When has Hyperosmolar Hyperglycemic State (HHS) been resolved?

From the Guidelines

HHS is resolved when the patient's glucose level is <200 mg/dl, serum bicarbonate ≥18 mEq/l, and a venous pH of >7.3, as indicated by recent studies 1. The resolution of HHS is a critical aspect of managing hyperglycemic crises in patients with diabetes mellitus. According to the most recent guidelines, the management goals for HHS include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis 1.

Key Considerations

• The resolution criteria for HHS include a glucose level <200 mg/dl, serum bicarbonate ≥18 mEq/l, and a venous pH of >7.3, as stated in the recent study 1.
• The use of continuous intravenous insulin is the standard of care for critically ill and mentally obtunded individuals with DKA or HHS, as recommended by the recent guidelines 1.
• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia, as reported in recent studies 1.

Treatment Approach

• The treatment approach for HHS involves individualization of treatment based on a careful clinical and laboratory assessment, as emphasized in the recent study 1.
• The administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia, as reported in recent studies 1.
• Aggressive fluid management and correction of electrolyte imbalance are essential components of the treatment approach for HHS, as stated in the recent guidelines 1.

From the Research

Resolution of Hyperosmolar Hyperglycemic State (HHS)

• The resolution of HHS is indicated by several criteria, including osmolality <300 mOsm/kg, correction of hypovolaemia (urine output ≥0.5 ml/kg/h), return of cognitive status to pre-morbid state, and blood glucose <15 mmol/L 2.
• Treatment of HHS involves aggressive volume-repletion of osmotic losses, insulin therapy, and treatment of the underlying cause 3.
• The aims of therapy in HHS include improving clinical status, replacing fluid losses, gradual decline in osmolality, and preventing hypoglycaemia and hypokalaemia 2.
• The management of HHS has largely been extrapolated from studies of patients with diabetic ketoacidosis (DKA), and there is a need for prospective, randomized studies to determine best treatment strategies in patients with HHS 4.

Treatment and Management

• Treatment guidelines recommend aggressive volume-repletion of osmotic losses in addition to insulin therapy, plus treatment of the underlying cause 3.
• Intravenous (IV) 0.9% sodium chloride is used to restore circulating volume, with caution in elderly patients 2.
• Fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement, unless there is ketonaemia 2.
• Glucose infusion (5% or 10%) should be started once glucose <14 mmol/L, and potassium replacement should be according to potassium levels 2.

Clinical Features and Diagnosis

• Clinical features of HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg, marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), and without significant acidosis (pH >7.3) 2.
• Diagnostic criteria for HHS include a plasma glucose level >600 mg/dL and increased effective plasma osmolality >320 mOsm/kg in the absence of ketoacidosis 4.