Which statement best describes hyperosmolar hyperglycemic state (HHS)?

• A. Profound ketosis and mild dehydration
• B. Profound dehydration, extreme hyperglycemia (>600 mg/dL), high serum osmolality, minimal/absent ketones; treat with aggressive IV fluids, then insulin after hemodynamic stability
• C. Rapid onset in children with lactic acidosis
• D. Ketosis with mild hyperglycemia and edema

Answer: (B)

Hyperosmolar hyperglycemic state occurs when there is severe hyperglycemia with profound dehydration and a very high serum osmolality, but little to no ketosis and no significant acidosis. The presence of enough insulin stops ketone production, but not enough to prevent extremely high glucose and osmotic diuresis, leading to massive fluid loss. The best description emphasizes extreme hyperglycemia (often >600 mg/dL), high osmolality, minimal or absent ketones, and a management approach that prioritizes aggressive intravenous fluids followed by insulin once the patient’s hemodynamics are stable.

This contrasts with conditions that feature marked ketosis and metabolic acidosis (as in diabetic ketoacidosis), or with scenarios not typical of HHS such as rapid onset in children with lactic acidosis, or ketosis with mild hyperglycemia and edema.