Hyperosmolar Hyperglycemic Nonketotic State

What is hyperosmolar hyperglycemic nonketotic state?

Hyperosmolar hyperglycemic nonketotic state (HHNS) is a life-threatening emergency. It is caused by very high blood sugar (hyperglycemia). Without prompt treatment HHNS can be fatal.

How does it occur?

HHNS is most common in adults with type 2 diabetes. Having diabetes means that there is too much sugar (glucose) in your blood. Because type 2 diabetes can be a silent disease for many years, unless your blood sugar is checked, HHNS could happen before you know that you have diabetes.

Most people with HHNS have a blood sugar level over 600 milligrams per deciliter (mg/dL), or 33.3 millimoles per liter (mmol/L). This is several times higher than a normal blood sugar. Your kidneys try to get rid of the extra sugar by putting more sugar into the urine. This makes you urinate more and you lose too much fluid and become dehydrated. As you get sicker, it may get harder for you to drink more fluids to help treat this problem. With the high blood sugar and dehydration comes an imbalance of minerals, especially sodium and potassium. This imbalance can lead to problems with the brain and heart.

The two most common causes of HHNS are:

• not taking diabetes medicines as prescribed
• getting an infection.

If you have diabetes and have an infection, your blood sugar often rises above your usual levels. However, you may not know that you have an infection. Many types of infections have few or no symptoms, at least in the early stages. This is especially true for older adults. This is one reason why checking your blood sugar regularly at home is so important. If the infection and rising blood sugar levels are not detected and treated, they can lead to HHNS.

Examples of other possible causes of dangerously high blood sugars are:

• If you have diabetes and are taking a diuretic (water pill) for high blood pressure and not checking your blood sugar regularly, your blood sugar can get high over time.
• If you are depressed or you are older and getting forgetful, you may forget to take your medicine or to check your blood sugar.
• Drug or alcohol abuse can increase your risk of HHNS.

What are the symptoms?

The most common early symptoms are:

• tiredness
• blurry vision
• dry mouth
• confusion, especially in older adults.

Other possible symptoms are:

• muscle cramps
• fever.

Eventually there is a loss of mental function, starting with confusion and disorientation. This can worsen to seizures and coma. When HHNS causes a coma, it is called hyperosmolar nonketotic diabetic coma.

How is it diagnosed?

Your medical history is very important. However, in the case of an emergency, the most important information for diagnosis comes from blood tests. There are also special tests to check the concentration (thickness) of the blood.

Tests will be done to look for infection that might have caused the HHNS. Blood cultures, urine cultures, and a chest X-ray are the usual first tests for infection.

How is it treated?

The first emergency treatment is intravenous (IV) fluids so that your body has more fluid and your sodium and potassium levels can be brought back to normal. You are also given continuous insulin in a vein to bring the blood sugar down. When you have HHNS, you need to be closely checked for brain swelling, kidney failure, and other serious problems. This usually means you need to be stay at the hospital for at least the first day or two.

Once the emergency phase has passed, treatment will continue for any infection or other medical problems that might have caused the HHNS.

How long will the effects last?

How long it takes to recover from HHNS depends on how healthy you are to begin with and how bad the complications are.

HHNS can cause severe dehydration. Severe dehydration can cause blood clots anywhere in the body. If you have a blood clot in the brain, you may have a stroke. A blood clot in the heart can cause a heart attack. If you develop blood clots in the intestines, you will need surgery. Recovery from these kinds of problems can take weeks to months.

An otherwise healthy person with no medical problems other than diabetes and no HHNS complications may take only a few days to recover. A person with other medical problems or HHNS complications can take much longer to recover.

Some complications may be permanent. If your kidneys fail, you may need to start having dialysis. Brain swelling can cause permanent loss of mental abilities, seizures, or death.

How can I take care of myself?

It is very important for you to learn or relearn how to care for diabetes, including:

• taking all medicines as prescribed
• checking blood sugars as often as recommended by your healthcare provider
• keeping regular appointments with your provider

Call your healthcare provider right away if:

• Your blood sugars start going up for no obvious reason and don’t come down when you take your medicine.
• You have symptoms of infection.

What can I do to prevent HHNS?

The best way to prevent HHNS is to:

• Take your diabetes medicines exactly as prescribed.
• Talk with your healthcare provider if you have questions about your care.
• Use your home glucose monitor to check your blood sugar as often as your provider recommends.
• Keep your regular appointments with your provider (usually every 3 months).
• Ask your provider when you should call about high blood sugar, for example, a blood sugar over 240, or about 13 millimoles per liter (mmol/L).
• Report any symptoms of infection, such as fever, a cough, or cloudy urine right away to your provider.
• Check your blood sugar every 4 hours when you are sick. Work with your healthcare provider to develop a sick-day plan.

For more information on diabetes, contact the:

• American Diabetes Association
  Phone: 800-DIABETES, or 800-342-2383
  Web site: http://www.diabetes.org.