Hyperosmolar Hyperglycemic State (HHS) is a life-threatening medical emergency seen most commonly in people with type 2 diabetes mellitus. It is characterized by extremely high blood glucose levels, severe dehydration, and increased blood osmolarity, without significant ketoacidosis. If not recognized and treated promptly, HHS can lead to coma, organ failure, and death.
This condition often develops insidiously over days to weeks, making early recognition difficult. Understanding its symptoms, causes, diagnostic criteria, and treatment is crucial for timely intervention.
What Is Hyperosmolar Hyperglycemic State (HHS)?
Hyperosmolar Hyperglycemic State is a serious metabolic complication of diabetes in which:
Blood glucose levels rise extremely high (often >600 mg/dL or >30 mmol/L)
Blood becomes highly concentrated (hyperosmolar)
Severe fluid loss and dehydration occur
Ketone production is minimal or absent
Unlike Diabetic Ketoacidosis (DKA), HHS usually has normal or near-normal blood pH and no significant ketone accumulation.
Who Is at Risk of Developing HHS?
HHS primarily affects:
Older adults with type 2 diabetes
People with undiagnosed diabetes
Patients with limited access to water or healthcare
Individuals with infections or acute illnesses
Common Risk Factors
Poorly controlled diabetes
Missed insulin or oral hypoglycemic drugs
Acute infections (pneumonia, urinary tract infection, sepsis)
Use of medications such as:
Steroids
Thiazide diuretics
Antipsychotics
Causes of Hyperosmolar Hyperglycemic State
HHS develops due to a relative insulin deficiency combined with increased counter-regulatory hormones like cortisol and glucagon.
Key Pathophysiological Mechanism
Insulin deficiency → inability of glucose to enter cells
Rising blood glucose → osmotic diuresis (excessive urination)
Massive fluid loss → dehydration
Increased serum osmolarity → neurologic dysfunction
Because some insulin is still present, fat breakdown and ketone formation are suppressed, differentiating HHS from DKA.
Symptoms of Hyperosmolar Hyperglycemic State
Symptoms often develop gradually and may go unnoticed initially.
Early Symptoms
Dry mouth and dry skin
Progressive Symptoms
Weight loss
Neurological Symptoms (Hallmark of HHS)
Confusion
Drowsiness or lethargy
Blurred vision
Headaches
Focal seizures
Myoclonic jerking
Decreased muscle tone and reflexes
Reversible paralysis
Coma (in severe cases)
Neurologic impairment correlates directly with serum osmolarity, making it a key distinguishing feature of HHS.
Diagnostic Criteria for Hyperosmolar Hyperglycemic State
Diagnosis is confirmed through clinical assessment and laboratory testing.
Blood Test Findings in HHS
| Parameter | Typical Value |
|---|---|
| Blood glucose | >600 mg/dL (>30 mmol/L) |
| Serum osmolarity | >320 mOsm/kg |
| Blood pH | >7.30 |
| Serum ketones | Absent or mild |
| Bicarbonate | Normal or mildly reduced |
| Sodium | Normal or elevated |
| Creatinine & urea | Elevated (due to dehydration) |
Additional Tests
Urine analysis
Electrolyte panel
Difference Between HHS and Diabetic Ketoacidosis (DKA)
| Feature | HHS | DKA |
|---|---|---|
| Common in | Type 2 diabetes | Type 1 diabetes |
| Onset | Gradual | Rapid |
| Blood glucose | Very high | Moderately high |
| Ketones | Minimal | High |
| pH | >7.3 | <7.3 |
| Dehydration | Severe | Moderate |
| Mortality | Higher | Lower |
Complications of Hyperosmolar Hyperglycemic State
If untreated, HHS can cause:
Blood clots (hyperviscosity)
Coma
Death
Mortality rates range from 10–20%, higher than DKA, especially in elderly patients.
Treatment of Hyperosmolar Hyperglycemic State
HHS is a medical emergency and requires immediate hospital management, often in an ICU setting.
1. Fluid Replacement (Most Important Step)
Initial rapid infusion of 0.9% normal saline
Corrects dehydration and reduces blood glucose
Careful monitoring to avoid fluid overload
2. Insulin Therapy
Low-dose intravenous insulin after fluids
Gradual glucose reduction to prevent cerebral edema
3. Electrolyte Correction
Potassium monitoring and replacement
Sodium correction based on serum levels
Magnesium and phosphate as needed
4. Treat Underlying Cause
Antibiotics for infection
Manage myocardial infarction or stroke
Adjust medications
Recovery and Prognosis
With timely treatment, patients can recover fully. However, prognosis depends on:
Age
Presence of comorbidities
Severity at presentation
Speed of diagnosis and treatment
Delayed treatment significantly increases mortality risk.
Prevention of Hyperosmolar Hyperglycemic State
Preventive strategies are crucial for people with diabetes.
Key Preventive Measures
Regular blood glucose monitoring
Adequate hydration, especially during illness
Never skipping insulin or diabetes medications
Sick-day management plans
Early treatment of infections
Regular follow-ups and HbA1c testing
When to Seek Emergency Care
Seek immediate medical attention if a person with diabetes experiences:
Persistent blood sugar >300 mg/dL
Extreme thirst and reduced urination
Confusion or altered consciousness
Seizures or weakness
Signs of severe dehydration
Frequently Asked Questions (FAQs)
1. Is Hyperosmolar Hyperglycemic State the same as diabetic coma?
HHS can lead to diabetic coma, but not all cases progress to coma. Early treatment can prevent loss of consciousness.
2. Can HHS occur in non-diabetics?
Rarely, but it may occur in individuals with undiagnosed type 2 diabetes, especially during severe illness or dehydration.
3. Why are ketones absent in HHS?
Because some insulin is still present, fat breakdown and ketone production are suppressed.
4. How long does recovery from HHS take?
Hospital recovery may take several days, while full metabolic stabilization can take 1–2 weeks.
5. Is HHS preventable?
Yes. Good diabetes control, hydration, and early illness management significantly reduce risk.
6. What is the biggest danger in HHS?
Severe dehydration and high blood osmolarity leading to neurological damage or death.
7. Can HHS recur?
Yes, especially if diabetes remains uncontrolled or precipitating factors are not addressed.
Hyperosmolar Hyperglycemic State is a silent but deadly complication of diabetes that requires high clinical suspicion and rapid treatment. Recognizing early symptoms such as excessive thirst, urination, and confusion can save lives. With prompt diagnosis, aggressive fluid replacement, insulin therapy, and prevention strategies, outcomes can be significantly improved.
Early testing and timely intervention at a trusted diagnostic centre play a crucial role in managing and preventing HHS.
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No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
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