1. MANAGEMENT OF
HYPEROSMOLAR
HYPERGLYCEMIC STATE
Dr. MUSA E.
NEPHROLOGY UNIT
POST-CALL REVIEW

2. LEARNING OBJECTIVES
• Define Diabetes Mellitus
• Diagnose & differentiate common diabetic
emergencies
• Know red flags of diabetic emergencies
• Manage common diabetic emergencies

3. What is Diabetes Melitus?
Body does not make or properly use insulin:
– no insulin production
– insufficient insulin production
– resistance to insulin’s effects
No insulin to move glucose from blood into
cells:
– high blood glucose means:
s fuel loss. cells starve
s short and long-term complications
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4. Acute Complications of Diabetes
(Diabetic Emergencies)
D ia b e te s
D ia b e tic K e to a c id o s is H y p e rg ly c e m ic H y p e ro s m o la r S ta te H y p o g ly c e m ia
H y p e rg ly c e m ia H y p e rg ly c e m ia
A c id o s is w ith a n io n g a p N o a c id o s is
E le c tro ly te D is tu rb a n c e s H y p e rn a tre m ia a n d o th e rs

5. HYPEROSMOLAR HYPERGLYCAEMIC
STATE (HHS)
 This is a metabolic emergency in persons with
uncontrolled type 2 DM. It was previously called
hyperosmolar non-ketotic state (HONK).
Diagnosis: the following must be present
 Severe hyperglycaemia ( plasma glucose
>>35mmol/l)
 Altered mental status
 Serum osmolarlity > 320 mosm/L (normal
270-290mosm/L)

6. Other findings which may be present include;
• ketonaemia/ketonuria – mild or absent.
• Anion gap – normal or slightly elevated.
• pH > 7.3
• serum HCO3 > 18 mmol/L
• -patients are older, presenting in middle or later life.
• -mortality may be as high as 35%
• Accounts for 35.3% of DM-related admissions in Kano1
• 1. Uloko AE et al. AACE Presentation, Houston, Texas. May 2009

7. Precipitating factors
-newly diagnosed type 2 DM
-consumption of glucose-rich fluids (eg Lucozade)
-discontinuation of drugs
-surgery
-concurrent medications- thiazide diuretics or steroids
-intercurrent illness- CVD, MI, pancreatitis, UTI,
respiratory tract infection etc.

8. Pathophysiology of DKA/HHS
Insulin Deficiency
Increased Lipolysis Hyperglycemia
Increased ketogenesis Osmotic Diuresis
Ketoacidosis Hyperosmolality
Pure Diabetic Ketoacidosis Pure Hyperosmolar State

9. Presentation
-insidious onset with symptoms progressing over 1 week or more
-polyuria
-polydipsia
-severe dehydration (8 – 12litres)
-confusion, seizures
-stupor or coma in up to 20% of cases
-evidence of underlying illness eg UTI, pneumonia etc
-stroke, MI, or peripheral arterial disease in the lower limbs due to
hyperosmolality

10. Management
Principles
 Rehydration
 Correction of hyperglycaemia using insulin
 Correction of electrolyte imbalance especially
potassium.
 Treatment of underlying cause/precipitant
 Prevention of complication

11. General measures
 Same as for DKA
 Calculate serum osmolality based on the formular:
Serum osmolality = [2(Na+ + K+) + plasma glucose + Urea]
mosm/L.
 Fluid replacement;
-normal saline is the fluid of choice
-fluid replacement regimen as in DKA.

12. Insulin replacement
-similar to DKA with the following exceptions:
1. use ½ the dose of soluble insulin as in DKA
2. double the dose of insulin if no appreciable fall in
plasma glucose at a rate of 3mmol/l/hr after 3
hours of starting treatment.
3. commence insulin therapy only after
rehydration has started.

13. Correction of electrolyte inbalance
Treatment of precipitating cause;
-broad spectrum antibiotics if infection is suspected
-treat for MI, CVD, if indicated.
 Prevention of complications;
 -prophylactic anticoagulant is compelling because of
the high tendency of thrombo-embolic events.
 -give subcut Heparin 5000 U 12Hourly (if no absolute
contra-indications). OR
 -subcut Enoxaparin 40mg 12Hourly. Do baseline
clotting profile and INR monitoring especially if using
Heparin.

14. Diabetes Management 24/7
Constant Juggling:
Insulin/medication
with:
Exercise BG
BG
&
Food intake
BG
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15. THANK YOU