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Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes
Omar G Mustafa1,2, Masud Haq3, Umesh Dashora4
1Department of diabetes, King's College Hospital NHS Foundation Trust, London, UK.
Insights
Hyperosmolar Hyperglycaemic State (HHS) is a serious diabetes emergency. This pathway outlines critical care steps for managing HHS, focusing on fluid resuscitation, insulin therapy, and monitoring to reduce mortality and complications.
Area of Science:
- Endocrinology
- Internal Medicine
- Emergency Medicine
Background:
- Hyperosmolar Hyperglycaemic State (HHS) is a life-threatening diabetic emergency with high mortality rates.
- HHS is less common than diabetic ketoacidosis (DKA), primarily affecting individuals with type 2 diabetes, including a growing number of children and young adults.
- Mixed DKA/HHS presentations can occur, complicating diagnosis and management.
Purpose of the Study:
- To present the JBDS-supported HHS care pathway, detailing a structured approach to management.
- To outline the key clinical features, diagnostic criteria, and therapeutic goals for HHS.
- To provide evidence-based interventions for prompt and effective HHS treatment, aiming to minimize complications.
Main Methods:
- The JBDS HHS care pathway is structured around three themes: clinical assessment and monitoring, interventions, and assessment/prevention of harm.
- Therapy is divided into five distinct phases: 0-60 minutes, 1-6 hours, 6-12 hours, 12-24 hours, and 24-72 hours.
- Key interventions include intravenous fluid resuscitation with 0.9% sodium chloride, fixed-rate intravenous insulin infusion (FRIII), glucose infusion as needed, and potassium replacement.
Main Results:
- Clinical features of HHS include severe hypovolemia, osmolality ≥320 mOsm/kg, and hyperglycemia ≥30 mmol/L, without significant ketosis or acidosis.
- Therapeutic aims include restoring fluid volume within 24 hours, achieving a gradual decline in osmolality (3-8 mOsm/kg/h), and maintaining blood glucose between 10-15 mmol/L in the first 24 hours.
- Resolution criteria for HHS include osmolality <300 mOsm/kg, corrected hypovolemia, return to pre-morbid cognitive status, and blood glucose <15 mmol/L.
Conclusions:
- Effective management of HHS requires prompt identification of underlying precipitants and adherence to a structured care pathway.
- Careful fluid and insulin management, alongside vigilant monitoring, is crucial to prevent complications such as VTE, osmotic demyelination, and fluid overload.
- The outlined care pathway provides a framework for optimizing outcomes in patients with Hyperosmolar Hyperglycaemic State.
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.
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