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Hyperosmolar Syndrome

Hyperosmolar Syndrome is a topic covered in the 5-Minute Emergency Consult.

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  • Results from a relative insulin deficiency in the undiagnosed or untreated diabetic
  • Sustained hyperglycemia creates an osmotic diuresis and dehydration:
    • Extracellular space maintained by the osmotic gradient at the expense of the intracellular space
    • Eventually profound intracellular dehydration occurs.
  • Total body deficits of H2O, Na+, Cl, K, PO4, Ca2+, and Mg2+
  • In contrast to diabetic ketoacidosis (DKA), severe ketoacidosis does not occur:
    • Circulating insulin levels are higher.
    • The elevation of insulin counter-regulatory hormones is less marked.
    • The hyperosmolar state itself inhibits lipolysis (the release of free fatty acids) and subsequent generation of keto acids

Geriatric Considerations
  • Most commonly seen in elderly type II diabetics who experience a stressful illness that precipitates worsening hyperglycemia and reduced renal function
  • In the elderly, 30–40% of cases are associated with the initial presentation of diabetes.

Pediatric Considerations
Hyperosmolar hyperglycemic states (HHS) rare in pediatric patients


  • Hyperosmolar state precipitated by factors that:
    • Impair peripheral insulin action
    • Increase endogenous or exogenous glucose
    • Decrease patient's ability to replace fluid loss
  • Infection is the most common precipitating factor in 32–60% of cases.
  • Other precipitating causes include:
    • Inadequate diabetes therapy
    • Medication omission
    • Diet indiscretion
    • Infections
    • Pneumonia
    • UTI
    • Sepsis
    • Medications/drugs
    • Diuretics
    • β-blockers
    • Calcium channel blockers
    • Phenytoin
    • Cimetidine
    • Amphetamines
    • Ethanol
    • Myocardial infarction
    • Stroke
    • Renal failure
    • Heat stroke
    • Pancreatitis
    • Intestinal obstruction
    • Endocrine disorders
    • Burns
    • Heat stroke

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Rosen, Peter, et al., editors. "Hyperosmolar Syndrome." 5-Minute Emergency Consult, 5th ed., Lippincott Williams & Wilkins, 2016. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307538/all/Hyperosmolar_Syndrome.
Hyperosmolar Syndrome. In: Rosen P, Shayne P, Barkin AZ, et al, eds. 5-Minute Emergency Consult. 5th ed. Lippincott Williams & Wilkins; 2016. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307538/all/Hyperosmolar_Syndrome. Accessed April 22, 2019.
Hyperosmolar Syndrome. (2016). In Rosen, P., Shayne, P., Barkin, A. Z., Wolfe, R. E., Hayden, S. R., Barkin, R. M., & Schaider, J. J. (Eds.), 5-Minute Emergency Consult. Available from https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307538/all/Hyperosmolar_Syndrome
Hyperosmolar Syndrome [Internet]. In: Rosen P, Shayne P, Barkin AZ, Wolfe RE, Hayden SR, Barkin RM, Schaider JJ, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2016. [cited 2019 April 22]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307538/all/Hyperosmolar_Syndrome.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Hyperosmolar Syndrome ID - 307538 ED - Rosen,Peter, ED - Shayne,Philip, ED - Barkin,Adam Z, ED - Wolfe,Richard E, ED - Hayden,Stephen R, ED - Barkin,Roger M, ED - Schaider,Jeffrey J, BT - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307538/all/Hyperosmolar_Syndrome PB - Lippincott Williams & Wilkins ET - 5 DB - Emergency Central DP - Unbound Medicine ER -