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

Clinical features of HHS: 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

Therapy aims: improve clinical status/replace fluid losses by 24 h; gradual decline in osmolality (3.0-8.0 mOsm/kg/h); blood glucose 10-15 mmol/L in first 24 h; prevent hypoglycaemia/hypokalaemia and harm (VTE, osmotic demyelination, fluid overload, foot ulceration)

Underlying precipitants must be identified and treated

Intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly)

Fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement; if ketonaemia, FRIII commenced at the same time as IV fluids

Glucose infusion (5% or 10%) started once glucose <14 mmol/L

Potassium replacement according to potassium levels

Resolution criteria: 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