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
Investigations
- Laboratory glucose
- FBC
- U&Es
- Calculate osmolality
- CXR/blood cultures/urine cultures
- ECG
Management
- 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
Complications
- 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
References
