Hyperosmolar Hyperglycemic State (HHS) - Symptoms, Diagnosis, and Treatment

Introduction

Diabetes mellitus is a medical condition characterized by hyperglycemia as the primary metabolic disorder. This is due to an absolute or relative insulin deficiency. Insulin is an anabolic hormone produced by the beta cells of the pancreatic islets of Langerhans. This hormone's main function is to lower blood glucose levels by promoting glucose uptake by adipose tissue and skeletal muscle, a process known as glycogenesis. Insulin also inhibits lipolysis or the breakdown of fat in adipose tissue. Insulin's metabolic effect is mitigated by hormones such as glucagon and catecholamines. The autoimmune destruction of beta cells in the pancreas occurs in type 1 diabetes. This category accounts for only five to ten percent of all diabetes cases. Diabetic ketoacidosis is the most common complication of type 1 diabetes.

Diabetes type 2 accounts for 90 to 95 % of all diabetes cases. It is most commonly seen in obese patients. Obesity and a high body mass index (BMI) cause peripheral tissue resistance to insulin action. The pancreatic beta-cell continues to produce insulin, but not enough to compensate for the end organ's resistance to its effect. HHS is a serious and potentially fatal type 2 diabetes complication. The mortality rate in HHS can reach 20 %, approximately ten times higher than in diabetic ketoacidosis.

What Is Hyperosmolar Hyperglycemic State?

The hyperosmolar hyperglycemic state is a potentially fatal condition characterized by a significant increase in blood glucose and hyperosmolarity with little or no ketosis. HHS occurs when a person's blood glucose (sugar) levels remain abnormally high for an extended period, resulting in severe dehydration (extreme thirst) and confusion. Although there are numerous precipitating factors, the most common are underlying infections.

Hyperosmolar hyperglycemic state (HHS) is less common than other complications. HHS is responsible for less than one percent of diabetes hospital admissions. HHS primarily affects people with type 2 diabetes who are older (usually in their 60s or 70s). Other health issues, such as illness, infection, or heart conditions, have an impact. If not treated, HHS can be fatal. HHS can rarely affect children and young adults with type 1 or type 2 diabetes, especially if they are obese. HHS can develop in people who have not yet been diagnosed with diabetes.

What Causes Hyperosmolar Hyperglycemic State?

Diabetes patients have an excess of glucose (sugar) in their blood. The glucose accumulates because their bodies either do not produce enough insulin or have difficulty using the insulin that they do produce.

HHS occurs when a diabetic's blood sugar remains abnormally high (hyperglycemia) for an extended period. The excess sugar is excreted through urine, causing the person to urinate frequently. As a result, they lose a significant amount of fluid, which can result in severe dehydration (extreme thirst). HHS typically occurs in people who do not have type 2 diabetes under control and who:

• Have a medical condition or infection, such as pneumonia or a urinary tract infection.

• Stopped taking diabetes medication.

• Had a heart attack or a stroke.

• Take certain medications that can cause the syndrome, such as steroids or diuretics.

What Are the Symptoms of Hyperosmolar Hyperglycemic State (HHS)?

HHS symptoms usually appear gradually and can last for days or weeks. Among the symptoms are:

• High blood sugar (more than 600 mg/dL).

• Confusion, hallucinations, drowsiness, or passing out.

• Dry mouth and extreme thirst that may improve over time.

• Frequent urination.

• Fever of more than 100.4 degrees Fahrenheit.

• Blurred vision or loss of vision.

• Weakness or paralysis, possibly on one side of the body.

How Is Hyperosmolar Hyperglycemic State (HHS) Diagnosed?

The hyperosmolar hyperglycemic state is initially suspected when a significantly elevated glucose level is observed in a fingerstick specimen obtained during a workup of altered mental status. If measurements have not already been taken, urine should be tested for ketones, and blood should be drawn to measure the following:

• Serum electrolytes.

• Blood urea nitrogen (BUN).

• Creatinine.

• Glucose.

• Ketones.

• Plasma osmolality.

Although serum potassium levels are usually normal, sodium levels can be low or high depending on volume deficits. Hyperglycemia can cause dilutional hyponatremia; measured serum sodium is improved by adding 1.6 mmol/L (millimoles per liter) for each 5.6 mmol/L increase in serum glucose. BUN (blood urea nitrogen) and serum creatinine levels are significantly elevated. Although arterial pH usually exceeds 7.3, mild metabolic acidosis can occur due to lactate accumulation.

How Is Hyperosmolar Hyperglycemic State (HHS) Treated?

• HHS treatment necessitates a multidisciplinary approach. Endocrinologist and intensive care specialist consultations are advised. Appropriate resuscitation should be initiated, paying special attention to the principles of the airway, breathing, and circulation (ABC). As a result of significant fluid depletion and decreased cerebral perfusion, patients with HHS may present with altered mental status. If the Glasgow coma score is less than eight, it is best to secure the airway.

• The standard practice in HHS management is aggressive hydration with isotonic fluid and electrolyte replacement. Adults should receive an initial fluid bolus of 15 to 20 ml/kg, followed by an infusion rate of 200 to 250 ml/hour (milliliter per hour).

• In pediatric patients, the infusion rate should be approximate twice that of the maintenance rate. Isotonic fluid hydration has been shown to help reduce the amount of counterregulatory hormones secreted during HHS. This can reduce serum glucose levels by 75 to 100 mg/hour (milligram per hour).

• The serum potassium level in HHS is usually high, but the total body potassium level is low due to the extracellular shift caused by insulin deficiency. Potassium replacement should be started if the serum potassium level is between 4 and 4.5 mmol/L.

• Starting insulin drip in the early stages of treatment should be avoided because it may cause a rapid drop in serum glucose levels, leading to cerebral edema. To avoid the development of cerebral edema, glucose levels must be maintained around 300 mg/dL.

• In pediatrics, prolonged rehydration and electrolyte correction for 48 hours may prevent cerebral edema.

What Are the Complications Associated With Hyperosmolar Hyperglycemic State (HHS)?

HHS is a severe medical condition. If left untreated, it can lead to:

• Seizures.

• Coma.

• Swelling of the brain.

• Organ failure.

• Death.

Conclusion

HHS is a potentially fatal medical condition. It occurs when a person's blood glucose (sugar) levels remain abnormally high for an extended period. It is associated with extreme thirst, frequent urination, fever, etc. it is managed by a multidisciplinary approach. The best way to prevent HHS is by following a healthy lifestyle and controlling diabetes.