 Hi and welcome to Nursing School Explained. Today's topic is hyper or smaller hypoglycemic state or syndrome also called HHS. And this is usually a complication that happens to patients who are type 2 diabetics. Diabetics. Most likely the cause is going to be infection or stress. And type 2 diabetes, like I said, as well as elderly patients at higher risk. And it's usually gradual onset. So what happens physiologically? So there's increased levels of blood sugars in the body because of this infection that the patient is suffering from, which leads to increase in osmolarity. So their blood is more concentrated because of these elevated levels of blood glucose in their serum, which leads to dehydration but without ketoacidosis. So ketoacidosis is something that happens when there's a complete lack of insulin in type 1 diabetics, but in type 2 diabetics for the most part the beta cells of the pancreas still work to a certain degree where they still secrete some kind of insulin to prevent this ketoacidosis, which is basically breakdown of fatty acid stores to help with cellular metabolism when there's no increased source of glucose available. So in HHS we have osmolarity, dehydration, but no ketoacidosis because we have sufficient insulin available in the system to prevent ketone breakdown. Now patients will present with these three symptoms again, the three P's, polyuria, polydipsia and polyphasia. Lots of urination because the patient has all these increased levels of blood glucose circulating in their bloodstream. So the kidneys will try and get rid of these molecules. Polydipsia because the patient is very dehydrated, so now the thirst mechanism kicks in. And then polyphasia because we have the glucose that's circulating in the bloodstream, but is unable to be absorbed by the cells because there is a lack of insulin, but not quite to the extent that type 1's would have where they have absolutely no insulin available. Patients will be severely dehydrated, they might be nauseated or vomiting, and lots of times because we're dealing with the elderly population, the patient will come in with a chief complaint of altered level of consciousness. And then eventually during the workup it will be discovered that the patient is in HHS. And the altered level of consciousness can be so severe because the dehydration leads to electrolyte imbalances that the patient can suffer from seizures. Now diagnostic tests usually include the blood glucose level of more than 600. So that is a very very high blood glucose level as discussed over here causing this increase in osmolarity and the significant amount of dehydration that we'll see in these patients. Their osmolarity will be greater than 320, so again very concentrated serum because the patient is so significantly dehydrated. Along with that with the dehydration they'll be hypotensive and tachycardic. And then their pH is usually above 7.30 and their bicarb is greater than 18 which means that the patient is not in metabolic acidosis like patients in DKA would be. And they may have a small amount of ketone spilling in the urine that can be detected. So diagnosis sorry treatment for HHS includes isotonic IV fluid administration to treat the severe dehydration and increase in serum osmolarity the patient is suffering from. But because we're dealing with elderly patients we want to be extra careful to monitor them very closely when we do administer large amounts of isotonic fluids because some of these elderly patients might have comorbidity such as congestive heart failure, hypertension, underlying renal disorders and they might not tolerate large amounts of isotonic IV fluids over a short period of time because that can lead to fluid volume overload and then they will be exhibiting signs and symptoms such as pulmonary edema, crackles, peripheral edema, JVD all those things because their heart and kidneys are just not able to handle large amounts of fluids given over a short period of time. So certainly they will need isotonic IV fluids but at a much more controlled rate such as maybe 250 an hour over you know six to eight hours or whatever it is that the patient needs and then certainly they will need to be monitored very closely their labs will be needed to be monitored very closely blood sugar as well as serum osmolarity and then urine output and then patients in HHS they may or they may not need insulin depending on how their pancreatic function is they may need insulin in the IV or they may not and then certainly once the patient recovers from that from their altered level of consciousness whatever the infection or stressor was that caused the syndrome in the first place a lots of education will be needed to teach the patients what to watch out for so that they don't have this complication again of hyper osmotic hyperglycemic symptom syndrome. So in order to really understand HHS I also recommend you watching the video on type 1 and 2 diabetes and DKA diabetic ketoacidosis to grasp the difference between the two of you I hope between the two of them I hope you enjoyed this video I'll see you next time at nursing school explained