How to manage Hyperosmolar Hyperglycemic State (HHS)?

From the Guidelines

Management of Hyperosmolar Hyperglycemic State (HHS) requires immediate and aggressive treatment focusing on fluid replacement, insulin therapy, and electrolyte correction, with the goal of reducing morbidity, mortality, and improving quality of life. To manage HHS, the following steps should be taken:

• Begin with rapid intravenous fluid resuscitation using isotonic saline (0.9% NaCl) at a clinically appropriate rate aiming to replace 50% of the estimated fluid deficit in the first 8–12 h, as recommended by 1.
• Start insulin therapy with an IV bolus of regular insulin at 0.1 units/kg followed by continuous infusion at 0.1 units/kg/hr, titrating to achieve glucose reduction, as suggested by 1.
• Monitor potassium levels closely and begin replacement when levels fall below 5.0 mEq/L, aiming to maintain levels between 4-5 mEq/L, as recommended by 1.
• Throughout treatment, monitor vital signs, mental status, fluid balance, electrolytes, and glucose hourly, and identify and treat the underlying precipitating factors such as infection, medication non-adherence, or acute illness.
• The treatment goals include restoration of circulatory volume and tissue perfusion, resolution of hyperosmolarity, and correction of electrolyte imbalance, as stated by 1. Some key considerations in the management of HHS include:
• The use of bicarbonate is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge, as noted by 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 by 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 hyperosmolarity and rebound hyperglycemia, as recommended by 1.

From the Research

Management of Hyperosmolar Hyperglycemic State (HHS)

To manage HHS, the following steps can be taken:

• Monitor the response to treatment by measuring or calculating the serum osmolality regularly to monitor the response to treatment, and aim to reduce osmolality by 3-8 mOsm/kg/h 2
• Administer intravenous (IV) 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration 2, 3
• Withhold insulin until the blood glucose level is no longer falling with IV fluids alone, unless ketonaemic 2
• Use a fixed rate intravenous insulin infusion (FRIII) once osmolality stops falling with fluid replacement, unless there is ketonaemia 3
• Start glucose infusion (5% or 10%) once glucose <14 mmol/L 3
• Replace potassium according to potassium levels 3

Identification and Treatment of Underlying Precipitants

It is essential to identify and treat the underlying precipitants of HHS, such as:

• Infections
• Myocardial infarction
• Stroke
• Seizures
• Cerebral oedema
• Central pontine myelinolysis 2, 3

Delivery of Care

Patients with HHS should be nursed in areas where staff are experienced in the management of HHS, and the diabetes specialist team should be involved as soon as possible 2, 3

Resolution Criteria

HHS resolution criteria include:

• Osmolality <300 mOsm/kg
• Hypovolaemia corrected (urine output ≥0.5 ml/kg/h)
• Cognitive status returned to pre-morbid state
• Blood glucose <15 mmol/L 3