OVERVIEW

What is Hyperosmolar Hyperglycemic State?

Hyperosmolar Hyperglycemic State (HHS), also known as "diabetic nonketotic hyperosmolar syndrome," "hyperosmolar syndrome," "hyperosmolar nonketotic diabetic coma," or "diabetic hyperosmolar coma," is a highly dangerous acute complication of diabetes. Although rare, it has a very high mortality rate.

HHS can occur in people of any age but is primarily seen in the elderly. More than two-thirds of patients had not been diagnosed with diabetes before developing HHS, meaning even elderly individuals without a prior diabetes diagnosis should be vigilant about this condition.

The main manifestations of HHS include extremely high blood sugar levels (often exceeding 33.3 mmol/L), significantly elevated plasma osmolality, severe dehydration, and possible confusion or even coma.

SYMPTOMS

What are the manifestations of hyperosmolar hyperglycemic state?

In the early stages, symptoms may include fever, fatigue, thirst, increased water intake, increased urine output, dizziness, lethargy, nausea, and vomiting.

If not treated promptly, the condition may gradually worsen, leading to obvious signs of dehydration: dry skin, poor elasticity, dry and peeling lips, sunken eyes, reduced urine output, low blood pressure, cold limbs, and a rapid, weak pulse.

Severe cases may experience altered mental status: headache, restlessness, confusion, sluggish response, blank expression, indifference to surroundings, drowsiness, hallucinations, inability to communicate normally, or even coma. Sometimes, hemiplegia or seizures may also occur.

What serious consequences can hyperosmolar hyperglycemic state cause?

Hyperosmolar hyperglycemic state can be complicated by ketoacidosis and lactic acidosis. All three are acute complications of diabetes, and their simultaneous occurrence increases the complexity of the condition and the difficulty of treatment.

Additionally, brain cells are particularly vulnerable to hyperosmolar hyperglycemic state, leading to complications such as cerebral edema, brain herniation, cerebral thrombosis, seizures, and paralysis.

CAUSES

What causes hyperosmolar hyperglycemic state?

The root cause of hyperosmolar hyperglycemic state (HHS) is diabetes and insufficient insulin secretion. However, not all diabetic patients develop HHS—certain triggering factors are also required, such as:

• Stress conditions: infection, trauma, surgery, childbirth, cardiovascular or cerebrovascular accidents, psychological trauma, etc.

• Diabetic patients arbitrarily discontinuing insulin or glucose-lowering medications.

• Use of medications that affect blood sugar due to other illnesses: such as glucocorticoids, azathioprine, chlorpromazine, beta-blockers (e.g., XX-lol), hydrochlorothiazide, furosemide, etc.

• Unintentional excessive glucose supplementation: Many HHS patients were previously unaware of their diabetes but were already in the early stages with insulin deficiency. Consuming large amounts of carbohydrates (sugary drinks, sweets, pastries) or receiving intravenous glucose infusions can trigger HHS.

• Illnesses causing dehydration: such as high fever, vomiting, diarrhea, etc.

• Inadequate water intake: In elderly individuals, the thirst center may deteriorate, preventing the sensation of thirst even when the body is dehydrated, leading to insufficient water intake and triggering HHS. Timely hydration when blood sugar rises can prevent HHS.

DIAGNOSIS

What tests are needed for hyperosmolar hyperglycemic state (HHS)?

• Blood glucose: Often exceeds 33.3 mmol/L. Fingerstick glucose meters may fail to measure it (displaying "high") due to exceeding the detection range, requiring venous blood testing at a hospital.

• Serum osmolality: Usually above 330 mmol/L.

• Blood ketones and urine ketones: Normal or mildly elevated. Significantly elevated blood ketones (> 0.85 mmol/L or 5 mg/dL) suggest possible concurrent ketoacidosis.

• Electrolytes: Markedly elevated sodium (often > 150 mmol/L); potassium normal or low; calcium and magnesium may be low.

• Arterial blood gas (ABG): Requires painful arterial blood draw from the wrist. Blood pH is normal or slightly low. Significantly low pH suggests concurrent ketoacidosis or lactic acidosis.

• Other tests: Elevated hemoglobin and hematocrit, abnormal liver function, increased creatinine and blood urea nitrogen (BUN), strongly positive urine glucose, high urine specific gravity, positive urine protein, and ECG signs of myocardial ischemia or arrhythmia.

Which conditions resemble hyperosmolar hyperglycemic state (HHS)?

Diabetic ketoacidosis (DKA) and lactic acidosis share similar manifestations with HHS. All are acute diabetic complications and may coexist. Differentiation relies on blood/urine ketones, ABG, and lactate levels.

