Diabetic hyperglycemic hyperosmolar syndrome

  • Definition
    • Diabetic hyperglycemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes. It involves extremely high blood sugar (glucose) level without the presence of ketones.

  • Alternative Names
    • HHS; Hyperglycemic hyperosmolar coma; Nonketotic hyperglycemic hyperosmolar coma (NKHHC); Hyperosmolar nonketotic coma (HONK); Hyperglycemic hyperosmolar non-ketotic state; Diabetes - hyperosmolar

  • Causes
    • HHS is a condition of:

      • Extremely high blood sugar (glucose) level
      • Extreme lack of water (dehydration)
      • Decreased alertness or consciousness (in many cases)

      Buildup of ketones in the body (ketoacidosis) may also occur. But it is unusual and is often mild compared with diabetic ketoacidosis.

      HHS is more often seen in people with type 2 diabetes who don't have their diabetes under control. It may also occur in those who have not been diagnosed with diabetes. The condition may be brought on by:

      • Infection
      • Other illness, such as heart attack or stroke
      • Medicines that decrease the effect of insulin in the body
      • Medicines or conditions that increase fluid loss

      Normally, the kidneys try to make up for a high glucose level in the blood by allowing the extra glucose to leave the body in the urine. But this also causes the body to lose water. If you do not drink enough water, or you drink fluids that contain sugar and keep eating foods with carbohydrates, the kidneys may become overwhelmed. When this occurs, they are no longer able to get rid of the extra glucose. As a result, the glucose level in your blood can become very high.

      The loss of water also makes the blood more concentrated than normal. This is called hyperosmolarity. It is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances. This draws the water out of the body's other organs, including the brain.

      Risk factors include:

      • A stressful event such as infection, heart attack, stroke, or recent surgery
      • Heart failure
      • Impaired thirst
      • Limited access to water (especially in people with dementia or who are bedbound)
      • Older age
      • Poor kidney function
      • Poor management of diabetes, not following the treatment plan as directed
      • Stopping insulin or other medicines that lower glucose level
  • Symptoms
    • Symptoms may include any of the following:

      • Increased thirst and urination (at the beginning of the syndrome)
      • Feeling weak
      • Nausea
      • Weight loss
      • Dry mouth, dry tongue
      • Fever
      • Seizures
      • Confusion
      • Coma

      Symptoms may get worse over days or weeks.

      Other symptoms that may occur with this disease:

      • Loss of feeling or function of muscles
      • Problems with movement
      • Speech impairment
  • Exams and Tests
  • Treatment
    • At the start of treatment, the goal is to correct the water loss. This will improve the blood pressure, urine output, and circulation. Blood sugar will also decrease.

      Fluids and potassium will be given through a vein (intravenously). This must be done carefully. High glucose level is treated with insulin given through a vein.

  • Outlook (Prognosis)
    • People who develop HHS are often already ill. If not treated right away, seizures, coma, or death may result.

  • Possible Complications
    • Untreated, HHS may lead to any of the following:

      • Shock
      • Blood clot formation
      • Brain swelling (cerebral edema)
      • Increased blood acid level (lactic acidosis)
  • When to Contact a Medical Professional
    • This condition is a medical emergency. Go to the emergency room or call the local emergency number (such as 911) if you develop symptoms of HHS.

  • Prevention
    • Controlling type 2 diabetes and recognizing the early signs of dehydration and infection can help prevent HHS.

  • References
    • Crandall J, Shamoon H. Diabetes mellitus. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 229.

      Graber MN. Diabetes and hyperglycemia. In: Adams JG, ed. Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2013:chap 162.

      Lebovitz HE. Hyperglycemia secondary to nondiabetic conditions and therapies. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 42.