Management of Hyperglycaemic Hyperosmolar State (HHS) 

The complex pathophysiology and management of HHS means that all patients should be treated in a level 2 care setting, with early input from the specialist inpatient Diabetes Team.

Diagnosis criteria for HHS

• Laboratory glucose >30mmol/L
• Serum osmolality >320mosmol/kg [calculate serum osmolality: 2(Na⁺ + K⁺) + glucose + urea]
• Venous blood gas [H⁺] <50nmol/L
• Venous bicarbonate >15mmol/L 
• Capillary blood ketones <3mmol/L (urine ketones <3+).

Management

The local guideline on the management of HHS can be found here (link only active if accessing via NHS network). Otherwise, the guideline can be found via AthenA / Guidelines - Prescribing / Endocrine system.

It covers:

• Care pathway 1: 0–6 hours of HHS management
• Care pathway 2: >6 hours – resolution
• Appendix A – Five headline concepts: 
  • Correct diagnosis - differentiating between HHS and diabetic ketoacidosis
  • Appropriate IV fluids to use
  • Insulin - when to commence it and at what rate
  • Treatment target ranges
  • Other issues - electrolytes, anticoagulation, co-presenting illness, pressure ulcer risk.
• Appendix B – when to start fixed rate insulin.