eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic

Hyperosmolar Hyperglycemic State: Follow-up

Author: Paulina B Sergot, MD, Staff Physician, Department of Emergency Medicine, New York University/Bellevue Hospital Center
Coauthor(s): Lewis S Nelson, MD, FACEP, FACMT, FAACT, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Attending Physician, Department of Emergency Medicine, Bellevue Hospital Center, New York University Medical Center and New York Harbor Healthcare System
Contributor Information and Disclosures

Updated: Oct 28, 2009

Follow-up

Further Inpatient Care

  • Continued management of the fluid, electrolyte, and glucose disturbances is necessary until these have resolved.
  • Diabetic teaching is necessary to prevent recurrence.

Further Outpatient Care

  • Primary care follow-up is necessary for additional diabetic teaching and any appropriate immunizations.
  • Visiting home nurse referral may be necessary to enhance compliance.

Inpatient & Outpatient Medications

  • Adjust insulin or oral hypoglycemic therapy on the basis of the patient's insulin requirement once serum glucose level has been relatively stabilized.

Transfer

  • Transfer to appropriate level of care if the patient is critically ill.

Deterrence/Prevention

  • Diabetic teaching, both in the hospital and after discharge, by the primary care physician and/or a visiting home nurse, is essential to modify behavior and enhance compliance.
  • A home evaluation by a visiting nurse may be useful to identify factors limiting adequate access to water.

Complications

Prognosis

  • The overall mortality rate is between 10% and 20% and is dependent on coexisting conditions and complications.2,3

Miscellaneous

Medicolegal Pitfalls

  • Failure to manage the airway with endotracheal intubation when necessary
  • Failure to provide adequate fluid resuscitation (leading to shock)
  • Cerebral edema (more common in children) secondary to overly rapid hydration (especially with hypotonic fluids) or failure to add glucose to fluids when the level falls to less than 250 mg/dL
  • Hypoglycemia due to excessive insulin use without the initiation of glucose-containing fluids
  • Failure to replete potassium in patients who have a total body potassium deficit but an initially normal serum potassium level (On the other hand, administration of intravenous potassium has been associated with significant morbidity and death, especially with iatrogenic errors.)
  • Failure to treat empirically and early with broad-spectrum antibiotics when sepsis appears to be a possible precipitant
 


More on Hyperosmolar Hyperglycemic State

Overview: Hyperosmolar Hyperglycemic State
Differential Diagnoses & Workup: Hyperosmolar Hyperglycemic State
Treatment & Medication: Hyperosmolar Hyperglycemic State
Follow-up: Hyperosmolar Hyperglycemic State
References
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References

  1. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care. Jan 2001;24(1):131-53. [Medline].

  2. Nugent BW. Hyperosmolar hyperglycemic state. Emerg Med Clin North Am. Aug 2005;23(3):629-48, vii. [Medline].

  3. Trence DL, Hirsch IB. Hyperglycemic crises in diabetes mellitus type 2. Endocrinol Metab Clin North Am. Dec 2001;30(4):817-31. [Medline].

  4. Kershaw MJ, Newton T, Barrett TG, Berry K, Kirk J. Childhood diabetes presenting with hyperosmolar dehydration but without ketoacidosis: a report of three cases. Diabet Med. May 2005;22(5):645-7. [Medline].

  5. Bhowmick SK, Levens KL, Rettig KR. Hyperosmolar hyperglycemic crisis: an acute life-threatening event in children and adolescents with type 2 diabetes mellitus. Endocr Pract. Jan-Feb 2005;11(1):23-9. [Medline].

  6. Middleton P, Kelly AM, Brown J, Robertson M. Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate. Emerg Med J. Aug 2006;23(8):622-4. [Medline].

  7. [Guideline] Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Hyperglycemic crises in diabetes. Diabetes Care. Jan 2004;27 Suppl 1:S94-102. [Medline]. [Full Text].

  8. Keenan CR, Murin S, White RH. High risk for venous thromboembolism in diabetics with hyperosmolar state: comparison with other acute medical illnesses. J Thromb Haemost. Jun 2007;5(6):1185-90. [Medline].

  9. Rosa EC, Lopes AC, Liberatori Filho AW, et al. Rhabdomyolysis due to hyperosmolarity leading to acute renal failure. Ren Fail. Mar 1997;19(2):295-301. [Medline].

  10. Kitabchi AE, Murphy MB, Spencer J, Matteri R, Karas J. Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis?. Diabetes Care. Nov 2008;31(11):2081-5. [Medline].

  11. Kitabchi AE, Nyenwe EA. Hyperglycemic crises in diabetes mellitus: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Endocrinol Metab Clin North Am. Dec 2006;35(4):725-51, viii. [Medline].

  12. Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. Dec 2006;29(12):2739-48. [Medline].

  13. MacIsaac RJ, Lee LY, McNeil KJ, et al. Influence of age on the presentation and outcome of acidotic and hyperosmolar diabetic emergencies. Intern Med J. Aug 2002;32(8):379-85. [Medline].

  14. Singhi SC. Hyperglycemic hyperosmolar state and type 2 diabetes mellitus: yet another danger of childhood obesity. Pediatr Crit Care Med. Jan 2005;6(1):86-7. [Medline].

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Further Reading

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Keywords

hyperglycemic hyperosmolar nonketotic coma, hyperosmolar hyperglycemic state, hyperglycemic, diabetic coma, hyperosmolar coma, diabetic nonketotic coma, hyperosmolar nonketotic state, diabetic hyperosmolarity, diabetes, hyperglycemia, diabetic ketoacidosis, DKA, adult-onset diabetes

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Contributor Information and Disclosures

Author

Paulina B Sergot, MD, Staff Physician, Department of Emergency Medicine, New York University/Bellevue Hospital Center
Paulina B Sergot, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Lewis S Nelson, MD, FACEP, FACMT, FAACT, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Attending Physician, Department of Emergency Medicine, Bellevue Hospital Center, New York University Medical Center and New York Harbor Healthcare System
Lewis S Nelson, MD, FACEP, FACMT, FAACT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, and American College of Medical Toxicology
Disclosure: Nothing to disclose.

Medical Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard A Bessen, MD, Professor of Medicine, Department of Emergency Medicine, UCLA School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

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