Hyperosmolar hyperglycemic state management in the emergency department

Abstract

Background: Hyperosmolar hyperglycemic state is an emergency condition characterized by a significant elevation in blood glucose and serum osmolality level with altered sensorium in the absence of significant ketoacidosis. It is commonly found in the elderly population with poorly controlled type 2 diabetes, but it can also be found in children and adolescents. Early recognition is crucial to establish the precipitating factor and to start proper management immediately. Objective: This literature review aims to provide an overview and pathogenesis of hyperosmolar hyperglycemic state and address the necessity of early recognition by the emergency physician and immediate management approach. Methodology: We searched for relevant articles on the topic in the PubMed database. Common Mesh terms were used: Hyperosmolar hyperglycemic state, emergency management, and complications. Conclusion: The backbone treatment restores the large water deficit and correct electrolyte imbalance induced by severe dehydration. Early identifying the precipitating factor is essential, but not to delay in management. Further instructions must be provided to avoid further attack as HHS has a high mortality rate that reaches 40%.

Diagnosis and Acute Management of Hyperglycemic Hyperosmolar Syndrome in Children and Adolescents

“…1,3 Hyperglycemia is worsened by a surge of counterregulatory hormones (eg, glucagon, cortisol, catecholamines), which induces glycogenolysis (breakdown of glycogen) and gluconeogenesis (glucose generation by noncarbohydrate sources), with catecholamine circulation also reducing glucose uptake by peripheral tissues. 1,3,5 This hyperglycemia results in extracellular hyperosmolality, which in turn creates an osmolar gradient that pulls water from cells. 5,7 Otherwise, healthy children can initially compensate for the hyperglycemia and fluid shifts through glucosuria, slowing the rise in serum glucose but leading to dehydration.…”

“…1,3,5 This hyperglycemia results in extracellular hyperosmolality, which in turn creates an osmolar gradient that pulls water from cells. 5,7 Otherwise, healthy children can initially compensate for the hyperglycemia and fluid shifts through glucosuria, slowing the rise in serum glucose but leading to dehydration. 1,5 Renal compensation and maintenance of intravascular volume can occur for days to weeks.…”

“…3,4 This increase is thought to be closely linked to increasing rates of childhood obesity and T2D, the prevalent consumption of sugar-rich beverages, and a spreading awareness of HHS presentations in children. 1,5 The increased incidence is also likely due to a renewed understanding that HHS can also affect T1D pediatric patients both with and without diabetic ketoacidosis (DKA). 5,6 Emergency medicine clinicians should be aware that HHS may be present in hyperglycemic children with varying body mass indices, racial and ethnic backgrounds, and known and undiagnosed T1D and T2D.…”

“…1,5 The increased incidence is also likely due to a renewed understanding that HHS can also affect T1D pediatric patients both with and without diabetic ketoacidosis (DKA). 5,6 Emergency medicine clinicians should be aware that HHS may be present in hyperglycemic children with varying body mass indices, racial and ethnic backgrounds, and known and undiagnosed T1D and T2D. 4,7,8 Hyperglycemic hyperosmolar syndrome can also occur following recent trauma, burns, dialysis, or the initiation of certain medications, even in children who do not have underlying diabetes.…”

“…1,3 Further contributors to hypovolemia, such as poor oral intake from developmental delay or feeding intolerance, will worsen the syndrome. 3,5,6 As T2D is the primary risk factor of HHS in children, medication and insulin noncompliance are also precipitators. 3 Some studies have reported increased HHS risk in children on atypical antipsychotic medications.…”