Hypoglycemia can also cause coma but lacks dehydration. Immediate blood glucose testing distinguishes it from HHS.

HHS patients may present with seizures or hemiparesis, mimicking neurological disorders. Brain CT or MRI aids differentiation.

TREATMENT

How is hyperosmolar hyperglycemic state treated?

• Fluid replacement: More than 5,000 ml of intravenous fluids may be required within the first 24 hours of hospitalization, with the specific amount adjusted based on the patient's condition. Normal saline is typically administered first, followed by glucose infusion after blood sugar levels decrease.

• Blood sugar control: Insulin is necessary to lower blood sugar levels. Continuous intravenous insulin is administered initially, followed by subcutaneous insulin injections as the condition improves. The decision to continue insulin or switch to oral hypoglycemic drugs after discharge will be made by the doctor based on the patient's condition.

• Potassium supplementation: Potassium deficiency can lead to heart problems. Potassium is initially replenished intravenously, then orally once the condition stabilizes. Potassium supplementation can be discontinued after full recovery.

• Other treatments: If the patient has concurrent infections, kidney failure, myocardial infarction, cerebral thrombosis, or other conditions, these should also be actively treated.

Which department should be consulted for hyperosmolar hyperglycemic state?

Hyperosmolar hyperglycemic state is usually a critical condition. Patients should be sent to the emergency department immediately for urgent care, followed by further diagnosis and treatment by an endocrinologist.

Is hospital treatment necessary for hyperosmolar hyperglycemic state?

Yes. Elderly individuals, whether diabetic or not, should seek prompt medical attention if they experience symptoms such as dry mouth, excessive thirst, frequent urination, dizziness, lethargy, dry skin and lips, or mental confusion.

What should be noted during hospitalization for hyperosmolar hyperglycemic state?

Upon admission, patients are often in poor condition and may require treatment in the emergency room or intensive care unit. Family members should fully cooperate with the medical team.

After transfer to a general ward, the patient may still need continuous ECG monitoring, oxygen therapy, and insulin pump therapy. Since the patient may be surrounded by medical equipment, family members should carefully monitor to prevent the patient from unconsciously removing devices such as ECG monitors, oxygen tubes, or IV lines.

Blood sugar and plasma osmolality should not be lowered too quickly in hyperosmolar hyperglycemic state patients, as this may lead to cerebral edema or brain damage. Frequent blood tests and glucose monitoring are required, necessitating cooperation from the patient and family.

It is important to understand insulin correctly—do not assume it is only for type 1 diabetes or that it is addictive like a drug. In this condition, insulin is life-saving. The choice of medication for blood sugar control after discharge can be discussed with the doctor once the condition stabilizes.

Is follow-up necessary for hyperosmolar hyperglycemic state? How often should it be done?

Yes, follow-up is required. After recovery and discharge, patients with hyperosmolar hyperglycemic state, like those with ordinary diabetes, need regular check-ups and medication refills.

If blood sugar control is unstable, frequent follow-ups as prescribed are necessary. If blood sugar is well-controlled, check-ups every 1–3 months may suffice, provided blood sugar is monitored regularly at home.

Can hyperosmolar hyperglycemic state be completely cured? Can it recur?

It can be fully treated, but recurrence is possible if blood sugar control is poor.

What is the likelihood of death from hyperosmolar hyperglycemic state?

The mortality rate is relatively high, approximately 15%.

DIET & LIFESTYLE

What should patients with hyperosmolar hyperglycemic state pay attention to in daily life?

Hyperosmolar hyperglycemic state generally occurs in elderly individuals, so it's best to have someone care for them. Remind the elderly to take medication on time, eat meals regularly and in proper portions, drink water, monitor blood sugar, and go to the hospital for regular check-ups. If the elderly feel unwell, seek medical attention promptly.

What should patients with hyperosmolar hyperglycemic state pay attention to in their diet?

During hospitalization, a dietitian will provide meals, transitioning gradually from liquid to semi-liquid and then to regular food.

After discharge, follow the dietary principles for diabetes. Click "Diabetes Diet Guide" for more details.

PREVENTION

How to Prevent Hyperosmolar Hyperglycemic State?

• For diabetic patients, maintaining good blood sugar control can prevent hyperosmolar hyperglycemic state. For elderly individuals without diabetes, regular medical check-ups are essential to detect abnormal blood sugar levels early.

• Elderly individuals are often less sensitive to dehydration and may not feel thirsty, so it's important to remind themselves to drink more water. Those with heart or kidney conditions may need to limit fluid intake—consult a doctor for guidance.

• Elderly individuals, whether diabetic or not, should seek medical attention promptly if symptoms such as dry mouth, excessive thirst, frequent urination, dizziness, lethargy, dry skin/lips, or confusion occur.