Anesthetic Management of a Diabetic Patient With a Suspected Hyperosmolar Hyperglycemic State: A Case Report

The hyperosmolar hyperglycemic state (HHS) is an acute metabolic complication of diabetes mellitus type 2 (DMT2) and a life-threatening emergency. A 76-year-old man with DMT2 that was well controlled with oral medications underwent oral cancer surgery. Postoperatively, a surgical site infection and aspiration pneumonia developed, exacerbating the patient's diabetes. His blood glucose level increased to >500 mg/dL, and both dehydration and hyperosmolality were observed. His effective plasma osmolality exceeded 300 mOsm/kg and corrected serum sodium level was 159 mEq/L, which were suggestive of HHS. Because the leading cause of HHS is surgical site infection, emergency surgery was scheduled for infection control. Prior to general anesthesia, the patient received an infusion of 500 mL of normal saline and insulin. Awake intubation was performed after the administration of midazolam and fentanyl after which general anesthesia was induced. The patient tolerated the emergent procedure well, and his HHS resolved. As HHS can occur even in patients with adequately controlled DMT2, the signs and symptoms of HHS must be monitored carefully during the perioperative period.