HHS
HYPEROSMOLAR HYPERGLYCEMIC STATE
While DKA is more commonly seen in patients <65 years old, HHS is most common in older patients (>65 years). Although rate of hospital admissions for HHS are typically lower than DKA, the mortality rates are about 10x higher. HHS differs from DKA in that it doesn't have the "A" for acidosis. The criteria for HHS can be found in the name:
H – hyperglycemia (glucose > 600 mg/dl)
H – hyperosmolarity (serum osm >320 mOsm/kg)
Patients with HHS can have very high glucose levels, and in some ways, mimic DKA patients in their initial clinical presentation. Symptoms of HHS include excessive thirst and urination, fever, AMS, vision loss, and seizure/coma. It is important to note that, unlike DKA, HHS typically does NOT present with abdominal pain and is more likely to have neurologic abnormalities such as focal weakness, sensory changes, and seizures/coma.
These patients are usually in profound fluid deficit, even more so than those in DKA. The fluid deficit for HHS can be as much as 5-20 liters. As mentioned before – you can use NS, but LR or plasmalyte would be a better option for fluid resuscitation given the large volumes needed.
Treatment for HHS is essentially the same as that for DKA except with a few small key differences:
The patient may require up to 12L of fluid over a 24-26 hour period
D5 should be added to the IVF when BG reaches 250-300
The target to correct the effective osm is 3 mOsm/kg/hr
Make sure you do not overcorrect this too quickly or else you will run the risk of causing cerebral edema
And don’t forget to keep an eye on those electrolytes!
Points to remember:
No ketoacid accumulation, glucose often >1000, plasma osmolality elevated as high as 380
Can present with neuro abnormalities and coma
Same precipitating factors as DKA
Treatment: fluid replacement and electrolyte repletion:
0.9% NS followed by 0.45% saline to replace typical volume loss of 8-12L. Half of volume over 12hrs then the other half over 24hrs. Could consider other balanced solutions like PlasmaLyte or LR.
K, Mg, Phos all monitored and treated as in DKA
Insulin drip will be needed
If there is no neuro deficit, even patients with glucose >1000 and not acidotic are not technically in HSS and could even be treated with IV fluids and subcutaneous insulin.
