Hyperosmolar hyperglycemic state is a life-threatening emergency manifested by marked elevation of
blood glucose, hyperosmolarity, and little or no
ketosis. With the dramatic increase in the prevalence of
type 2 diabetes and the aging population, this condition may be encountered more frequently by family physicians in the future. Although the precipitating causes are numerous, underlying
infections are the most common. Other causes include certain medications, non-compliance, undiagnosed diabetes,
substance abuse, and coexisting disease. Physical findings of
hyperosmolar hyperglycemic state include those associated with profound
dehydration and various
neurologic symptoms such as
coma. The first step of treatment involves careful monitoring of the patient and laboratory values. Vigorous correction of
dehydration with the use of
normal saline is critical, requiring an average of 9 L in 48 hours. After urine output has been established,
potassium replacement should begin. Once fluid replacement has been initiated,
insulin should be given as an initial bolus of 0.15 U per kg intravenously, followed by a drip of 0.1 U per kg per hour until the
blood glucose level falls to between 250 and 300 mg per dL. Identification and treatment of the underlying and precipitating causes are necessary. It is important to monitor the patient for complications such as vascular occlusions (e.g., mesenteric artery occlusion,
myocardial infarction, low-flow syndrome, and disseminated intravascular coagulopathy) and
rhabdomyolysis. Finally, physicians should focus on preventing future episodes using patient education and instruction in self-monitoring.