Please register or login to view the chart

Hyperosmolar hyperglycemic syndrome ( HHS )

HYPEROSMOLAR HYPERGLYCEMIC SYNDROME ( HHS ) complication of diabetes ( type 2 diabetes in 90 % to 95 % of cases ) previously know by other names as non-ketotic hyperglycemic coma , hyperosmolar hyperglycemic non ketotic syndrome and hyperosmolar non-ketotic coma ( HONK ) Main features related to HHS are severe hyperglycemia ( e.g bl glucose > 30 mmol / L ) , high serum osmolality and extreme dehydration in the absence of ketoacidosis


Presentation – usually has a slower onset than DKA , develops over several days or weeks can be precipitated by infectious diseases , disorders of the respiratory , circulatory and genitourinary systems presentation can be with fatigue ( glucose cannot be utilized for energy ) , polyuria , polydipsia , weakness , blurred vision altered level of consciousness to confused , lethargic or comatose usually develops in the elderly mortality rates of 8 % to 20 % ( about 10 times higher than DKA patients )


Enquire – ask about insulin regimen ,compliance , missed doses infection is the most common precipitant ( particularly pneumonia & UTI ) over consumption of carbohydrate rich food chest pain , tightness , headache , dizziness , palpitations conditions as stroke , MI , trauma –> lead to counterregulatory hormone secretion and limit access to water bed ridden patient ( cannot access water , altered thirst response ) use of medications as glucocorticoid , thiazide diuretics , phenytoin , beta blockers , atypical antipsychotics


Check – raised blood sugar ( check capillary blood glucose & urinary ketones ) BP , pulse , respiratory rate signs/ symptoms of dehydration capillary refill , skin turgor, tenting sign ( pinch the skin & it stands
like a tent ) urine output fever ( if infection present ) mental state ( confused , altered )


Insulin deficiency- reduced 
glucose utilization by peripheral 
tissue leading to hyperglycemia


Peripheral tissue enters in 
starvation state.

Release of counterregulatory hormones like glucagon , growth hormone , cortisol and catecholamines -leads to gluconeogenesis & glycogenolysis


Increased glucose levels ( due to increased gluconeogenesis , glycogenolysis & reduced use ) cause serum osmolarity to rise , glucose cannot be used for energy (fatigue , wt loss )


Water follows glucose ( glucose is an osmotically active solute )
 ie free water is drawn out of the extravascular space due to 
increased osmotic gradient


Kidneys cannot handle the glucose load hence free water with electrolytes are lost via urinary excretion -glycosuria , leading to dehydration ( osmotic diuresis )


Causes further concentration of solutes and intense thirst ( polydipsia )


Due to higher levels of insulin still being produced by beta cells ( type 2 diabetes ) ie higher ratio of 
insulin/ glucagon -the generation of ketone bodies is minimal ( no ketogenesis )


  1. Karslioglu French EDonihi A CKorytkowski M TDiabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients doi:10.1136/bmj.l1114 Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients | The BMJ
  2. Adeyinka A, Kondamudi NP. Hyperosmolar Hyperglycemic Nonketotic Coma. [Updated 2021 Nov 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
  3. Pasquel, Francisco J, and Guillermo E Umpierrez. “Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment.” Diabetes care vol. 37,11 (2014): 3124-31. doi:10.2337/dc14-0984 Hyperosmolar Hyperglycemic State: A Historic Review of the Clinical Presentation, Diagnosis, and Treatment (


Related Charts:

Add Your Comments

Your email address will not be published.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

A4 Medicine  - Search Less and Learn More

Welcome to the A4 medicine community where we are constantly working to provide exceptional educational material to primary health care professionals. Subscribe to our website for complete access to our A4 Charts. They are aesthetically designed charts that contain 300 (plus and adding) common and complex medical conditions with the all information required for primary care in one single page that can help you in consultation/practice and exam.

Additionally, you will get complete access for our Learn From Experts : A4 Webinar Series in which domain experts share the video explainer presentation on one medical condition in one hour for the primary care. And you will also get a hefty discount on our publications and upcoming digital products.

We are giving a lifetime flat 30% discount to our first thousand users, discount code already applied to checkout.