From the Research
The Health and Human Services (HHS) criteria for Hyperosmolar Hyperglycemic State (HHS) diagnosis include plasma glucose >600 mg/dL, effective serum osmolality >320 mOsm/kg, and absence of significant ketosis, as stated in the most recent guideline from the Joint British Diabetes Societies for Inpatient Care Group 1. To diagnose HHS, the following criteria must be met:
- Plasma glucose >600 mg/dL (33.3 mmol/L)
- Effective serum osmolality >320 mOsm/kg
- Absence of significant ketosis (serum ketones may be small positive) Additional findings typically include:
- Profound dehydration with serum sodium often >150 mEq/L
- Blood urea nitrogen elevation
- Altered mental status ranging from confusion to coma Treatment requires:
- Aggressive fluid resuscitation (initially with isotonic saline at 15-20 mL/kg/hr)
- Insulin therapy (regular insulin 0.1 units/kg IV bolus followed by 0.1 units/kg/hr infusion)
- Electrolyte replacement (particularly potassium when levels fall below normal)
- Addressing the underlying precipitating cause HHS carries a higher mortality rate than diabetic ketoacidosis (10-20%) due to the advanced age of most patients and associated comorbidities, as noted in a recent review of treatment challenges and controversies in the management of critically ill diabetic ketoacidosis (DKA) patients in intensive care units 2. The most recent and highest quality study, published in 2023, provides an updated guideline for the management of HHS, emphasizing the importance of early recognition and prompt intervention to improve outcomes 1. Key points in the management of HHS include:
- Monitoring of the response to treatment, with regular measurement of serum osmolality and aim to reduce osmolality by 3-8 mOsm/kg/h
- Fluid and insulin administration, with use of i.v. 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration
- Delivery of care, with involvement of the diabetes specialist team as soon as possible and nursing in areas where staff are experienced in the management of HHS The resolution criteria for HHS 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 Early recognition and prompt intervention are essential for improved outcomes in HHS, as emphasized in a recent review of hyperosmolar hyperglycemic state 3.