Hyperosmolar hyperglycaemic state: A systematic review of management guidelines and their evidence

Hyperosmolar hyperglycaemic state (HHS) is an endocrine emergency associated with increased morbidity and mortality. HHS management is largely varied in clinical practice due to a lack of high-quality evidence. This systematic review aims to compare international guidelines and their underlying evidence base in HHS management.

Searching MEDLINE, Embase and Emcare databases and reviewing references of relevant papers identified 363 papers, of which seven met the inclusion criteria.

The features of HHS include hypovolaemia, hyperglycaemia and hyperosmolality, but criteria for diagnosis vary from glucose ≥33.3 mmol/L and osmolality ≥320 mOsm/kg (American Diabetes Association [ADA] and Diabetes Canada [DC]) to glucose ≥30.0 mmol/L with osmolality ≥320 mOsm/kg (Joint British Diabetes Society [JBDS]). The ADA and DC guidelines recommend correction of serum osmolality <3 mOsm/kg/h, whereas the JBDS accepts an osmolality change of 3-8 mOsm/kg/h. ADA guidelines suggest 0.9% normal saline at 15-20 mL/kg/h or 1-1.5 L/h, whereas JBDS guidelines suggest replacing ~50% of the estimated fluid loss within the first 12 h. The ADA and DC guidelines recommend a fixed rate insulin infusion of 0.1 units/kg/h. The JBDS guidelines recommend 0.05 units/kg/h, increasing by 1.0 units/h as required.

These guidelines are consensus-based rather than evidence-based because no randomised controlled trials exist. Further research specific to HHS is required to standardise diagnosis and optimise management.