Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group

Abstract

Hyperosmolar Hyperglycaemic State (HHS) is a medical emergency associated with high mortality. It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre-existing/new type 2 diabetes mellitus and increasingly affecting children/younger adults. Mixed DKA/HHS may occur. The JBDS HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6, 6-12, 12-24 and 24-72 h). Clinical features of HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg using [(2×Na + ) + glucose+urea], marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L. Aims of the therapy are to 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). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose <14 mmol/L and (4) potassium replacement according to potassium levels. HHS resolution criteria are: osmolality <300 mOsm/kg, hypovolaemia corrected (urine output ≥0.5 ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.

Tonicity or serum osmolality? Comment on management of hyperosmolar hyperglycaemic state in adults: An updated guideline from the Joint British Diabetes Societies for Inpatient Care Group

“…We have carefully reviewed the article titled, 'Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group', authored by Mustafa et al, 1 recently published in Diabetic Medicine. The authors present a comprehensive and detailed description of the pathogenesis and treatment of HHS.…”

“…However, their ultimate conclusion centres on 'serum osmolality', which is calculated using sNa, BG and blood urea nitrogen (BUN), and noneffective osmolality, for the purpose of management. 1 From a nephrologist's perspective, we wish to emphasize the superiority of using 'tonicity' in assessing potential brain damage as opposed to using 'serum osmolality'. This distinction is important, especially in complex cases of hyponatraemia or osmolar abnormalities such as HHS or diabetic ketoacidosis (DKA).…”

“…This is the formula used throughout this guideline'. 1 We simulated several cases of HHS (Table 1). Patterns 1 and 2 show cases of translocational hyponatraemia yet exhibit normalized sNa post BG correction (Corrected sNa: 135 mEq/L).…”

Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis

“…Intravenous fluids are first-line treatment in the management of diabetic ketoacidosis (DKA) to restore intravascular volume, reduce counter-regulatory hormone production, and ensure adequate tissue perfusion. [1][2][3][4] Current guidelines from the American Diabetes Association (ADA) and Joint British Diabetes Societies for Inpatient Care (JBDS-IP) recommend 0.9% normal saline (NS) as the resuscitative fluid of choice, followed by the utilization of 0.45% NS or NS, respectively, for maintenance fluid therapy. 1,3 However, this approach increases the risk of hyperchloremic metabolic acidosis (HMA) and there is growing evidence of additional detrimental metabolic sequelae that occur with the use of NS in the management of DKA.…”

“…[1][2][3][4] Current guidelines from the American Diabetes Association (ADA) and Joint British Diabetes Societies for Inpatient Care (JBDS-IP) recommend 0.9% normal saline (NS) as the resuscitative fluid of choice, followed by the utilization of 0.45% NS or NS, respectively, for maintenance fluid therapy. 1,3 However, this approach increases the risk of hyperchloremic metabolic acidosis (HMA) and there is growing evidence of additional detrimental metabolic sequelae that occur with the use of NS in the management of DKA. [5][6][7][8][9][10][11] Development of iatrogenic HMA in the setting of DKA management may delay resolution of acidosis, delay transfer to lower level of hospital care, and increase length of stay (LOS).…”