Internal medicine endocrine, DM Lec.6 Dr. Basim
Hyperglycaemic hyperosmolar state HHS
Hyperglycaemic hyperosmolar state (HHS) is a medical emergency that is different from DKA
and so treatment requires a different approach
It is characterised by:
1- Hypovolaemia.
2- Severe hyperglycaemia (> 30 mmol/L (600 mg/dL))
3- Hyperosmolality (serum osmolality > 320 mOsmol/kg),
4- No significant ketonaemia (< 3 mmol/L)
5- No acidosis (pH > 7.3 (H+ < 50 nmol/L), bicarbonate > 15 mmol/L).
As with DKA there is glycosuria , leading to an osmotic diuresis with loss of water , potassium , and
other electrolytes . However in HHS, hyperglycaemia usually develop over a longer period ( a few
days to weeks ), causing more profound hyperglycaemia and dehydration ( fluid loss may be 10-12
L in a person weighting 100 kg)
Although typically occurring in older patients, HHS is increasingly seen in younger adults.
Common precipitating factors include
1- Infection.
2- Myocardial infarction.
3- Cerebrovascular events.
4- Drug therapy (e.g. glucocorticoids).
Poor prognostic signs include:
1- Hypothermia.
2- Hypotension (systolic blood pressure < 90 mmHg).
3- Tachy or bradycardia.
4- Severe hypernatraemia (sodium > 160 mmol/L).
5- Serum osmolality > 360 mOsmol/kg.
6- The presence of other serious comorbidities.
MANAGEMENT
The aims are to normalize osmolality, replace fluid and electrolyte losses, and normalize blood
glucose, at the same time as preventing complications such as arterial or venous thrombosis,
cerebral edema and central pontine demyelinosis.
osmolarity can be calculated as follows (based on plasma values in mmol/L):
⚫ Plasma osmolality = 2[Na]+[glucose]+[urea]
⚫ The normal value is 280–296 mOsmol/kg and consciousness is impaired when it is high (>
340 mOsmol/kg), as commonly occurs in HHS.
Emergency management of HHS
Time 0–60 mins
Commence IV 0.9% sodium chloride 1 L over 1 hr
• Commence insulin infusion (0.05 U/kg/hr)
• Perform initial investigations
• Perform clinical assessment to assess degree of dehydration, mental status and any source of
infection
⚫ Assess foot
• Establish monitoring regimen – generally hourly glucose and calculated osmolality (2Na+ +
glucose + urea) for first 6 hrs. then 2-hourly if responding
• Insert urinary catheter to monitor hourly urine output and calculate fluid balance
• Commence LMWH in a prophylactic dose • Consider antibiotic therapy if sepsis suspected
Time 60 mins to 6 hrs
• Continue with 0.9% sodium chloride infusion 0.5–1.0 L/hr, depending on clinical
assessment and response
• calculate osmolality hourly and aim for gradual decline ( 3-8 mOsmol\ kg\hr); if
osmolality is increasing and fluid balance adequate , consider 0.45% sodium chlorid
• Maintain potassium in the reference range (3.6–5.0 mmol/L), as with DKA
• Avoid hypoglycaemia – aim to keep blood glucose at 10–15 mmol/L (180–270 mg/dL) in
the first 24 hrs. If blood glucose falls below 14 mmol/L (252 mg/dL), commence 5% or
10% glucose infusion in addition to 0.9% saline
• Monitor fluid balance
Time 6–12 hrs
Assess for complication of treatment
• Continue IV fluid replacement to target 3–6 L.
• Continue treatment of underlying precipitant
• Avoid hypoglycaemia
Time 12–24 hrs
Assess for complications of treatment
• Continue IV fluid replacement
• Continue IV insulin with or without 5% or 10% glucose to maintain blood glucose at 10–15
mmol/L (180–270 mg/dL)
• Continue treatment of underlying precipitant
• Avoid hypoglycaemia
Time 24 hrs to day 3
Continue IV fluids until eating and drinking.
• Convert to appropriate SC insulin regimen
• Assess for signs of fluid overload
• Encourage early mobilization
• Carry out daily foot checks
• Continue LMWH until discharge
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