The most dangerous emergency in diabetes: Are you aware of HHS? (Hyperosmolar Hyperglycemic State)

Do you have diabetes? Or does your mother, father, or someone else in your family have diabetes? Then this topic we are talking about today will be very important for you. Diabetes is a condition that can be managed properly, and you can live a normal life. However, if it is not properly controlled, it can lead to serious emergencies that can even be life-threatening. That is the most dangerous emergency we are talking about today. This is called Hyperosmolar Hyperglycemic State , which we call HHS for short.

Simply put, what is HHS?

Okay, let's put this very simply. Imagine that your blood sugar level (blood glucose) gets so high that it's impossible to control it. When your blood sugar level goes above 180 mg/dL, our kidneys have to excrete that excess sugar in the urine. But this sugar doesn't just come out on its own, it also takes with it the body's precious water.

Now, what happens if your blood sugar level goes to an extremely high level, like 600 mg/dL, and it stays that way for days, maybe weeks? You start to urinate excessively, and your body becomes severely dehydrated. As the amount of water in your body decreases, your blood gradually thickens. Just like when we make honey, water thickens. In medical terms, we call this thickening of the blood hyperosmolarity .

So, HHS is a life-threatening emergency that occurs when these three factors come together: very high blood sugar levels (hyperglycemia) , severe dehydration , and hyperosmolarity. This condition is mainly seen in people with Type 2 Diabetes. This is a condition that requires immediate hospitalization and treatment. If left untreated, it can even lead to death.

HHS and DKA: What's the difference between the two?

Another dangerous emergency that can occur in people with diabetes is DKA (Diabetic Ketoacidosis). While both HHS and DKA are life-threatening conditions caused by high blood sugar, there are clear differences between the two. It is important to know this difference.

• DKA (Diabetic Ketoacidosis): This mainly occurs in people with Type 1 Diabetes. What happens here is that the body has almost no insulin hormone. Because of the lack of insulin, the body's cells cannot use sugar to make energy. Then the body goes to another way to find energy. That is, by burning the fat in the body. When fat is burned in this way, a chemical substance called ketones is added to the blood as a byproduct. These ketones are an acid. When ketones increase in the blood, the blood becomes acidic. This is the most dangerous thing about DKA.

• HHS (Hyperosmolar Hyperglycemic State): This mainly occurs in people with type 2 diabetes. Here, there is a little insulin in the body. Due to that small amount of insulin, the body burns fat and prevents the formation of ketones. Therefore, in HHS, the blood does not become acidic. But the main problem here is the uncontrollable increase in sugar levels and the severe dehydration and thickening of the blood that occurs as a result.

Let's look at this table to further clarify this difference.

What are the symptoms of HHS? Watch out for these!

The most dangerous thing about HHS is that the symptoms don't appear all at once . They develop slowly, over days or weeks. So a person may not realize it until it's very serious. That's why it's important to be aware of these symptoms.

• Extremely high blood sugar level: A home glucose meter reading that is much higher than 600 mg/dL (or 33 mmol/L).
• Mental confusion: Loss of consciousness, inability to concentrate, confusion in speech, loss of time, place, and familiar people.
• Seeing or hearing things that are not there (Hallucinations): It can be said that you see or hear things that are not really there.
• Loss of consciousness: In severe cases, coma may occur.
• Dry mouth, tongue, and excessive thirst: A feeling of being thirsty that doesn't go away no matter how much water you drink.
• Frequent urination: Although you may urinate excessively at first, you may urinate less as dehydration becomes severe.
• Blurred vision or loss of vision: Vision may gradually become blurred.
• Body weakness: A feeling of weakness in the body. Sometimes one side of the body can become paralyzed, as if having a stroke.

Why does this HHS condition occur? What are the main causes?

A person with well-controlled diabetes is much less likely to develop HHS. However, in someone whose diabetes is not well-controlled, this condition can occur due to a "trigger." That is, an event can cause blood sugar levels to become uncontrollable, causing HHS.

The main triggers for HHS are:

• Infections: 50% to 60% of people who develop HHS have some form of infection. Pneumonia , urinary tract infections (UTI ), and sepsis are the most common infections. For example, an elderly mother with diabetes develops a chest infection that causes a lot of mucus. The stress caused by this infection can cause blood sugar levels to rise to levels that are too high to control.
• Not taking your diabetes medication as prescribed: This is also a very common reason. Some people get bored and stop taking their medication, or they don't take it on time. If you take insulin, if you don't take it properly, your blood sugar levels can get dangerously high.
• Other medications: Some medications, such as corticosteroids (used to treat asthma and arthritis), thiazide diuretics (used to treat high blood pressure), and some medications for mental illness, can also cause high blood sugar levels and cause HHS.
• Cardiovascular emergencies: In a serious event such as a stroke , heart attack , or pulmonary embolism , the body is under a lot of stress. The stress hormones released by the body at this time can cause blood sugar levels to rise suddenly.

Who is at higher risk of developing HHS?

As mentioned earlier, this risk is low if diabetes is well controlled. However, the following people are at higher risk of developing HHS:

• People who do not control diabetes well.
• Adults over 65: As they age, their ability to sense thirst may decrease, so they may not realize they are dehydrated.
• Those with other illnesses (infection, illness) or heart conditions.

What complications can occur due to HHS?

If HHS is not treated in time, it can lead to very serious complications.

• Seizures
• Coma
• Organ failure
• Death

Between 10% and 20% of people who develop HHS die. That means one or two out of every 10 people will die. That's how serious this condition is.

How is HHS diagnosed and treated in a hospital?

When you are admitted to the Emergency Department (ETU), a doctor will examine you and ask about your symptoms. Then, they will order several blood tests. These will check your blood sugar level , blood osmolality, kidney function, and whether there are ketones in your blood.

If the blood sugar level is much higher than 600 mg/dL and the blood ketone level is low, it is diagnosed as HHS.

The treatment involves keeping you in a ward or intensive care unit (ICU) and giving you IV fluids.

There are three main goals of treatment:

1. Rehydration: Saline is given intravenously to eliminate dehydration.

2. Balancing Electrolytes: With dehydration, a lot of valuable minerals like potassium are lost from the body. They are replaced through saline.

3. Controlling blood sugar levels: Insulin is given intravenously to slowly and controlledly lower blood sugar levels.

In addition to these treatments, if there is an underlying infection that caused the HHS condition, that is also treated.

Can complications occur during treatment?

Yes, although very rare, complications can occur from treatment. That is, if blood sugar levels are lowered suddenly and rapidly, brain cells can suddenly fill with water and the brain swells (cerebral edema). But this is very rare. Doctors know how to lower blood sugar levels safely and slowly. So there is no need to worry about it.

How to protect yourself from HHS?

The best and only way to avoid this dangerous situation is to manage your diabetes very well. To do this, be sure to do these things.

• Check your blood sugar levels regularly and try to keep them within the target range your doctor has given you.
• Take the medication (pills or insulin) prescribed by your doctor at the right time and in the right dosage, without missing a single day.
• If you are having difficulty controlling your diabetes, talk to your doctor about it and get the necessary advice.
• Follow a healthy diet that suits you.
• When you have an illness like a cold or flu, be extra careful. Drink plenty of water, get plenty of rest, and check your blood sugar more often than usual. This is because the stress on your body when you're sick can cause your blood sugar to rise.
• Be aware of the symptoms of HHS. If you notice any of these symptoms, take action immediately.