Medicine (MD/DO)
Diabetes Mellitus
Hyperosmolar Hyperglycemic State

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Hyperosmolar Hyperglycemic State

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Hyperosmolar Hyperglycemic State

Hyper-Oz-Polar Bear and Hiker-glue
Hyperosmolar hyperglycemic state, also known as HHS or HHNK, is a state of extreme glucose toxicity. It is characterized by the presence of insulin alongside increased serum osmolality. Other characteristics include blood glucose levels above 600 mg/dL without significant acidosis or ketosis. Clinical features include severe dehydration, altered neurological status, tachycardia and hypotension. Management includes IV fluids, insulin, and the treatment of the underlying disorder.
Insulin Present

In HHS, insulin is present which prevents lipolysis and ketogenesis. Lipolysis is the breakdown of fat which produces acid as a byproduct. Ketogenesis is the breakdown of fatty acids which produces ketones as a byproduct.

Increased Serum Osmolality
Thick as Mud

Serum osmolality is increased due to hyperglycemia induced polyuria leading to a state of severe dehydration. This state of severe dehydration leads to the symptoms of HHS.

Glucose >600 mg/dL
Hiker-glue-bottle 6-sax

Patients with hyperosmolar hyperglycemic state may have glucose levels of 600mg/dl or more. This severe glucose level leads to glucose toxicity and has a large osmotic effect. Patients have pronounced glucosuria as well, which leads to polyuria.

No Significant Acidosis or Ketosis
Police Blocking Acidic-lemon and Keys

Lipolysis and ketogenesis does not occur in HHS, so acidosis and ketones are not present.

Severe Dehydration
Dehydrated David

Patients present with a dry parched mouth and extreme thirst due to polyuria, a symptom of hyperglycemia.

Altered Neurological Status
Nervous Party Man with Delta-halos

Hyperosmolar hyperglycemic state may induce confusion, weakness, trouble talking, seizures, hallucinations, coma, or signs and symptoms that mimic a stroke.

Tachycardia and Hypotension
Tack-heart-card and Hippo-BP

Tachycardia and hypotension occur as a compensatory mechanism to the decreased blood volume and cardiac output. This decrease in body fluid is due to the polyuria and excessive dehydration of HHS.

IV Fluids
IV Fluid

Rehydrate patients slowly to prevent cerebral edema. Be cautious when rehydrating the elderly, CHF patients, and renal disease patients.


Patients in HHS aren't producing enough insulin to counteract the hyperglycemia, so insulin must be administered.

Treat Underlying Disorder
Treat-pill Underlying-roots

Treat the underlying cause of HHS. Possible precipitating factors of HHS include burns, severe diarrhea, medications, uncontrolled diabetes, or myocardial infarction.


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