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| [[Hyperglycemic crises resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
| [[Hyperosmolar hyperglycemic state resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{SI}}
{{Hyperosmolar hyperglycemic state}}
{{CMG}}
'''For patient information, click [[Hyperosmolar hyperglycemic state (patient information)|here]]'''


{{SK}} Hyperosmolar hyperglycemic nonketotic syndrome; hyperosmolar non-ketotic coma (HONK); nonketotic hyperosmolar coma
{{CMG}}; {{AE}} {{HS}}


==Overview==
{{SK}} Hyperosmolar hyperglycemic nonketotic syndrome; hyperosmolar non-ketotic coma (HONK); nonketotic hyperosmolar coma; hyperosmolar hyperglycemic state; diabetic coma; non-ketotic coma; HHS
'''Hyperosmolar hyperglycemic state''' (HHS) is a complication of [[diabetes mellitus]] (predominantly [[diabetes mellitus type 2|type 2]]) in which [[Hyperglycemia|high blood sugars]] cause severe [[dehydration]], increases in [[osmolarity]] (relative concentration of solute) and a high risk of complications, [[coma]] and death. It is diagnosed with [[blood test]]s. It is related to [[diabetic ketoacidosis]] (DKA), another complication of diabetes more often (but not exclusively) encountered in people with [[diabetes mellitus type 1|type 1 diabetes]]; they are differentiated with measurement of [[ketone bodies]], organic molecules that are the underlying driver for DKA but are usually not detectable in HHS.


The treatment of HHS consists of correction of the dehydration with [[intravenous fluid]]s, reduction of the blood sugar levels with [[insulin]], and management of any underlying conditions that might have precipitated the illness, such as an acute infection.
==[[Hyperosmolar hyperglycemic state overview|Overview]]==


==Signs and symptoms==
==[[Hyperosmolar hyperglycemic state historical perspective|Historical Perspective]]==
The increasing hemoconcentration and volume depletion may result in:
* Disordered mental functioning.
* Neurologic signs including [[focal neurologic signs|focal signs]] such as sensory or motor impairments or focal seizures or motor abnormalities, including flaccidity, depressed reflexes, tremors or fasciculations.
* [[Hyperviscosity syndrome|Hyperviscosity]] and increased risk of [[thrombosis]]
* Ultimately, if untreated, will lead to death
* Increase thirst


==Diagnosis==
==[[Hyperosmolar hyperglycemic state classification|Classification]]==
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, but an anion-gap metabolic acidosis is absent or mild. Altered mental status is also more common in HHS than DKA. Although traditionally DKA has been associated with Type I Diabetes, whereas HHS has been associated with Type II, HHS can be seen in patients of both types.
 
==[[Hyperosmolar hyperglycemic state pathophysiology|Pathophysiology]]==
 
==[[Hyperosmolar hyperglycemic state causes|Causes]]==
 
==[[Hyperosmolar hyperglycemic state differential diagnosis|Differentiating Hyperosmolar Hyperglycemic State From Other Diseases]]==
 
==[[Hyperosmolar hyperglycemic state epidemiology and demographics|Epidemiology and Demographics]]==
 
==[[Hyperosmolar hyperglycemic state risk factors|Risk Factors]]==
 
==[[Hyperosmolar hyperglycemic state screening|Screening]]==


Cranial imaging is not used for diagnosis of this condition. However, if MRI were performed, it may show cortical restricted diffusion with unusual characteristics of reversible T2 hypointensity in the subcortical white matter.  <ref>Neuroradiology. 2007 Apr;49(4):299-305. Epub 2007 Jan 3.</ref>
==[[Hyperosmolar hyperglycemic state natural history, complications and prognosis|Natural History, Complications and Prognosis]]==


