The management of the hyperosmolar hyperglycaemic state in adults with diabetes: a summary of a report from the Joint British Diabetes Societies for Inpatient Care

Abstract

The Joint British Diabetes Societies for Inpatient Care have recently provided guidance on the management of hyperosmolar hyperglycaemic state (HHS), a medical emergency which differs from diabetic ketoacidosis (DKA) through higher mortality and potential for complication by myocardial infarction, stroke, seizures, cerebral oedema and central pontine myelinolysis (the latter possibly precipitated by rapid changes in osmolality during treatment). DKA presents within hours of onset, whereas HHS develops over many days, and its associated dehydration and metabolic disturbances are more extreme. A different therapeutic approach is required for HHS than for DKA. The key points in these guidelines are:

Monitoring of the response to treatment:

• Measure or calculate serum osmolality regularly to monitor the response to treatment

• Aim to reduce osmolality by 3–8 mOsm/kg/h

Fluid and insulin administration:

• Use intravenous 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration

• Note that fluid replacement alone will cause a fall in blood glucose; withhold insulin until blood glucose is no longer falling with intravenous fluids alone (unless ketonaemic)

• An initial rise in sodium is expected and is not itself an indication for hypotonic fluids

• Early use of insulin (before fluids) may be detrimental

Delivery of care:

• Involve the diabetes specialist team as soon as possible.

• Nurse patients in areas where staff are experienced in the management of HHS