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Review
. 2023 Mar;40(3):e15005.
doi: 10.1111/dme.15005. Epub 2022 Dec 21.

Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group

Omar G Mustafa  1   2 , Masud Haq  3 , Umesh Dashora  4 , Erwin Castro  4 , Ketan K Dhatariya  5   6 ; Joint British Diabetes Societies (JBDS) for Inpatient Care Group
Affiliations
Review

Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group

Omar G Mustafa et al. Diabet Med. 2023 Mar.

Abstract

Hyperosmolar Hyperglycaemic State (HHS) is a medical emergency associated with high mortality. It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre-existing/new type 2 diabetes mellitus and increasingly affecting children/younger adults. Mixed DKA/HHS may occur. The JBDS HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6, 6-12, 12-24 and 24-72 h). Clinical features of HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg using [(2×Na+ ) + glucose+urea], marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L. Aims of the therapy are to improve clinical status/replace fluid losses by 24 h, gradual decline in osmolality (3.0-8.0 mOsm/kg/h to minimise the risk of neurological complications), blood glucose 10-15 mmol/L in the first 24 h, prevent hypoglycaemia/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose <14 mmol/L and (4) potassium replacement according to potassium levels. HHS resolution criteria are: osmolality <300 mOsm/kg, hypovolaemia corrected (urine output ≥0.5 ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.

Keywords: HHS; emergency; hyperosmolar hyperglycaemic state; inpatient.

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Conflict of interest statement

OM has received honoraria, travel and personal fees from Sanofi Diabetes, Eli Lilly, Boehringer Ingelheim and Novo Nordisk. MH has received honoraria, travel and personal fees from Eli Lilly, Astra Zeneca, Novo Nordisk, NAPP, Sanofi and Boehringer Ingelheim. UD has received honoraria and speaker fee from Sanofi Diabetes, Eli Lillly, Astra Zeneca, Boehringer Ingelheim and Novo Nordisk. KD is the chair of the Joint British Diabetes Societies for Inpatient Care and has received honoraria, travel and personal fees from Sanofi Diabetes, Eli Lilly, AstraZeneca, Boehringer Ingelheim and Novo Nordisk.

Figures

FIGURE 1
FIGURE 1
Page 1 of the HHS care pathway. This side includes time‐based thematic division of the care pathway by clinical assessment and monitoring, interventions, assessments and preventions and referral to the inpatient diabetes team.
FIGURE 2
FIGURE 2
Page 2 of the HHS care pathway. This side includes algorithms for the management of osmolality, glucose and potassium during the management of HHS. Also included are the criteria of when escalate care.
FIGURE 3
FIGURE 3
Definition and characteristic features of a person with HHS.
FIGURE 4
FIGURE 4
The overlap between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HHS) and how to approach management.
See this image and copyright information in PMC

Comment in

References

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