6 hours
  3. 6–12 hours
  4. 12–24 hours
  5. 24–72 hours [11]

Intravenous fluids

Treatment of HHS begins with reestablishing tissue perfusion using intravenous fluids. People with HHS can be dehydrated by 8 to 12 liters. Attempts to correct this usually take place over 24 hours with initial rates of normal saline often in the range of 1 L/h for the first few hours or until the condition stabilizes. [12]

Electrolyte replacement

Potassium replacement is often required as the metabolic problems are corrected. [3] It is generally replaced at a rate 10 mEq per hour as long as there is adequate urinary output. [13]

Insulin

Insulin is given to reduce blood glucose concentration; however, as it also causes the movement of potassium into cells, serum potassium levels must be sufficiently high or dangerously low blood potassium levels may result. Once potassium levels have been verified to be greater than 3.3 mEq/L, then an insulin infusion of 0.1 units/kg/hr is started. [14] The goal for resolution is a blood glucose of less than 200 mg/dL. [6]

Related Research Articles

<span class="mw-page-title-main">Hypoglycemia</span> Health condition

Hypoglycemia, also called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose below 70 mg/dL (3.9 mmol/L), symptoms associated with hypoglycemia, and resolution of symptoms when blood sugar returns to normal. Hypoglycemia may result in headache, tiredness, clumsiness, trouble talking, confusion, fast heart rate, sweating, shakiness, nervousness, hunger, loss of consciousness, seizures, or death. Symptoms typically come on quickly.

The following is a glossary of diabetes which explains terms connected with diabetes.

<span class="mw-page-title-main">Diabetic ketoacidosis</span> Medical condition

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. A person's breath may develop a specific "fruity" smell. The onset of symptoms is usually rapid. People without a previous diagnosis of diabetes may develop DKA as the first obvious symptom.

<span class="mw-page-title-main">Ketone bodies</span> Chemicals produced during fat metabolism

Ketone bodies are water-soluble molecules or compounds that contain the ketone groups produced from fatty acids by the liver (ketogenesis). Ketone bodies are readily transported into tissues outside the liver, where they are converted into acetyl-CoA —which then enters the citric acid cycle and is oxidized for energy. These liver-derived ketone groups include acetoacetic acid (acetoacetate), beta-hydroxybutyrate, and acetone, a spontaneous breakdown product of acetoacetate.

<span class="mw-page-title-main">Glucose tolerance test</span> Medical test of how quickly glucose is cleared from the blood

The glucose tolerance test is a medical test in which glucose is given and blood samples taken afterward to determine how quickly it is cleared from the blood. The test is usually used to test for diabetes, insulin resistance, impaired beta cell function, and sometimes reactive hypoglycemia and acromegaly, or rarer disorders of carbohydrate metabolism. In the most commonly performed version of the test, an oral glucose tolerance test (OGTT), a standard dose of glucose is ingested by mouth and blood levels are checked two hours later. Many variations of the GTT have been devised over the years for various purposes, with different standard doses of glucose, different routes of administration, different intervals and durations of sampling, and various substances measured in addition to blood glucose.

<span class="mw-page-title-main">Hyperglycemia</span> Too much blood sugar, usually because of diabetes

Hyperglycemia is a condition in which an excessive amount of glucose circulates in the blood plasma. This is generally a blood sugar level higher than 11.1 mmol/L (200 mg/dL), but symptoms may not start to become noticeable until even higher values such as 13.9–16.7 mmol/L (~250–300 mg/dL). A subject with a consistent fasting blood glucose range between ~5.6 and ~7 mmol/L is considered slightly hyperglycemic, and above 7 mmol/L is generally held to have diabetes. For diabetics, glucose levels that are considered to be too hyperglycemic can vary from person to person, mainly due to the person's renal threshold of glucose and overall glucose tolerance. On average, however, chronic levels above 10–12 mmol/L (180–216 mg/dL) can produce noticeable organ damage over time.

<span class="mw-page-title-main">Ketosis</span> Using body fats as fuel instead of carbohydrates

Ketosis is a metabolic state characterized by elevated levels of ketone bodies in the blood or urine. Physiological ketosis is a normal response to low glucose availability, such as low-carbohydrate diets or fasting, that provides an additional energy source for the brain in the form of ketones. In physiological ketosis, ketones in the blood are elevated above baseline levels, but the body's acid–base homeostasis is maintained. This contrasts with ketoacidosis, an uncontrolled production of ketones that occurs in pathologic states and causes a metabolic acidosis, which is a medical emergency. Ketoacidosis is most commonly the result of complete insulin deficiency in type 1 diabetes or late-stage type 2 diabetes. Ketone levels can be measured in blood, urine or breath and are generally between 0.5 and 3.0 millimolar (mM) in physiological ketosis, while ketoacidosis may cause blood concentrations greater than 10 mM.