==Pathophysiology==
==Diagnosis==
Nonketotic coma is usually precipitated by an infection,<ref name="Stoner">{{cite journal |last=Stoner | first=GD | title=Hyperosmolar hyperglycemic state | journal=American Family Physician |volume=71 | issue=9 | pages=1723–30 | date=May 2005 | url=http://www.aafp.org/afp/20050501/1723.html| pmid=15887451 }}</ref> 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 [[polyuria]] (excessive urination, 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]] ([[lipolysis]]).
[[Hyperosmolar hyperglycemic state history and symptoms|History and Symptoms]] | [[Hyperosmolar hyperglycemic state physical examination|Physical Examination]] | [[Hyperosmolar hyperglycemic state electrocardiogram|Electrocardiogram]] | [[Hyperosmolar hyperglycemic state laboratory findings|Laboratory Findings]] | [[Hyperosmolar hyperglycemic state x ray|X-Ray Findings]] | [[Hyperosmolar hyperglycemic state echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Hyperosmolar hyperglycemic state CT scan|CT-Scan Findings]] | [[Hyperosmolar hyperglycemic state MRI|MRI Findings]] | [[Hyperosmolar hyperglycemic state other diagnostic studies|Other Diagnostic Studies]] | [[Hyperosmolar hyperglycemic state other imaging findings|Other Imaging Findings]]


==Management==
==Treatment==
===Intravenous fluids===
[[Hyperosmolar hyperglycemic state medical therapy|Medical Therapy]] | [[Hyperosmolar hyperglycemic state surgery|Surgery]] | [[Hyperosmolar hyperglycemic state primary prevention|Primary Prevention]] | [[Hyperosmolar hyperglycemic state secondary prevention|Secondary Prevention]] | [[Hyperosmolar hyperglycemic state cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Hyperosmolar hyperglycemic state future or investigational therapies|Future or Investigational Therapies]]
Treatment of HHS begins with reestablishing tissue perfusion using intravenous fluids.  People with HHS can be dehydrated by 8 to 12 L.  Attempts to correct this usually take place over 24 hrs with initial rates of normal saline often in the range of 1 L/hr for the first few hours.<ref>{{cite book |first1=Judith E. |last1=Tintinalli |first2=Gabor D. |last2=Kelen |first3=J. Stephan |last3=Stapczynski |coauthors=American College of Emergency Physicians |title=Emergency Medicine: A Comprehensive Study Guide |url=http://books.google.com/books?id=GQoDewvXQ74C|edition=6th |year=2004 |publisher=McGraw-Hill Prof Med/Tech |isbn=978-0-07-138875-7 |page=1309 |ref=harv}}</ref>


===Electrolyte replacement===
==Case Studies==
Severe potassium deficits often occur in HHS.  They usually range around 350 mEq in a 70 kg person.  This is generally replaced at a rate 10 mEq per hour as long as there is urinary output.<ref>{{harvnb|Tintinalli|Kelen|Stapczynski|2004|p=1320}}</ref>
[[Hyperosmolar hyperglycemic state case study one|Case #1]]


===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 dangerous [[hypokalemia]] 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 is begun.<ref>{{harvnb|Tintinalli|Kelen|Stapczynski|2004|p=1310}}</ref>


==References==
[[Category:Medicine]]
{{reflist|2}}
[[Category:Endocrinology]]
[[Category:Medical emergencies]]
[[Category:Up-To-Date]]​
[[Category:Diabetes]]
[[Category:Emergency medicine]]

Latest revision as of 14:44, 17 October 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]

Synonyms and keywords: Hyperosmolar hyperglycemic nonketotic syndrome; hyperosmolar non-ketotic coma (HONK); nonketotic hyperosmolar coma; hyperosmolar hyperglycemic state; diabetic coma; non-ketotic coma; HHS

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Hyperosmolar Hyperglycemic State From Other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms | Physical Examination | Electrocardiogram | Laboratory Findings | X-Ray Findings | Echocardiography and Ultrasound | CT-Scan Findings | MRI Findings | Other Diagnostic Studies | Other Imaging Findings

Treatment

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Case #1​

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