What You Should Know About Hyperosmolar Hyperglycemic State (HHS)

Many of the things about DKA apply to HHS. The first H stands for hyperosmolar and is a technical way of saying that all of the chemicals contained in blood are now dissolved in much less water. Because of this, water is drawn into the blood from the body cells so that the patient is very dehydrated. The blood may become so thick that it clots easily, which can cause strokes and heart attacks.


Hyperglycemic (the second H) means that BG levels are too high. HHS has a higher average blood glucose (900 mg/dl or higher) than DKA. BG can go higher for several reasons. HHS develops more slowly and gradually. The thirsty patient seems to prefer sweet liquids with higher carbohydrate content. The function of the kidneys is more greatly reduced because the patient becomes more dehydrated. And the patient or caregivers ignore or mistake the symptoms for something else and wait too long to see the health care team. By the time they do, the loss of salt and especially of plain water from the body can be enormous.


Ketoacids are not produced in HHS and do not build up in the blood. The reason may be that these patients have type 2 diabetes. They still make a small amount of insulin. The lack of high acid levels in the blood is a reason for the long delay in getting care: you are not alerted by nausea and vomiting that something is very wrong. HHS more often leads to coma (a state of unconsciousness) than does DKA. It is more life threatening and harder to reverse.


Who Is At Risk Of Developing HHS?


The typical patient is an elderly person, who is often living alone or in a nursing home and may be unaware that she even has type 2 diabetes. A heart attack or an infection that has spread into the bloodstream from a site such as the urinary tract or a foot ulcer may start the process. Certain drugs can contribute to a steep rise in BG, too. Examples are prednisone or other steroids, diuretics such as hydrochlorothiazide, and anticonvulsant medication such as dilantin.


What Are The Symptoms Of HHS?


You are usually more dehydrated – literally dried out – with prunelike wrinkled skin. You are more likely to be in shock; that is, to have very low blood pressure with poor blood flow to many organs. Coma is much more frequent. The brain may be so affected by the dehydration that seizures, paralysis, and other neurological problems can occur. Many patients seem to have had a stroke; yet with complete treatment, the abnormal neurological signs can disappear completely. It may take several days. HHS is a more serious acute complication of diabetes than is DKA, and the chances of recovering from it are not as good, even with correct treatment.


What Is The Treatment For HHS?


Usually only small amounts of insulin are required. HHS patients need emergency fluid flowing to their tissues to get them out of shock and to restore normal blood flow to the heart, brain, kidneys, liver, and limbs. Because elderly patients with type 2 diabetes usually have atherosclerosis, improving blood flow and oxygen delivery quickly is vital to prevent complete blockage of one of these narrowed major arteries. A blockage can cause a heart attack, stroke, or kidney failure.