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Hyperosmolar hyperglycemic state
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<h2 id="signs-and-symptoms">Signs and symptoms</h2> <p>Symptoms of <a href="/facts/Hyperglycemia/HM8eNqfX">high blood sugar</a> including <a href="/facts/Polydipsia/aYTYCDDb">increased thirst</a> (polydipsia), <a href="/facts/Polyuria/KIJNqUu9">increased volume of urination</a> (polyuria), and increased hunger (<a href="/facts/Polyphagia/F9hf1wRU">polyphagia</a>).<a class="footnote-ref" id="fnref:22" href="#fn:22"><sup>22</sup></a> </p><p>Symptoms of HHS include: </p> <ul><li>Altered level of consciousness</li> <li>Neurologic signs including: blurred vision, headaches, focal seizures, <a href="/facts/Myoclonus/Xkax4g4w">myoclonic jerking</a>, reversible paralysis<a class="footnote-ref" id="fnref:23" href="#fn:23"><sup>23</sup></a></li> <li>Motor abnormalities including flaccidity, depressed reflexes, tremors or fasciculations</li> <li><a href="/facts/Hyperviscosity_syndrome/tGvU7DIT">Hyperviscosity</a> and increased risk of <a href="/facts/Thrombosis/8Y3wh2UX">blood clot formation</a></li> <li>Dehydration<a class="footnote-ref" id="fnref:24" href="#fn:24"><sup>24</sup></a></li> <li>Weight loss<a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a></li> <li>Nausea, vomiting, and abdominal pain<a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a></li> <li>Weakness<a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a></li> <li><a href="/facts/Orthostatic_hypotension/pkeTyF8w">Low blood pressure with standing</a><a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a></li></ul> <h2 id="cause">Cause</h2> <p>The main risk factor is a history of <a href="/facts/Diabetes_mellitus_type_2/zCMXksmt">diabetes mellitus type 2</a>.<a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a> Occasionally it may occur in those without a prior history of diabetes or those with <a href="/facts/Diabetes_mellitus_type_1/IkuQadGx">diabetes mellitus type 1</a>.<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a><a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> Triggers include <a href="/facts/Infection/182XrncP">infections</a>, <a href="/facts/Stroke/DwpjdzY0">stroke</a>, <a href="/facts/Major_trauma/vAIyyy22">trauma</a>, certain medications, and <a href="/facts/Myocardial_infarction/xoGw0qcG">heart attacks</a>.<a class="footnote-ref" id="fnref:32" href="#fn:32"><sup>32</sup></a> </p><p>Other risk factors: </p> <ul><li>Lack of sufficient insulin (but enough to prevent ketosis)<a class="footnote-ref" id="fnref:33" href="#fn:33"><sup>33</sup></a></li> <li>Poor kidney function<a class="footnote-ref" id="fnref:34" href="#fn:34"><sup>34</sup></a></li> <li>Poor fluid intake (dehydration)<a class="footnote-ref" id="fnref:35" href="#fn:35"><sup>35</sup></a></li> <li>Older age (50–70 years)<a class="footnote-ref" id="fnref:36" href="#fn:36"><sup>36</sup></a></li> <li>Certain medical conditions (<a href="/facts/Stroke/DwpjdzY0">cerebral vascular injury</a>, <a href="/facts/Myocardial_infarction/xoGw0qcG">myocardial infarction</a>, <a href="/facts/Sepsis/n52bkffJ">sepsis</a>)<a class="footnote-ref" id="fnref:37" href="#fn:37"><sup>37</sup></a></li> <li>Certain medications (<a href="/facts/Glucocorticoid/2P91Aj3S">glucocorticoids</a>, <a href="/facts/Beta-blocker/PRsWgpLV">beta-blockers</a>, <a href="/facts/Thiazide_diuretic/y0xU4l4F">thiazide diuretics</a>, <a href="/facts/Calcium_channel_blocker/st91pD2K">calcium