Critical Care Medicine-Endocrine Disorders>>>>>Diabetes Mellitus
Question 6#

An 85-year-old male is admitted to the ICU with urosepsis. His blood sugar is 720 mg/dL.

Which of the following is TRUE about hyperglycemic hyperosmolar state (HHS)?

A. Positive urine ketones means that this cannot be a HHS
B. Mortality in HHS is similar to mortality in DKA
C. His free water deficit is likely higher than a patient with DKA
D. Acidemia rules out a diagnosis of HHS

Correct Answer is C

Comment:

Correct Answer: C

Though HHS is usually associated with type 2 diabetes mellitus and older age, the pathophysiology is similar to that of DKA. However, unlike DKA, patients with HHS usually have enough insulin to prevent ketosis. It should be noted that there is a subpopulation of patients with type 2 diabetes that can present with ketosis.

Given its slower onset (over several days to several weeks), patients with HHS usually have greater free water and electrolyte deficits than patients with DKA due to more prolonged glycosuria and lack of hydration due to concomitant illness. This results in a hyperosmolar state with a serum osmolarity of >320 mmol/kg.

ADA guidelines for diagnosis of HHS include a glucose level of >600 mg/dL, pH >7.3, and bicarbonate level >20 mEq/L. Although HHS is usually not associated with a metabolic acidosis, acidosis may occur due to dehydration and lactate acidosis, concomitant illness (sepsis), or renal failure. 

Mortality in HHS ranges from 5% to 16%, which is 10 times higher than mortality in DKA. The higher mortality may reflect the precipitating factor and not hyperglycemia and concomitant metabolic disarray.

References:

Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in adult patient with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(12):2739-2748.

Milanesi A, Weinreb J. Hyperglycemic hyperosmolar state. In: DeGroot LJ, Chrousous G, Dungan K, et al. eds. Endotext. South Darmouth, MA: MDText.com, Inc. www.endotext.org. Accessed December 20, 2018.