What is the diagnosis of Hyperosmolar Hyperglycemic State (HHS) based on glucose level?

From the Guidelines

The diagnosis of Hyperosmolar Hyperglycemic State (HHS) is typically based on a plasma glucose level greater than 600 mg/dL (33.3 mmol/L) 1. In addition to the high glucose level, other key diagnostic features of HHS include:

• Serum osmolality > 320 mOsm/kg
• Profound dehydration
• Absence of significant ketosis (serum ketones may be present but are usually mild)
• Altered mental status or neurological symptoms To diagnose and manage HHS effectively:

1. Obtain immediate laboratory tests including serum electrolytes, blood urea nitrogen, creatinine, and calculated serum osmolality.
2. Assess for precipitating factors such as infection, medication non-compliance, or acute illness.
3. Begin aggressive fluid resuscitation with normal saline.
4. Start insulin therapy, typically as an intravenous infusion at 0.1 units/kg/hour.
5. Monitor electrolytes closely, especially potassium, and replace as needed.
6. Correct any underlying precipitating factors. The extremely high glucose levels in HHS result from severe insulin deficiency or resistance, combined with increased counter-regulatory hormones, as noted in studies such as 1 and 1.

It's worth noting that while the glucose level is a key diagnostic criterion, it's not the only factor to consider, and other diagnostic features such as serum osmolality, dehydration, and altered mental status should also be taken into account, as highlighted in 1.

Overall, the diagnosis and management of HHS require a comprehensive approach that takes into account the patient's clinical presentation, laboratory results, and underlying medical conditions, with the goal of reducing morbidity, mortality, and improving quality of life.

From the Research

Diagnosis of Hyperosmolar Hyperglycemic State (HHS)

The diagnosis of HHS is based on several factors, including:

• Elevated glucose level: HHS is characterized by significantly increased levels of serum glucose 2, 3, 4, 5, 6
• Elevated serum osmolality: Hyperosmolarity is a key feature of HHS 2, 3, 4, 5, 6
• Minimal or absent ketones: HHS is distinguished from diabetic ketoacidosis by the absence of significant ketosis 2, 3, 4, 5, 6
• Neurologic abnormality: Altered mental status is a common presentation of HHS 2, 3, 4, 5, 6

Glucose Level in HHS

The glucose level in HHS is typically very high, with some studies suggesting that it can be above 600 mg/dL 5. The goal of treatment is to reduce the plasma glucose level by at least 75 to 100 mg per dL per hour 4. Insulin therapy is typically initiated once the patient's fluids and electrolytes have been repleted, with a target blood glucose level of between 250 and 300 mg per dL 5.

Key Points in HHS Diagnosis

Some key points to consider in the diagnosis of HHS include:

• Monitoring of serum osmolality and glucose levels 3
• Assessment of ketone levels to distinguish HHS from diabetic ketoacidosis 2, 3, 4, 5, 6
• Evaluation of neurologic status and mental alertness 2, 3, 4, 5, 6
• Identification and treatment of underlying and precipitating causes of HHS 5