channel blockers</a>, and <a href="/facts/Phenytoin/uFvxbwf2">phenytoin</a>)<a class="footnote-ref" id="fnref:38" href="#fn:38"><sup>38</sup></a></li></ul> <h2 id="pathophysiology">Pathophysiology</h2> <p>HHS is usually precipitated by an infection,<a class="footnote-ref" id="fnref:39" href="#fn:39"><sup>39</sup></a> <a href="/facts/Myocardial_infarction/xoGw0qcG">myocardial infarction</a>, <a href="/facts/Stroke/DwpjdzY0">stroke</a> or another acute illness. A relative insulin deficiency leads to a serum <a href="/facts/Glucose/oUSkoLCD">glucose</a> that is usually higher than 33 mmol/L (600 mg/dL), and a resulting serum <a href="/facts/Osmolarity/tgtkKAuk">osmolarity</a> that is greater than 320 mOsm. This leads to <a href="/facts/Polyuria/KIJNqUu9">excessive urination</a> (more specifically an <a href="/facts/Osmotic_diuresis/oWIcAEcN">osmotic diuresis</a>), which, in turn, leads to volume depletion and hemoconcentration that causes a further increase in blood glucose level. <a href="/facts/Ketosis/GIzSt3mL">Ketosis</a> is absent because the presence of some <a href="/facts/Insulin/oXG0myt1">insulin</a> inhibits <a href="/facts/Hormone-sensitive_lipase/uB2notDP">hormone-sensitive lipase</a>-mediated <a href="/facts/Lipolysis/wuQwM0nb">fat tissue breakdown</a>. </p> <h2 id="diagnosis">Diagnosis</h2> <h3>Criteria</h3> <p>According to the <a href="/facts/American_Diabetes_Association/3QzcRSwA">American Diabetes Association</a>, diagnostic features include:<a class="footnote-ref" id="fnref:40" href="#fn:40"><sup>40</sup></a><a class="footnote-ref" id="fnref:41" href="#fn:41"><sup>41</sup></a> </p> <ul><li>Plasma glucose level >30 mmol/L (>600 mg/dL)</li> <li>Serum osmolality >320 mOsm/kg</li> <li>Profound dehydration, up to an average of 9L (and therefore substantial thirst (<a href="/facts/Polydipsia/aYTYCDDb">polydipsia</a>))</li> <li>Serum pH >7.30<a class="footnote-ref" id="fnref:42" href="#fn:42"><sup>42</sup></a></li> <li>Bicarbonate >15 mEq/L</li> <li>Small ketonuria (~+ on dipstick) and absent-to-low ketonemia (<3 mmol/L)</li> <li>Some alteration in consciousness</li> <li>BUN > 30 mg/dL (increased)<a class="footnote-ref" id="fnref:43" href="#fn:43"><sup>43</sup></a></li> <li>Creatinine > 1.5 mg/dL (increased)<a class="footnote-ref" id="fnref:44" href="#fn:44"><sup>44</sup></a></li></ul> <h3>Imaging</h3> <p>Cranial imaging is not used for diagnosis of this condition. However, if an <a href="/facts/Magnetic_resonance_imaging/Vh9yG9qq">MRI</a> is performed, it may show cortical restricted diffusion with unusual characteristics of reversible T2 hypointensity in the subcortical white matter.<a class="footnote-ref" id="fnref:45" href="#fn:45"><sup>45</sup></a> </p> <h3>Differential diagnosis</h3> <p>The major differential diagnosis is <a href="/facts/Diabetic_ketoacidosis/QhhbSbeM">diabetic ketoacidosis</a> (DKA). In contrast to DKA, serum glucose levels in HHS are extremely high, usually greater than 40-50 mmol/L (600 mg/dL).<a class="footnote-ref" id="fnref:46" href="#fn:46"><sup>46</sup></a> <a href="/facts/Metabolic_acidosis/sSKCKBHA">Metabolic acidosis</a> is absent or mild.<a class="footnote-ref" id="fnref:47" href="#fn:47"><sup>47</sup></a> <a href="/facts/Delirium/f1zdzAc5">A temporary state of confusion (delirium)</a> is also more common in HHS than DKA. HHS also tends to affect older people more. DKA may have fruity breath, and rapid and deep breathing.