What are the resolution criteria for Hyperosmolar Hyperglycemic State (HHS)?

From the Guidelines

HHS is considered resolved when the calculated serum osmolality falls to 8.3 mmol/L, among other clinical criteria. The HHS resolutions criteria refer to the guidelines used to determine when Hyperosmolar Hyperglycemic State (HHS) has been resolved in a patient. According to the most recent evidence 1, resolution of HHS is determined by clinical judgment and may include criteria such as normalization of serum osmolality, improvement in mental status, and adequate hydration.

• Key aspects of treatment include:
  • Aggressive IV fluid replacement with normal saline initially
  • Insulin therapy administered as an IV infusion at 0.1 units/kg/hour
  • Potassium replacement when levels fall below 5.3 mEq/L
  • Identification and treatment of the underlying cause of HHS
• Careful monitoring of vital signs, mental status, fluid balance, electrolytes, and glucose levels is essential to prevent complications like cerebral edema, which can occur with overly rapid correction of osmolality, as noted in previous studies 1.
• The use of a standardized protocol, such as the one outlined in the evidence 1, can help guide treatment and ensure that patients receive appropriate care.
• It is also important to note that prevention measures, such as gradual replacement of sodium and water deficits and the addition of dextrose to the hydrating solution once blood glucose reaches 250 mg/dl, may help decrease the risk of cerebral edema in high-risk patients 1.

From the Research

HHS Resolutions Criteria

The resolution criteria for Hyperosmolar Hyperglycaemic State (HHS) include:

• Osmolality <300 mOsm/kg 2
• Hypovolaemia corrected, indicated by urine output ≥0.5 ml/kg/h 2
• Cognitive status returned to pre-morbid state 2
• Blood glucose <15 mmol/L 2

Key Considerations

When managing HHS, it is essential to:

• Monitor the response to treatment closely, including regular measurement of serum osmolality 3
• Aim to reduce osmolality by 3-8 mOsm/kg/h 3
• Use intravenous 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 intravenous fluids alone, unless ketonaemic 2, 3

Treatment Goals

The primary goals of HHS treatment are to:

• Improve clinical status and replace fluid losses by 24 h 2
• Achieve a gradual decline in osmolality to minimize the risk of neurological complications 2
• Maintain blood glucose levels between 10-15 mmol/L in the first 24 h 2
• Prevent hypoglycaemia, hypokalaemia, and other complications 2, 4, 5, 6