Hyperglycemic Hyperosmolar State Definition and Epidemiology

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The hyperosmolar hyperglycemic state (HHS) is also an acute complication that may occur in patients with diabetes mellitus. It is seen primarily in patients with T2DM and has previously been referred to as "hyperglycemic hyperosmolar non-ketotic coma" or "hyperglycemic hyperosmolar non-ketotic state" (13). HHS is marked by profound dehydration and hyper-glycemia and often by some degree of neurological impairment.

The term hyperglycemic hyperosmolar state is used because (1) ketosis may be present and (2) there may be varying degrees of altered sensorium besides coma (13). Like DKA, the basic underlying disorder is inadequate circulating insulin, but there is often enough insulin to inhibit free fatty acid mobilization and ketoacidosis. Figure 2 illustrates the differences in the underlying abnormalities seen in DKA and HHS.

Up to 20% of patients diagnosed with HHS do not have a previous history of diabetes mellitus (14). Population studies are lacking and therefore HHS incidence is difficult to determine. Kitabchi et al. estimated the rate of hospital admissions due to HHS to be lower than DKA, accounting for less than 1% of all primary diabetic admissions (13). Yet, HHS causes significant morbidity and mortality. Mortality rates near 15% (13, 61) and are even higher in patients who are substantially older or have concomitant life-threatening illnesses (13).

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