<a class="footnote-ref" id="fnref:48" href="#fn:48"><sup>48</sup></a> </p><p>DKA often has serum glucose level greater than 300 mg/dL (HHS is >600 mg/dL).<a class="footnote-ref" id="fnref:49" href="#fn:49"><sup>49</sup></a> DKA usually occurs in type 1 diabetics whereas HHS is more common in type 2 diabetics.<a class="footnote-ref" id="fnref:50" href="#fn:50"><sup>50</sup></a> DKA is characterized by a rapid onset, and HHS occurs gradually over a few days.<a class="footnote-ref" id="fnref:51" href="#fn:51"><sup>51</sup></a> DKA also is characterized by ketosis due to the breakdown of fat for energy.<a class="footnote-ref" id="fnref:52" href="#fn:52"><sup>52</sup></a> </p><p>Both DKA and HHS may show symptoms of dehydration, increased thirst, increased urination, increased hunger, weight loss, nausea, vomiting, abdominal pain, blurred vision, headaches, weakness, and low blood pressure with standing.<a class="footnote-ref" id="fnref:53" href="#fn:53"><sup>53</sup></a> </p> <h2 id="management">Management</h2> <h3>Phases and timelines</h3> <p>The <a href="https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group">JBDS</a> HHS care pathway<a class="footnote-ref" id="fnref:54" href="#fn:54"><sup>54</sup></a> comprises 3 main themes to consider when managing a patient with HHS: </p> <ul><li>clinical assessment and monitoring</li> <li>interventions</li> <li>assessments and prevention of harm</li></ul> <p>To streamline management, there are 5 phases of therapy from the time of recognition of the condition to resolution: </p> <ol><li>0–60 min</li> <li>1–6 hours</li> <li>6–12 hours</li> <li>12–24 hours</li> <li>24–72 hours<a class="footnote-ref" id="fnref:55" href="#fn:55"><sup>55</sup></a></li></ol> <h3>Intravenous fluids</h3> <p>Treatment of HHS begins with reestablishing tissue perfusion using intravenous fluids. People with HHS can be dehydrated by 8 to 12 liters. Attempts to correct this usually take place over 24 hours with initial rates of <a href="/facts/Saline_(medicine)/wNMLPtho">normal saline</a> often in the range of 1 L/h for the first few hours or until the condition stabilizes.<a class="footnote-ref" id="fnref:56" href="#fn:56"><sup>56</sup></a> </p> <h3>Electrolyte replacement</h3> <p><a href="/facts/Potassium/FWPwS7Rj">Potassium</a> replacement is often required as the metabolic problems are corrected.<a class="footnote-ref" id="fnref:57" href="#fn:57"><sup>57</sup></a> It is generally replaced at a rate 10 mEq per hour as long as there is adequate urinary output.<a class="footnote-ref" id="fnref:58" href="#fn:58"><sup>58</sup></a> </p> <h3>Insulin</h3> <p>Insulin is given to reduce blood glucose concentration; however, as it also causes the movement of potassium into cells, serum potassium levels must be sufficiently high or dangerously <a href="/facts/Hypokalemia/XvS1S7s6">low blood potassium</a> levels may result. Once potassium levels have been verified to be greater than 3.3 mEq/L, then an insulin infusion of 0.1 units/kg/hr is started.<a class="footnote-ref" id="fnref:59" href="#fn:59"><sup>59</sup></a> The goal for resolution is a blood glucose of less than 200 mg/dL.<a class="footnote-ref" id="fnref:60" href="#fn:60"><sup>60</sup></a> </p> <h2 id="external-links">External links</h2> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>Page, Piers; Skinner, Greg (17 January 2008). Emergencies in Clinical Medicine. OUP Oxford. pp. 224–225. ISBN 978-0-19-920252-2. <a href="978-0-19-920252-2" target="_blank">978-0-19-920252-2</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>Stoner, GD (1 May 2005). "Hyperosmolar hyperglycemic state". American Family Physician. 