From the Guidelines
Hyperosmolar Hyperglycemic State (HHS) is diagnosed when a patient has severe hyperglycemia (blood glucose >600 mg/dL), hyperosmolality, and significant dehydration without significant ketoacidosis, and management begins with aggressive fluid resuscitation and insulin therapy, as outlined in the most recent guidelines 1. The diagnostic criteria for HHS include:
- Blood glucose >600 mg/dL
- Venous pH >7.3
- Bicarbonate >15 mEq/l
- Altered mental status or severe dehydration Management of HHS involves:
- Aggressive fluid resuscitation using isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for the first hour, followed by 4-14 mL/kg/hour depending on hemodynamic status
- Insulin therapy with an IV bolus of regular insulin at 0.1 units/kg, followed by continuous infusion at 0.1 units/kg/hour, titrating to reduce glucose by 50-70 mg/dL/hour
- Potassium replacement when levels fall below 5.2 mEq/L, typically adding 20-30 mEq of potassium to each liter of IV fluid once urine output is established
- Phosphate replacement may be needed if levels are <1 mg/dL
- Identification and treatment of underlying causes such as infection, myocardial infarction, stroke, or medication non-adherence The most recent guidelines 1 emphasize the importance of individualizing treatment based on a careful clinical and laboratory assessment, and highlight the need for prompt recognition and aggressive management of HHS to reduce morbidity and mortality. Key considerations in the management of HHS include:
- Restoration of circulatory volume and tissue perfusion
- Resolution of hyperglycemia
- Correction of electrolyte imbalance and ketosis
- Treatment of any correctable underlying cause of HHS
- Transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h prior to the intravenous insulin being stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1.
From the Research
Hyperosmolar Hyperglycemic State (HHS) Criteria
- HHS is a life-threatening emergency characterized by marked elevation of blood glucose, hyperosmolarity, and little or no ketosis 2, 3, 4
- Clinical features of HHS include:
- Marked hypovolaemia
- Osmolality ≥320 mOsm/kg
- Marked hyperglycaemia ≥30 mmol/L
- Without significant ketonaemia (≤3.0 mmol/L)
- Without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L 4
- Precipitating causes of HHS include underlying infections, certain medications, nonadherence to therapy, undiagnosed diabetes mellitus, substance abuse, and coexisting disease 2, 3, 5
HHS Management
- Treatment begins with intensive monitoring of the patient and laboratory values, especially glucose, sodium, and potassium levels 2, 3, 6
- Vigorous correction of dehydration is critical, requiring an average of 9 L of 0.9% saline over 48 hours in adults 2, 3
- Potassium replacement should begin after urine output is established 2, 3
- Insulin should be given as 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 until the blood glucose level decreases below 300 mg per dL 3
- Identification and treatment of underlying and precipitating causes are necessary 2, 3, 4
- Aims of therapy include:
- Improve clinical status/replace fluid losses by 24 h
- Gradual decline in osmolality (3.0-8.0 mOsm/kg/h to minimise the risk of neurological complications)
- Blood glucose 10-15 mmol/L in the first 24 h
- Prevent hypoglycaemia/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration) 4
- HHS resolution criteria are:
- 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 4