Hyperglycemic Hyperosmolar State (HHS)

00:01 We’re also gonna talk about a hyperglycemic hyperosmolar state.

00:05 So this is characterized by marked hyperglycemia.

00:08 Patients are gonna have an elevated osmole count.

00:14 So they’re gonna be hyperosmolar, altered mental status.

00:18 So historically, this was called something with a coma.

00:22 So patients would present and they would be very altered and be in a coma.

00:25 That has since been removed from the title here.

00:28 And generally, they would have a mild degree of ketoacidosis.

00:32 So they’re not gonna be very acidotic.

00:34 They’re not gonna necessarily smell like ketones.

00:37 So for the ketone smellers out there, you’re not gonna necessarily have that advantage.

00:42 If an acidosis is present, look for other sources.

00:46 Potentially, the patient may have lactic acidosis, because this condition can be associated with sepsis, specifically, gram negative sepsis.

00:54 So what is the classic presentation here? So this is gonna be an older patient.

01:00 It’s generally a longer prodrome than DKA.

01:04 So patients present after a longer period of time.

01:08 DKA generally presents within the first few hours or within the first day of symptoms.

01:13 Patients are gonna be severely dehydrated.

01:16 They’re gonna be very, very dry.

01:19 And patients may have altered mental status and neuro symptoms and this will potentially dominate the presentation for the patient.

01:27 HHS is associated with kidney dysfunction, gram negative sepsis and pneumonia, and also possibly, GI bleed.

01:36 So important to look for those three key things when you’re evaluating a patient with the HHS.

01:42 What will your vital signs be? The patient’s gonna have an elevated heart rate.

01:46 They’re gonna be tachycardic.

01:48 They’re very volume deplete.

01:49 They may have a fever, and the blood pressure may be low.

01:54 The classic diagnostic things here are that your patient will have an elevated blood sugar.

02:00 This is generally gonna be more elevated than in DKA.

02:04 So in DKA, it’s about 300, 350, 400.

02:08 Here, it’s gonna be over 600.

02:10 It’s gonna be a very elevated blood sugar.

02:12 There should be no acidosis or minimal acidosis and ketosis.

02:17 We think of this generally as the bicarbonate level being greater than 15.

02:22 In DKA, the bicarbonate levels can be as low as 10, two, very, very low.

02:28 There will be potentially prominent electrolyte abnormalities, elevated BUN, elevated creatinine, lots of abnormalities with the sodium and the potassium.

02:41 The treatment though is very similar to DKA.

02:46 It technically does not need an insulin drip.

02:48 The main thing that you’re doing with the insulin drip in DKA is you’re helping the body clear the ketones and helping the body clear the acidosis.

02:56 Here, patients don’t necessarily need an insulin drip because they don’t have that element, but it’s the most controlled way to lower the blood sugar.

03:03 It’s gonna give you the most accurate way to do that.

03:07 For here, you really wanna make sure you’re aggressively looking for that underlying cause.

03:12 You don’t wanna miss an underlying cause here.