Hyperosmolar hyperglycaemic state

Last reviewed: 4 Jun 2022
Last updated: 14 Jun 2022
14 Jun 2022

UK guidance from the Joint British Diabetes Societies for Inpatient Care includes revised recommendations on mixed hyperosmolar hyperglycaemic state and diabetic ketoacidosis

The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) has published updated guidelines on the management of hyperosmolar hyperglycaemic state (HHS) in adults. The revised guidance details new advice on managing this hyperglycaemic emergency, including recommendations to:

  • Use fixed rate intravenous insulin infusion (FRIII) rate of 0.1 units/kg/hour for patients with mixed HHS and diabetic ketoacidosis (DKA), after initiation of intravenous fluids.

    • This rate is in line with JBDS-IP recommendations for patients with DKA alone.

  • Target treatment so that blood glucose falls at a rate between 4.0 mmol/L/hour (72 mg/dL/hour) and 6.0 mmol/L/hour (108 mg/dL/hour).

  • Follow adult guideline recommendations for patients aged 16 to 18 if they are being managed by the adult diabetes team. If the patient is under 18 and being managed by a paediatric team, follow separate paediatric guidelines.

See Management: approach

Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • acute cognitive impairment
  • presence of risk factors
Full details

Other diagnostic factors

  • polyuria
  • polydipsia
  • weight loss
  • nausea and vomiting
  • weakness
  • dry mucous membranes
  • poor skin turgor
  • tachycardia
  • hypotension
  • hypothermia
  • oliguria
  • abdominal pain
  • focal neurological signs
  • seizures
Full details

Risk factors

  • infection
  • inadequate insulin or oral antidiabetic therapy
  • acute illness in a known patient with diabetes
  • nursing home residents
  • postoperative state
  • precipitating medications
  • total parenteral nutrition (TPN)
  • Cushing's syndrome
  • hyperthyroidism
  • acromegaly
Full details

Diagnostic investigations

1st investigations to order

  • blood glucose
  • blood ketones
  • venous blood gas
  • serum osmolality
  • urea, electrolytes, and creatinine
  • full blood count
  • ECG
Full details

Investigations to consider

  • urinalysis
  • cardiac enzymes
  • chest x-ray
  • liver function tests
  • C-reactive protein
  • blood, urine, and sputum cultures
Full details

Treatment algorithm

ACUTE

serum potassium <3.5 mmol/L (<3.5 mEq/L)

serum potassium 3.5 to 5.5 mmol/L (3.5-5.5 mEq/L)

serum potassium >5.5 mmol/L (>5.5 mEq/L)

Contributors

Expert advisers

Edward Jude, MBBS, DNB, MRCP

Honorary Professor of Medicine

University of Manchester

Consultant Physician/Diabetologist/Endocrinologist

Tameside and Glossop Integrated Care NHS Foundation Trust

Manchester

UK

Disclosures

EJ declares that he has no competing interests.

Acknowledgements,

BMJ Best Practice would like to gratefully acknowledge the previous expert contributors, whose work has been retained in parts of the content:

Natasha Khazai, MD

Endocrinologist

Joslin Diabetes Clinic

Boston

MA

Guillermo Umpierrez, MD

Professor of Medicine

Emory University School of Medicine

Atlanta

GA

Disclosures

NK declares that she has no competing interests. GU is supported by research grants from the American Diabetes Association and the National Institutes of Health, and has received research funds from Sanofi-Aventis, Novo Nordisk, Takeda, and GlaxoSmithKline.

Peer reviewers

Gerry Rayman, MD, FRCP

Consultant Physician and Head of Service

Diabetes and Endocrine Centre and the Diabetes Research Unit

Ipswich Hospitals NHS Trust

Ipswich

UK

Disclosures

GR has been paid for advisory board meetings with the following companies: Sanofi Aventis, Abbott Diabetes UK, Lilly Diabetes, and Bayer. GR has received lecture fees from Sanofi Aventis, Abbott Diabetes UK, Lilly Diabetes, Novo Nordisk, and Napp Pharmaceuticals Ltd.

Edward Jude, MBBS, DNB, MRCP

Honorary Professor of Medicine

University of Manchester

Consultant Physician/Diabetologist/Endocrinologist

Tameside and Glossop Integrated Care NHS Foundation Trust

Manchester

UK

Disclosures

EJ declares that he has no competing interests.

Editors

Annabel Sidwell,

Section Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Rachel Wheeler,

Lead Section Editor, BMJ Best Practice

Disclosures

RW declares that she has no competing interests.

Julie Costello,

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Adam Mitchell,

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

  • Differentials

    • Diabetic ketoacidosis (DKA)
    • Lactic acidosis
    • Alcohol ketoacidosis
    More Differentials
  • Guidelines

    • The management of hyperosmolar hyperglycemic state in adults with diabetes
    • Diabetes at the front door: a guideline for dealing with glucose related emergencies at the time of acute hospital admission
    More Guidelines
  • Calculators

    Glasgow Coma Scale

    More Calculators
  • Videos

    Radial artery puncture animated demonstration

    How to perform an ECG animated demonstration

    More videos
  • Patient leaflets

    Diabetes: what is it?

    Diabetes type 2: what treatments work?

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer