- Diabetic hyperosmolar hyperglycemic state (HHS) is a life-threatening condition characterized by very high blood glucose levels, dehydration, and minimal ketosis. It occurs most often in older adults with type 2 diabetes who become severely dehydrated. - Treatment involves rapid rehydration with intravenous fluids, bringing down blood glucose levels with insulin, and identifying and addressing the underlying cause to prevent future crises. Fluid replacement of 9-12 liters may be needed over 48 hours. - Education is important to prevent recurrence through proper blood glucose monitoring and management of predisposing factors like infection, medications, and poor compliance with diabetes treatment.

2. HYPEROSMOLAR
HYPERGLYCEMIC STATE

3. DEFINITIONS AND BACKGROUND
• Diabetic HHS is a life-threatening emergency with marked elevation of
blood glucose, hyperosmolarity, and minimal or no ketosis
• HHS is preventable if blood glucose is monitored regularly in order to
correct elevating levels before problems occur.

4. • The condition occurs in patients older than
age 70 years with T2DM and profound
dehydration as precipitating factors.
• If recognized early, HHS can frequently be
treated in the outpatient setting if the
patient can take fluids.
• Sometimes DKA is the first time that diabetes
is diagnosed. Identification and treatment of
the underlying and precipitating causes of
HHS are absolutely essential.

5. Predisposing factors for this syndrome include
• long-term uncontrolled hyperglycemia
• pancreatic disease
• infections or sepsis
• Stroke
• Surgery
• extensive burns

6. • renal or CVD
• corticosteroid use
• Diuretics
• excessive total parenteral nutrition (TPN)
• dialysis.
• Underlying poor compliance with medications, infections, or cocaine
abuse are the most common causes.

7. • In children, corticosteroid use and gastroenteritis are common causes.
• The mortality rate is high at 10–20%.
• Areas of future research include prospective randomized studies to
determine the pathophysiological mechanisms for the absence of
ketosis in HHS and to investigate the reasons for elevated
proinflammatory cytokines and cardiovascular risk factors

8. INTERVENTION

9. OBJECTIVES
• Correct dehydration, shock, and cardiac arrhythmias.
• Reduce elevated blood glucose levels with isotonic saline, then
hypotonic saline along with insulin.
• Monitor fluid status and replace deficits, which may be 10–20% of
total body weight.
• This may require up to 9 L in 48 hours

10. OBJECTIVES
• Prevent future crises by appropriate DSME and regular monitoring of
blood glucose.
• Prevent acute renal failure, which could result from pro- longed
hypovolemia

11. FOOD AND
NUTRITION

12. • Offer fluid replacement, often 1 L/h until
volume is restored; 9–12 L may be needed.
• Patient is likely to nothing by mouth (NPO)
during a crisis or perhaps tube fed during a
comatose state.
• As appropriate, intake may be progressed
gradually to a balanced diet, controlling
calories as needed.

13. • Correct electrolyte deficits.
• Potassium or magnesium may be needed.
• The reported sodium level should be corrected
when the patient’s glucose level is markedly
elevated.
•

14. • In this circumstance, extracellular fluid (ECF)
osmolality rises and exceeds that of intracellular fluid
(ICF), since glucose penetrates cell membranes slowly
in the absence of insulin, resulting in movement of
water out of cells into the ECF
• Types of fluids administered will depend on the
corrected serum sodium level, calculated using the
following formula: measured sodium [(serum glucose
100)/100) 1.6].
• A renal diet plan may be needed if renal failure is
identified.

15. COMMON DRUGS USED
AND POTENTIAL SIDE
EFFECTS

16. • Insulin is needed to normalize blood glucose
levels.
• Infusions will be needed until full rehydration
is complete.
• DKA and HHS are associated with elevation of
proinflammatory cytokines; insulin therapy
provides a strong anti-inflammatory effect

17. • Potassium replacements may be needed.
Monitor care- fully.
• Antibiotic therapy may be needed in cases of
underlying infections.
• Drugs that may precipitate HHS include
diuretics, beta blockers, clozapine, olanzapine,
H2 blockers, cocaine.

18. HERBS, BOTANICALS,
AND SUPPLEMENTS

19. • Herbs and botanical supplements should not be used without
discussing with physician.

20. NUTRITION EDUCATION,
COUNSELING, CARE
MANAGEMENT

21. • Discuss, where possible, predisposing factors, how to
avoid future incidents, and blood glucose monitoring.
• CHO-controlled diets may be beneficial if patient can
comprehend. Family intervention may be required.
• Discuss possible neglect or abuse, if suspected.

22. • Continuous management of the fluid, electrolyte, and
glucose disturbances is necessary until resolved.
• Provide diabetes teaching to prevent recurrence.

23. • Adjust insulin or oral hypoglycemic therapy on the
basis of the insulin requirement once serum glucose
level are stable.
• Coordinate home visits from nursing or dietitian if
needed to evaluate the inadequate access to water.

24. Patient Education—Foodborne Illness
• If home tube feeding is needed, teach appropriate sanitation and
food-handling procedures.