Hyperosmolar hyperglycaemic state

Hyperosmolar hyperglycaemic state (previously known as HONK = hyperosmolar non-ketotic state) is an endocrinological emergency in which there is: 
  • raised blood glucose (usually >34mml/l) 
  • hyperosmolality (>320mmol/kg) and 
  • little or no ketosis

Presentation is insidious over days to weeks:
  • Polyuria 
  • Polydipsia 
  • Malaise 
  • Orthostatic dizziness 
  • Weight loss 
  • Signs of dehydration 
  • Mental blunting 
  • Occasionally focal neurological signs (may mimic stroke) 

Note that as HHS is usually accompanied by hypothermia a normal or raised temperature may indicate infection 

Precipitating factors 
  • Infection (=most common precipitating cause) 
  • Medications, including 
    • Antihypertensives – calcium channel blockers, loop and thiazide diuretics, propranolol 
    • Antipsychotics – olanzapine, chlorpromazine 
    • Other – chemo, cimetidine, phenytoin, glucocorticoids 
  • Co-existing conditions
    • Acute MI 
    • Pancreatitis 
    • Renal failure 
    • PE 
  • Hypo or hyper thermia 
  • Alcohol
  • Undiagnosed diabetes 

  • Laboratory glucose 
  • FBC
  • U&Es 
  • Calculate osmolality 
  • CXR/blood cultures/urine cultures 
  • ECG 

  • IV fluids - initially 0.9% saline
  • Insulin-glucose infusion 
  • Electrolyte replacement (if indicated; pay particular attention to potassium) 
  • Treat underlying cause 
  • Careful fluid balance - ?catheter 
  • Anticoagulation 
  • NG tube if impaired consciousness 
  • ? HDU/ITU 

  • Hypoglycaemia 
  • Hypokalaemia 
  • Vascular thrombosis 
  • ARDs 
  • Cerebral oedema – rare in adults 

Prognosis: Mortality rate 10-50% (= far higher than DKA) 

Small print gem: Average water deficit in HHS = 9 L 

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