<span class="mw-page-title-main">Diabetic coma</span> Medical condition

Diabetic coma is a life-threatening but reversible form of coma found in people with diabetes mellitus.

<span class="mw-page-title-main">Type 2 diabetes</span> Type of diabetes mellitus with high blood sugar and insulin resistance

Type 2 diabetes (T2D), formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urination, fatigue and unexplained weight loss. Symptoms may also include increased hunger, having a sensation of pins and needles, and sores (wounds) that do not heal. Often symptoms come on slowly. Long-term complications from high blood sugar include heart disease, strokes, diabetic retinopathy which can result in blindness, kidney failure, and poor blood flow in the limbs which may lead to amputations. The sudden onset of hyperosmolar hyperglycemic state may occur; however, ketoacidosis is uncommon.

<span class="mw-page-title-main">Blood sugar level</span> Concentration of glucose present in the blood (Glycaemia)

The blood sugar level, blood sugar concentration, blood glucose level, or glycemia is the measure of glucose concentrated in the blood. The body tightly regulates blood glucose levels as a part of metabolic homeostasis.

<span class="mw-page-title-main">Ketoacidosis</span> Medical condition

Ketoacidosis is a metabolic state caused by uncontrolled production of ketone bodies that cause a metabolic acidosis. While ketosis refers to any elevation of blood ketones, ketoacidosis is a specific pathologic condition that results in changes in blood pH and requires medical attention. The most common cause of ketoacidosis is diabetic ketoacidosis but can also be caused by alcohol, medications, toxins, and rarely, starvation.

Diabetes is a chronic disease in cats whereby either insufficient insulin response or insulin resistance leads to persistently high blood glucose concentrations. Diabetes affects up to 1 in 230 cats, and may be becoming increasingly common. Diabetes is less common in cats than in dogs. The condition is treatable, and if treated properly the cat can experience a normal life expectancy. In cats with type 2 diabetes, prompt effective treatment may lead to diabetic remission, in which the cat no longer needs injected insulin. Untreated, the condition leads to increasingly weak legs in cats and eventually to malnutrition, ketoacidosis and/or dehydration, and death.

<span class="mw-page-title-main">Glucose meter</span> Medical device for determining the concentration of glucose in the blood

A glucose meter, also referred to as a "glucometer", is a medical device for determining the approximate concentration of glucose in the blood. It can also be a strip of glucose paper dipped into a substance and measured to the glucose chart. It is a key element of glucose testing, including home blood glucose monitoring (HBGM) performed by people with diabetes mellitus or hypoglycemia. A small drop of blood, obtained from slightly piercing a fingertip with a lancet, is placed on a disposable test strip that the meter reads and uses to calculate the blood glucose level. The meter then displays the level in units of mg/dL or mmol/L.

<span class="mw-page-title-main">Diabetes and pregnancy</span> Effects of pre-existing diabetes upon pregnancy

For pregnant women with diabetes, some particular challenges exist for both mother and fetus. If the pregnant woman has diabetes as a pre-existing disorder, it can cause early labor, birth defects, and larger than average infants. Therefore, experts advise diabetics to maintain blood sugar level close to normal range about 3 months before planning for pregnancy.

Hyperosmolar syndrome or diabetic hyperosmolar syndrome is a medical emergency caused by a very high blood glucose level.

<span class="mw-page-title-main">Regular insulin</span> Short-acting insulin formulation

Regular insulin, also known as neutral insulin and soluble insulin, is a type of short-acting medical insulin. It is used to treat type 1 diabetes, type 2 diabetes, gestational diabetes, and complications of diabetes such as diabetic ketoacidosis and hyperosmolar hyperglycemic states. It is also used along with glucose to treat high blood potassium levels. Typically it is given by injection under the skin, but may also be used by injection into a vein or muscle. Onset of effect is typically in 30 minutes and it typically lasts for 8 hours.

