HHS is a metabolic emergency characterized by severe hyperglycemia and hyperosmolarity without ketoacidosis in type 2 diabetes patients. It can be fatal if not treated properly. The key goals of treatment are to 1) rehydrate the patient aggressively, 2) correct electrolyte imbalances, 3) lower blood glucose levels, 4) treat any underlying conditions, and 5) monitor cardiovascular, pulmonary, renal, and neurological functions closely. Rapid assessment and treatment is needed, starting with airway management, IV fluids, insulin administration, and correcting electrolyte abnormalities to prevent further complications.

1. HHS
Hyperglycemic Hyperosmolar state
By:
Dr. Mohamed Saber
Meeqat Hospital - Madinah

2. Def:
HHS is a metabolic emergencey
Characterized by hyperglycemia and
Hyperosmolarity without ketoacidosis in a
DM II patient

3. DKAHHS
>250> 600mg/dlPlasma Glucose
300-320≥ 320mosol/kgSr Osmolarity
3-6 L8-12 L + ↑ BUN and Cr.Dehydration
<15> 15HCO3
VariableSome alteration of
consciousness
GCS
<7.30>7.30PH
125-135135-145Na+
Normal or highNormalK+
HighNormalAG
20-30NormalPCO2

4. Why HHS happens?
 Infection
 Dialysis
 Dehydration
 TPN
 Diuretics
 Β-Bs

5. What happens?
Illness → ↓ insulin + ↑ Anti-insulin
hormones → ↓ renal clearance and
peripheral utilization of glucose → ↑ ↑
↑ Glucose → Hyperosmolarity
→Severe Dehydration → Loss of water
and Electrolytes

6. So we are Facing a patient like
this:
 DM II - Adult or Old Age
 Symptoms of hyperglycemia
 Severely dehydrated
 ↑↑↑ RBS
 Acidosis?: maybe: it will be due to lactic acidosis (due
to hypoxia) rather than ketoacidosis
 ↑↑ Mortality rate
 Neuro: ↓GCS, Delirium, Focal or generalized
seizures, visual changes,Hemiparesis

7. DO not Underestimate HHS
It can be Fatal

8. Treatment Goals
1. REHYDRATE your patient
2. Correct electrolyte imbalance
3. Correct hyperglycemia
4. Treat underlying disease
5. Monitor and support CVS,
Pulmonary, Renal, and CNS
functions

9. What is your role?
Step 1: ABCD always First
 Airway: may be compromised
due to decreased GCS
 Breathing: may be tachypnic
due to Pneumonia
 Circulation: may be
hypotensive
 Disability: decreased GCS

10. :Step 2
 Rapidly examine and asses
severity:
• Dehydrated: dry lips, skin, MM, loss
of skin turgor
• Vitals:
oTachycardiac (Early dehydration and
Shock)
oHypotensive (late)
• Systemic examination to rule out
other causes

11. What are the other causes?
 Delerium for any reason
 Alcoholic ketoacidosis
 Dementia
 Thyrotoxicosis (Fever, ↑RR, Dehydration)

12. Step 3:
 Insert 2 wide-bore cannulae (16 or 18)
and start fluid resuscitation
 Start 0.9% at 15-20 mL/kg or greater
 = about 1-1.5 L in average –sized person
 Then IVF at 200mL/hr
 If hypernatremic start with 0.45%
 You can increase the boluse and infusion
according to severity of dehydration but
Do not exceed 50mL/kg/first 4 hrs

13. Step 4:
 Start Regular Insulin
 Give 0.1 unit/kg as bolus
 Then 0.1 unit/kg/hr as infusion
Never start insulin before Fluids
 When RBS reaches 300 change fluid
type to D5 0.45%

14. Step 4:
 Correct electrolytes

15. Summary
 ABCD
 Aggressively Rehydrate
 Start insulin
 Correct electrolytes
 Add Antibiotics, Antipyretics
and Antiemetics

16. Thank you