71 (9): 1723–30. PMID 15887451. <a href="/wiki/PMID_(identifier)" target="_blank">/wiki/PMID_(identifier)</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Frank, LA; Solomon, A (2 September 2016). "Hyperglycaemic hyperosmolar state". British Journal of Hospital Medicine. 77 (9): C130-3. doi:10.12968/hmed.2016.77.9.C130. PMID 27640667. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Stoner, GD (1 May 2005). "Hyperosmolar hyperglycemic state". American Family Physician. 71 (9): 1723–30. PMID 15887451. <a href="/wiki/PMID_(identifier)" target="_blank">/wiki/PMID_(identifier)</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>Frank, LA; Solomon, A (2 September 2016). "Hyperglycaemic hyperosmolar state". British Journal of Hospital Medicine. 77 (9): C130-3. doi:10.12968/hmed.2016.77.9.C130. PMID 27640667. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>Stoner, GD (1 May 2005). "Hyperosmolar hyperglycemic state". American Family Physician. 71 (9): 1723–30. PMID 15887451. <a href="/wiki/PMID_(identifier)" target="_blank">/wiki/PMID_(identifier)</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> <li id="fn:11"><p>Frank, LA; Solomon, A (2 September 2016). "Hyperglycaemic hyperosmolar state". British Journal of Hospital Medicine. 77 (9): C130-3. doi:10.12968/hmed.2016.77.9.C130. PMID 27640667. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:11" class="footnote-back-ref">↩</a></p></li> <li id="fn:12"><p>Frank, LA; Solomon, A (2 September 2016). "Hyperglycaemic hyperosmolar state". British Journal of Hospital Medicine. 77 (9): C130-3. doi:10.12968/hmed.2016.77.9.C130. PMID 27640667. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:12" class="footnote-back-ref">↩</a></p></li> <li id="fn:13"><p>Frank, LA; Solomon, A (2 September 2016). "Hyperglycaemic hyperosmolar state". British Journal of Hospital Medicine. 77 (9): C130-3. doi:10.12968/hmed.2016.77.9.C130. PMID 27640667. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:13" class="footnote-back-ref">↩</a></p></li> <li id="fn:14"><p>Frank, LA; Solomon, A (2 September 2016). "Hyperglycaemic hyperosmolar state". British Journal of Hospital Medicine. 77 (9): C130-3. doi:10.12968/hmed.2016.77.9.C130. PMID 27640667. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:14" class="footnote-back-ref">↩</a></p></li> <li id="fn:15"><p>Frank, LA; Solomon, A (2 September 2016). "Hyperglycaemic hyperosmolar state". British Journal of Hospital Medicine. 77 (9): C130-3. doi:10.12968/hmed.2016.77.9.C130. PMID 27640667. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:15" class="footnote-back-ref">↩</a></p></li> <li id="fn:16"><p>Frank, LA; Solomon, A (2 September 2016). "Hyperglycaemic hyperosmolar state". British Journal of Hospital Medicine. 77 (9): C130-3. doi:10.12968/hmed.2016.77.9.C130. PMID 27640667. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:16" class="footnote-back-ref">↩</a></p></li> <li id="fn:17"><p>Stoner, GD (1 May 2005). "Hyperosmolar hyperglycemic state". American Family Physician. 