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Hyperosmolar Hyperglycemic State (HHS) is a life-threatening diabetic emergency characterized by severe hyperglycemia (>600 mg/dL), hyperosmolality (>320 mOsm/kg), and dehydration without significant ketoacidosis. It primarily affects patients with type 2 diabetes and has a higher mortality rate than diabetic ketoacidosis, requiring immediate recognition and aggressive treatment.
HHS develops when insulin deficiency is relative rather than absolute, allowing enough insulin action to prevent lipolysis and ketogenesis but insufficient to prevent severe hyperglycemia. The resulting osmotic diuresis leads to profound dehydration and electrolyte losses, while the hyperosmolar state causes cellular dehydration and neurological dysfunction. Precipitating factors include infections, medications, acute illness, or poor medication compliance.
Patients typically present with altered mental status, severe dehydration, and a gradual onset over days to weeks, distinguishing it from the more rapid presentation of DKA. The absence of significant ketones and the presence of extreme hyperglycemia with hyperosmolality are key diagnostic features. Treatment focuses on gradual fluid resuscitation, careful insulin administration, and electrolyte replacement while addressing underlying precipitating factors.