Updated guideline on managing hyperosmolar hyperglycemic state issued by U.K. experts
The recommendations from the Joint British Diabetes Societies for Inpatient Care Group cover clinical assessment and monitoring, interventions, and assessments and prevention of harm, as well as five phases of therapy.
Clinicians caring for hyperosmolar hyperglycemic state (HHS), a medical emergency associated with high mortality, must base treatment decisions on both biochemical and clinical evaluation, according to a recent guideline from the Joint British Diabetes Societies for Inpatient Care Group.
The guideline, which updates the group's previous recommendations on this condition, is based on published evidence when available and on expert consensus and is intended for all clinicians managing HHS in adults. The care pathway outlined in the guideline covers clinical assessment and monitoring, interventions, and assessments and prevention of harm. It outlines five phases of therapy according to time from presentation (0 to 60 min, 1 to 6 hours, 6 to 12 hours, 12 to 24 hours, and 24 to 72 hours).
Infections, discontinuation/omission of diabetes medications, cardiovascular events, pancreatitis, and drugs (corticosteroids, thiazides, sympathomimetic agents, and conventional antipsychotics) are the most common precipitating factors of HHS, the guideline said. Clinical features include marked hypovolemia, osmolality of 320 mOsm/kg or higher, marked hyperglycemia (glucose level ≥30 mmol/L [≥540 mg/dL]), no significant ketonemia, no significant acidosis, and a bicarbonate level of 15 mmol/L or greater, according to the guideline. The authors noted that goals of therapy are to improve clinical status and replace fluid losses by 24 hours, achieve a gradual decline in osmolality (3.0 to 8.0 mOsm/kg/h) to minimize risk of neurological complications, achieve a blood glucose level of 10 to 15 mmol/L (180 to 270 mg/dL) in the first 24 hours, prevent hypoglycemia or hypokalemia, and prevent harm.
Recommended interventions include the following, the guideline said:
- IV 0.9% sodium chloride to restore circulating volume;
- fixed-rate IV insulin infusion once osmolality stops falling with fluid replacement, unless there is ketonemia;
- glucose infusion (5% or 10%) once the glucose level falls below 14 mmol/L (252 mg/dL); and
- potassium replacement according to potassium levels.
A senior clinician familiar with HHS management should confirm the treatment plan and review the patient's progress, and the diabetes inpatient team should be involved in care as soon as possible, the guideline said. Rapid changes in osmolality can be harmful, the guideline stressed, noting that the rate of decrease of the serum sodium level should not exceed 10 mmol/L in 24 hours and that plasma glucose level should not decrease more quickly than 5 mmol/L (90 mg/L) per hour.
Complete normalization of electrolytes and osmolality may take up to 72 hours, the guideline said. HHS is considered to have resolved when osmolality is below 300 mOsm/kg, hypovolemia is corrected (urine output ≥0.5 mL/kg/h), cognitive status has returned to baseline, and the blood glucose level is below 15 mmol/L (270 mg/dL), according to the guideline.
The guideline includes a detailed care pathway covering all phases of treatment, as well as an algorithm for changes in osmolality and glucose and other tools. It was published Nov. 12 by Diabetic Medicine.