What is the management of Hyperosmolar Hyperglycemic State (HHS)?

From the Guidelines

Management of hyperosmolar hyperglycemic state (HHS) requires prompt fluid resuscitation, insulin therapy, electrolyte replacement, and identification of underlying causes, with the primary goal of restoring circulatory volume and tissue perfusion, as emphasized in the 2024 standards of care in diabetes 1. The initial step involves aggressive IV fluid replacement using 0.9% saline at 15-20 mL/kg/hr for the first hour, typically 1-1.5 L, and then adjusting based on hemodynamic status and serum sodium.

• Key considerations include:
  • Insulin therapy should be initiated after initial fluid resuscitation, with a fixed rate of 0.1 units/kg/hr, which is lower than for DKA as patients with HHS are more insulin-sensitive, as noted in recent guidelines 1.
  • Monitoring blood glucose hourly and aiming for a gradual decrease of 50-70 mg/dL per hour is crucial.
  • When glucose reaches 250-300 mg/dL, switching to 5% dextrose with continued insulin is necessary to prevent rapid drops in osmolality.
  • Electrolyte replacement, particularly potassium, is vital when levels fall below 5.5 mEq/L, typically with 20-30 mEq/L of IV fluids.
  • Regular monitoring of electrolytes, renal function, and osmolality every 2-4 hours is essential.
  • Identifying and treating precipitating factors such as infection, stroke, or medication non-adherence is critical in managing HHS. The management approach may vary depending on the individual's clinical and laboratory assessment, and it is essential to individualize treatment based on these factors, as highlighted in the 2024 standards of care in diabetes 1.
• Important aspects to consider include:
  • The use of continuous intravenous insulin in critically ill and mentally obtunded individuals with HHS.
  • The potential benefits of administering a low dose of basal insulin analog in addition to intravenous insulin infusion to prevent rebound hyperglycemia without increased risk of hypoglycemia, as reported in recent studies 1.
  • The importance of providing adequate fluid replacement, frequent POC blood glucose monitoring, treatment of any concurrent infections, and appropriate follow-up to avoid recurrent HHS when using subcutaneous insulin administration.

From the Research

Management of Hyperosmolar Hyperglycaemic State

• The management of hyperosmolar hyperglycaemic state (HHS) involves intensive monitoring of the patient and laboratory values, especially glucose, sodium, and potassium levels 2.
• Vigorous correction of dehydration is critical, requiring an average of 9 L of 0.9% saline over 48 hours in adults 2.
• In children and adolescents, dehydration should be corrected at a rate of no more than 3 mOsm per hour to avoid cerebral edema 2.
• Once dehydration is partially corrected, adults should receive an initial bolus of 0.1 units of intravenous insulin per kg of body weight, followed by a continuous infusion of 0.1 units per kg per hour (or a continuous infusion of 0.14 units per kg per hour without an initial bolus) until the blood glucose level decreases below 300 mg per dL 2.

Treatment Considerations

• Fluid resuscitation and correction of electrolyte abnormalities are essential in the treatment of HHS 3.
• It is important to monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes 3.
• The diabetes specialist team should be involved as soon as possible, and patients should be nursed in areas where staff are experienced in the management of HHS 4.
• The aims of therapy are to improve clinical status, replace fluid losses, gradual decline in osmolality, and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration) 5.

Guidelines for Management

• The Joint British Diabetes Societies (JBDS) for Inpatient Care Group recommends a care pathway consisting of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6-12-24 and 24-72 h) 5.
• Interventions include intravenous (IV) 0.9% sodium chloride to restore circulating volume, fixed rate intravenous insulin infusion (FRIII), glucose infusion, and potassium replacement according to potassium levels 5.
• 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 5.