Complications of diabetes are secondary diseases that are a result of elevated blood glucose levels that occur in diabetic patients. These complications can be divided into two types: acute and chronic. Acute complications are complications that develop rapidly and can be exemplified as diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), lactic acidosis (LA), and hypoglycemia. Chronic complications develop over time and are generally classified in two categories: microvascular and macrovascular. Microvascular complications include neuropathy, nephropathy, and retinopathy; while cardiovascular disease, stroke, and peripheral vascular disease are included in the macrovascular complications.

<span class="mw-page-title-main">Diabetes in dogs</span>

Diabetes mellitus is a disease in which the beta cells of the endocrine pancreas either stop producing insulin or can no longer produce it in enough quantity for the body's needs. The disease can affect humans as well as animals such as dogs.

Ketosis-prone diabetes (KPD) is an intermediate form of diabetes that has some characteristics of type 1 and some of type 2 diabetes. Type 1 diabetes involves autoimmune destruction of pancreatic beta cells which create insulin. This occurs earlier in a person's life, leading to patients being insulin dependent, and the lack of natural insulin makes patients prone to a condition called diabetic ketoacidosis (DKA). Type 2 diabetes is different in that it is usually caused by insulin resistance in the body in older patients leading to beta cell burnout over time, and is not prone to DKA. KPD is a condition that involves DKA like type 1, but occurs later in life and can regain beta cell function like type 2 diabetes. However, it is distinct from latent autoimmune diabetes of adults (LADA), a form of type 1 sometimes referred to as type 1.5 that does not occur with DKA. There are also distinctions to be made between KPD and LADA as patients who exhibit KPD symptoms can regain beta cell function similar to type 2 diabetics whereas LADA will not exhibit this reclamation of beta cell function.

The Joint British Diabetes Societies for Inpatient Care group (JBDS-IP) was formed in 2008.

References

  1. ↑ "Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)". American Diabetes Association. Archived from the original on 2 July 2012. Retrieved 6 July 2012.
  2. 1 2 3 4 5 6 7 8 9 Stoner, GD (1 May 2005). "Hyperosmolar hyperglycemic state". American Family Physician. 71 (9): 1723–30. PMID   15887451.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 Frank, LA; Solomon, A (2 September 2016). "Hyperglycaemic hyperosmolar state". British Journal of Hospital Medicine. 77 (9): C130-3. doi:10.12968/hmed.2016.77.9.C130. PMID   27640667.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC   4207202 . PMID   25342831.
  5. ↑ Page, Piers; Skinner, Greg (17 January 2008). Emergencies in Clinical Medicine. OUP Oxford. pp. 224–225. ISBN   978-0-19-920252-2.
  6. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Henry, McMichael (2016). ATI RN Adult Medical Surgical Nursing 10.0. Assessments Technology Institutes. pp. 537–538. ISBN   9781565335653.
  7. ↑ Stoner, GD (May 2005). "Hyperosmolar hyperglycemic state". American Family Physician. 71 (9): 1723–30. PMID   15887451. Archived from the original on 24 July 2008.
  8. ↑ Lewis P. Rowland; Timothy A. Pedley (2010). Merritt's Neurology. Lippincott Williams & Wilkins. pp. 369–370. ISBN   978-0-7817-9186-1. Archived from the original on 24 March 2017.
  9. 1 2 Magee MF, Bhatt BA (2001). "Management of decompensated diabetes. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome". Crit Care Clin. 17 (1): 75–106. doi:10.1016/s0749-0704(05)70153-6. PMID   11219236.
  10. ↑ Neuroradiology 2007 Apr;49(4):299-305.
  11. 1 2 Mustafa, Omar G.; Haq, Masud; Dashora, Umesh; Castro, Erwin; Dhatariya, Ketan K.; the Joint British Diabetes Societies (JBDS) for Inpatient Care Group (March 2023). "Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group". Diabetic Medicine. 40 (3): e15005. doi:10.1111/dme.15005. ISSN   0742-3071. PMC   10107355 . PMID   36370077.
  12. ↑ Tintinalli, Judith E.; Kelen, Gabor D.; Stapczynski, J. Stephan (2004). Emergency Medicine: A Comprehensive Study Guide (6th ed.). McGraw-Hill Prof Med/Tech. p. 1309. ISBN   978-0-07-138875-7. Archived from the original on 24 March 2017.
  13. ↑ Tintinalli, Kelen & Stapczynski 2004 , p. 1320
  14. ↑ Tintinalli, Kelen & Stapczynski 2004 , p. 1310
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.