Hyperosmolar hyperglycaemic state

Definition
 Non-ketotic hyperglycaemic syndrome
 Defined as extreme elevation in serum glucose (BSL >33.3) + hyperosmolality (>320mmol/kg) and
absence of ketoacidosis (pH >7.3 + HCO3 >15)
 May be the first presentation of type 2 diabetes
 Can be a mixed picture with DKA

Aetiology (precipitants of HHS)

 Infection
o Major precipitating factor (e.g. pneumonia, urinary tract infections, sepsis)
 Acute illness
o E.g. CVA (stroke), MI, pancreatitis, Trauma (where counter-regulatory hormones are
produced – catecholamines, glucagon, cortisol, growth hormone + compromised water
intake)
 Post-operative (post-CABG or neurosurgery)
 Endocrine
o Hyperthyroidism, acromegaly, ectopic ACTH, hypercortisolism
 Medications
o Corticosteroids, thiazide diuretics, beta-blockers, didanosine
o Discontinued, omitted, or inadequate antihyperglycaemic therapy
 Elderly
o Bed-ridden causes an altered thirst response that reduces water intake  leads to severe
dehydration  HHS

Pathophysiology
 High insulin suppresses lipolysis and ketogenesis but does not regulate blood gluoce production
and utilisation
 Hyperosmolality inhibits lipolysis, insulin secretion and glucose uptake
 Hypernatraemia + hyperglycaemia + inadequate water intake  hypovolaemic state
 Adrenaline  insulin resistance, decreased insulin production/secretion, increased lipolysis

Risk factors
 Non-modifibale
o Age >65 (70 onwards – high mortality risk)
o Endocrine: Cushing’s syndrome, hyperthyroidism, acromegaly
 Modifiable
o Poorly controlled diabetes (inadequate insulin/oral antiglycaemic therapy)
o Acute illness in diabetic patient
o Infections
o Post-operative risk
o Precipitating medications (corticosteroids, thiazides, beta-blockers, didanosine)

Signs and symptoms

 Diabetes/hyperglycaemia: Polyuria + polydipsia + weight loss + weakness
 Dehydration – poor skin turgor, dry mucous membranes, altered mental status, tachycardia,
hypotension, shock
 Seizures
  Abdominal pain (more common in DKA than HHS)
 Focal neurological signs (similar to stroke, cresolves rapidly once high BSL is corrected)

Investigations
 Symptomatic hyperglycaemia (polyuria, polydipsia, abdominal pain, acidotic breath, volume
depletion, altered mental state) should prompt immediate investigation
o Plasma glucose
o Urine ketones
 Bedside
o Urine ketones – negative/low
o Urinalysis – positive for gluclose, negative for ketones
o ECG – hyperkalaemia/hypokalaemia
o Look for cause – urine/sputum culture (infection)
 Bloods
o ABG - acidosis
o FBE – leucocytosis present in hyperglycaemic crisis
o Blood ketones – negative/low
o Serum urea and creatinine (UECr) – elevated (volume depletion)
o Serum sodium – varied
o Serum potassium – high
o Serum CMP – low
o Serum osmolality - >320mmol/kg
o Look for cause – troponins (MI), blood culture (infection)
 Imaging
o Look for cause – CXR (pneumonia)

Prevention
 Primary prevention
o Contact diabetes care team/GP quickly when symptomatic or high blood sugars on
glucometer
o Educate on proper insulin and medication use + carbohydrate diet when nauseated
o Educate on frequent blood sugar monitoring
o Eliminate drugs that can precipitate hyperglycaemia

Acute management
 Fluid replacement therapy – to reduce DIC
 IV insulin – slow infusion with short-acting insulin
o When serum potassium concentration > 3.5mmol/L
 Potassium replacement
 Phosphate replacement
 SPIDER
o S: Saline 10-20ml/kg bolus
o P: Potassium
 High: Give insulin
 Low: Give potassium first, then give insulin
o I: Insulin
 Actaprapid short acting, continue until normal pH in and normal ketone, usually 12
hours
o D: Dextrose
o E: Embolism (heparin due to VTE risk)
o E: Eat nothing (NBM)
 o R: Reason  treat cause

Prognosis
 Mortality rates
o 5-20%  about 10x higher than DKA
o Significant mortality risk in people aged >70

Complications
 Life-threatening: VTE, confusion, DIC, MI, PE, cerebral oedema, coma, stroke
 Treatment-related: Hypoglycaemia, hypokalaemia

DKA HHS

Clinical Abdominal pain Confusion/coma Lethargy

features Nausea, vomiting Weakness, polyuria, polydipsia
Kussmaul respirations
Fruity smelling breath
Coma
Blood ↑ >13.9 ↑↑ >30.0-33.3
glucose

Ketones Ketouria +++ Ketouria +/-

Blood ketones +++ Blood ketones +/-
Acid-base pH <7.3 pH normal
Metabolic acidosis due to No acid-base imbalance
ketosis
Serum Variable >320
osmolality