Hyperglycemic hyperosmolar syndrome (HHS) is a serious condition caused by low insulin levels and high blood glucose levels, resulting in excessive thirst, frequent urination, and dehydration. It predominantly affects older adults with type 2 diabetes and is triggered by illnesses that increase insulin demand. HHS is characterized by hyperglycemia, hyperosmolarity, and alterations in mental status without significant ketosis. Treatment involves fluid replacement, electrolyte management, and insulin administration to restore hydration and metabolic balance while closely monitoring for complications. Lifestyle changes and medical management after recovery can help prevent recurrence of HHS.

1. Safad R. Isam
Msn,CollegeOfnursing,universityofBaghdad
Hyperglycemic
Hyperosmolar Syndrome

2. Main types
Symptoms
Prevention
Organs affected
Treatment
Diabetes Summary
IDDM NIDDM GDM
Polyuria Fatigue weight loss
Polydipsia weakness
Polyphagia
Healthy Physical Weight
Nutrition Exercise Control
Insulin & Medication
Nutritional Therapy
Blood glucose
Monitoring
+ LADA
Complications

3. Short-term imbalances in blood glucose levels
ACUTE COMPLICATIONS OF DIABETES
Hyperglycemic
Hyperosmolar
Syndrome
(HHS)
Diabetic
Ketoacidosis (DKA)
Hypoglycemia

4. Hyperglycemic Hyperosmolar Syndrome
HHS is a metabolic disorder of type 2 diabetes resulting from a relative
insulin deficiency initiated by an illness that raises the demand for insulin.
This is a serious condition in which:
hyperosmolarity and hyperglycemia predominate,
with alterations of the sensorium.

5. Hyperglycemic Hyperosmolar Syndrome
At the same time, ketosis is usually minimal or absent.
The basic biochemical defect is the lack of effective insulin (i.e., insulin
resistance).

6. Hyperglycemic Hyperosmolar Syndrome
Persistent hyperglycemia causes osmotic diuresis, which results in losses of water
and electrolytes.
To maintain osmotic equilibrium, water shifts from the intracellular fluid space to
the extracellular fluid space.
With glycosuria and dehydration, hypernatremia and increased osmolarity occur.

7. PATHOPHYSIOLOGY

8. Causes
HHS often can be traced to
 An infection or a precipitating event such as an acute illness (e.g., stroke)
 Medications that exacerbate hyperglycemia (e.g., thiazides)
 Treatments such as dialysis.
HHS occurs most often in older adults (50 to 70 years of age) who have no known history of
diabetes or who have type 2 diabetes
Occurrence

9. What distinguishes HHS from DKA?
Ketosis and acidosis generally do not occur in HHS,
partly because of differences in insulin levels.
 In DKA, no insulin is present, and this promotes the breakdown of stored
glucose, protein, and fat, which leads to the production of ketone bodies and
ketoacidosis.
 In HHS, the insulin level is too low to prevent hyperglycemia (and subsequent
osmotic diuresis), but it is high enough to prevent fat breakdown.

10. What distinguishes HHS from DKA?

11. Clinical Manifestation
 Hypotension
 Profound dehydration:
- dry mucous membranes,
- poor skin turgor
 Tachycardia
 Variable neurologic signs:
- alteration of consciousness,
- seizures,
- hemiparesis

12. Assessment and Diagnostic Findings
Diagnostic assessment includes a range of laboratory tests,
including:
 blood glucose
 electrolytes
 BUN
 complete blood count
 serum osmolality
 arterial blood gas analysis
 The blood glucose level is usually 600 to 1200 mg/dL,
 the osmolality exceeds 320 mOsm/kg.

13. MANAGEMENT
The overall approach to the treatment of HHS is similar
to that of DKA:
 Fluid replacement
 Correction of electrolyte imbalances
 Insulin administration

14. Management
 Because patients with HHS are typically older, close
monitoring of volume and electrolyte status is important for
prevention of fluid overload, heart failure, and cardiac
dysrhythmias.
 Fluid treatment is started with 0.9% or 0.45% NS, depending
on the patient’s sodium level and the severity of volume
depletion.

15. Management
 Central venous or hemodynamic pressure monitoring
guides fluid replacement. Potassium is added to IV fluids
when urinary output is adequate and is guided by continuous
ECG monitoring and frequent laboratory determinations
of potassium

16. Management
 Insulin plays a less important role in the treatment of HHS
because it is not needed for reversal of acidosis, as in DKA.
 Other therapeutic modalities are determined by the underlying illness and the
results of continuing clinical and laboratory evaluation.
 It may take 3 to 5 days for neurologic symptoms to clear, and treatment of
HHS usually continues well after metabolic abnormalities have resolved

17. Management
After recovery from HHS,
 Many patients can control their diabetes with
Medical Nutrition Therapy (MNT) alone or
with MNT and oral antidiabetic medications.
 Insulin may not be needed once the acute
hyperglycemic complication is resolved.
 Frequent SBGM is important in prevention of
recurrence of HHS.