71 (9): 1723–30. PMID 15887451. <a href="/wiki/PMID_(identifier)" target="_blank">/wiki/PMID_(identifier)</a> <a href="#fnref:17" class="footnote-back-ref">↩</a></p></li> <li id="fn:18"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:18" class="footnote-back-ref">↩</a></p></li> <li id="fn:19"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:19" class="footnote-back-ref">↩</a></p></li> <li id="fn:20"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:20" class="footnote-back-ref">↩</a></p></li> <li id="fn:21"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:21" class="footnote-back-ref">↩</a></p></li> <li id="fn:22"><p>Henry, McMichael (2016). ATI RN Adult Medical Surgical Nursing 10.0. Assessments Technology Institutes. pp. 537–538. ISBN 9781565335653. <a href="9781565335653" target="_blank">9781565335653</a> <a href="#fnref:22" class="footnote-back-ref">↩</a></p></li> <li id="fn:23"><p>Henry, McMichael (2016). ATI RN Adult Medical Surgical Nursing 10.0. Assessments Technology Institutes. pp. 537–538. ISBN 9781565335653. <a href="9781565335653" target="_blank">9781565335653</a> <a href="#fnref:23" class="footnote-back-ref">↩</a></p></li> <li id="fn:24"><p>Henry, McMichael (2016). ATI RN Adult Medical Surgical Nursing 10.0. Assessments Technology Institutes. pp. 537–538. ISBN 9781565335653. <a href="9781565335653" target="_blank">9781565335653</a> <a href="#fnref:24" class="footnote-back-ref">↩</a></p></li> <li id="fn:25"><p>Henry, McMichael (2016). ATI RN Adult Medical Surgical Nursing 10.0. Assessments Technology Institutes. pp. 537–538. ISBN 9781565335653. <a href="9781565335653" target="_blank">9781565335653</a> <a href="#fnref:25" class="footnote-back-ref">↩</a></p></li> <li id="fn:26"><p>Henry, McMichael (2016). ATI RN Adult Medical Surgical Nursing 10.0. Assessments Technology Institutes. pp. 537–538. ISBN 9781565335653. <a href="9781565335653" target="_blank">9781565335653</a> <a href="#fnref:26" class="footnote-back-ref">↩</a></p></li> <li id="fn:27"><p>Henry, McMichael (2016). ATI RN Adult Medical Surgical Nursing 10.0. Assessments Technology Institutes. pp. 537–538. ISBN 9781565335653. <a href="9781565335653" target="_blank">9781565335653</a> <a href="#fnref:27" class="footnote-back-ref">↩</a></p></li> <li id="fn:28"><p>Henry, McMichael (2016). ATI RN Adult Medical Surgical Nursing 10.0. Assessments Technology Institutes. pp. 537–538. ISBN 9781565335653. <a href="9781565335653" target="_blank">9781565335653</a> <a href="#fnref:28" class="footnote-back-ref">↩</a></p></li> <li id="fn:29"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:29" class="footnote-back-ref">↩</a></p></li> <li id="fn:30"><p>Frank, LA; Solomon, A (2 September 2016). "Hyperglycaemic hyperosmolar state". British Journal of Hospital Medicine. 77 (9): C130-3. doi:10.12968/hmed.2016.77.9.C130. PMID 27640667. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:30" class="footnote-back-ref">↩</a></p></li> <li id="fn:31"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:31" class="footnote-back-ref">↩</a></p></li> <li id="fn:32"><p>Pasquel, FJ; Umpierrez, GE (November 2014). "Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment". Diabetes Care. 37 (11): 3124–31. doi:10.2337/dc14-0984. PMC 4207202. PMID 25342831. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4207202</a> <a href="#fnref:32" class="footnote-back-ref">↩</a></p></li> <li id="fn:33"><p>Henry, McMichael (2016). ATI RN Adult Medical Surgical Nursing 10.0. Assessments Technology Institutes. pp. 537–538. ISBN 9781565335653. <a href="9781565335653" target="_blank">9781565335653</a> <a href="#fnref:33" class="footnote-back-ref">↩</a></p></li> <li id="fn:34"><p>Henry, McMichael (2016). 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