Snapshot A 65-year-old woman with a past medical history significant for type 2 diabetes, glaucoma, and psoriasis presents to the emergency room for altered mental status. For the past few days, she has had increasing cough followed by polyuria, weakness, and fatigue. She has had a few tactile fevers at home. On physical exam, she is febrile and tachycardic. Her skin turgor is poor and she has dry mucous membranes. She is alert and oriented only to self, a change from her baseline. Laboratory results are significant for an elevated serum glucose of 730 mg/dL. Arterial blood gas shows a normal pH. No ketones are detected in the serum. Chest radiograph shows a new right lower lobe infiltrate. She is given a bolus of fluids and admitted to the intensive care unit for further management. Introduction Clinical definition hyperosmolar hyperglycemic state (HHS) is also known as nonketotic hyperglycemic coma a complication of diabetes mellitus characterized by hyperglycemia ↑ osmolality dehydration minimal or no ketoacidosis Associated conditions type 2 diabetes Epidemiology Demographics patients with type 2 diabetes insulin resistance + increased serum insulin levels beta cell burnout in the long run etiology Medication noncompliance Acute medical illness myocardial infarction stroke pancreatitis infection Pathogenesis hyperglycemia results in osmotic diuresis dehydration and electrolyte loss increased intravascular osmolarity impaired renal function increased proinflammatory cytokines Presentation Symptoms symptoms develop over days with gradual onset polyuria polydipsia weight loss weakness and fatigue mental status changes dehydration may present with shock blurry vision from lens swelling secondary to osmotic pressure Studies Diagnostic testing studies ↑ blood glucose small or absent ketones (β-hydroxybutyrate) serum osmolality > 320 mOsm/kg pH > 7.3 serum bicarbonate > 15-18 mmol/L may have ↑ lactate Differential Diabetic ketoacidosis distinguishing factors often occurs in patients with type 1 diabetes patients are acidotic and with ketones more often presents with nausea, vomiting, and abdominal pain DIAGNOSIS Diagnostic criteria ↑ glucose-induced stupor/coma without ketonemia or acidosis Treatment Management approach mainstay of treatment is to normalize osmolality, normalize serum glucose, and replete fluids/electrolytes First-line intravenous fluid resuscitation replete electrolytes especially potassium with goal of 4-5 mEq/L intravenous insulin after fluid resuscitation Complications Thrombosis