Trust Clinical Policy

Developed by the Diabetes and Endocrinology Directorate

for Trust wide use

The Management of
Hyperosmolar Hyperglycaemic State

Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Quality.Mydocs.ClinicalGovernance.Policies

Document Control
Policy Title

The Management of Hyperosmolar

Hyperglycaemic State

Author/Contact

Dhanya Kalathil, StR in Diabetes;

Sally James, Senior Pharmacist for Diabetes;
Dr Dushyant Sharma, Consultant Diabetologist;
Lesley Lamen, Diabetes Nurse Specialist;

Document Reference
Version

Status
Publication Date

October 2013

Review Date

September 2015

Approved by

Executive Lead

Ratified by

Clinical & Cost Effectiveness

Group

Distribution:
Royal Liverpool and Broadgreen University hospitals NHS Trust-intranet
Please note that the Intranet version of this document is the only version that is
maintained.
Any printed copies must therefore be viewed as uncontrolled and as such, may
not necessarily contain the latest updates and amendments.

Version
1

Date
01/09/13

Comments

Author
As above

Review Process Prior to Ratification:

Name of Group/Department/Committee
Medicines management Group
Clinical & Cost Effectiveness Group

Date

Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Management of Hyperosmolar Hyperglycaemic State 2013

Main Policy
1.0

Introduction
Hyperosmolar Hyperglycaemic State (HHS) (previously known as HONK)
is a metabolic emergency which is different from Diabetic Ketoacidosis
(DKA) and requires a different approach to management. New national
guidance for the management of HHS has been issued by the Joint British
Diabetes Societies Inpatient Care Group (1).The current RLBUHT
guidance on HHS therefore needed updating to ensure that the Trust
conforms to national guidance.

2.0

Objective
To provide guidance on how to diagnose and manage Hyperosmolar
Hyperglycaemic State
To ensure there is appropriate review and follow up of these patients by
the diabetes team

3.0

Scope of Policy (who, where, when)

This covers all patients with suspected Hyperosmolar Hyperglycaemic
State at RLBUHT

4.0

Policy

HYPEROSMOLAR HYPERGLYCAEMIC STATE (HHS) - (previously known as

HONK)

4.1 INTRODUCTION
HHS is a metabolic emergency characterised by hyperglycaemia and severe
dehydration which requires prompt treatment with intravenous fluids and insulin.
Mortality attributed to HHS is considerably higher than that attributed to DKA,
with mortality rates of 520%. These patients should be referred to the Diabetes
Specialist Team at the earliest and triaged to Wards 7A or 7B.

Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Management of Hyperosmolar Hyperglycaemic State 2013

4.2 RECOGNITION AND ASSESSMENT

4.2.a Clinical Features

Symptoms

Signs

Polydipsia, polyuria, vomiting, weight

loss, lethargy, altered mental state,
seizures, coma

Loss of skin turgor, dehydration,

tachycardia, hypotension, focal
neurological signs, low GCS

4.2.b Diagnosis

The diagnosis of HHS is made in the presence of:

Hypovolaemia

+
Marked
hyperglycaemia
(>30
mmol/L)
without
significant
hyperketonaemia (<3.0 mmol/L) or acidosis (pH>7.3, bicarbonate >15
mmol/L)

+
Serum Osmolality >320 mOsmol/kg

Serum Osmolality should be calculated as follows:

Serum Osmolality (mOsmol/kg) = [2 x Na] + glucose + urea

Mild ketosis or acidosis may be present in up to 30% of patients with HHS.

The precipitating factor for the HHS should be identified and may be:
sepsis
non - compliance with treatment
inadequate insulin treatment
pancreatitis
cerebrovascular accident
myocardial infarction
alcohol or drug use

Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Management of Hyperosmolar Hyperglycaemic State 2013

4.2.c Investigations
Blood glucose
U&E, Bicarbonate
Calculated serum osmolality
FBC, CRP
LFTs, Amylase
Cardiac markers in the elderly to rule out silent MI
Lactate
Ketones in blood to rule out DKA
Venous blood gas to rule out DKA
MSSU
Blood culture
ECG
CXR

4.2.d Consider Level 2 or Level 3 care if

Serum osmolality > 350 mOsmol/kg
Sodium > 160 mmol/L
Venous/arterial pH < 7.1
Hypo (<3.5) or hyperkalaemia (> 6 )
GCS < 12 or abnormal AVPU
Oxygen saturation <92% on air
Systolic blood pressure <90 mmHg
Pulse > 100 or < 60 beats per minute
Urine output < 0.5 ml/kg/hr
Serum creatinine > 200 mol/L
Hypothermia
Macrovascular event
Other serious co-morbidity
These patients will be extremely unwell, and will need very close monitoring of
fluid and electrolyte status with hourly measurement of U&Es and serum
osmolality.

4.3 MANAGEMENT

4.3.a Fluids

Fluid resuscitation is the mainstay of treatment and arguably more

important than insulin therapy. However, it is important not to correct
Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Management of Hyperosmolar Hyperglycaemic State 2013

the fluid and electrolyte abnormalities too rapidly as this could

precipitate cerebral oedema and/or cardiac failure.
The typical fluid loss is 100 to 220 ml/kg.
Initial fluid replacement must be with Sodium Chloride 0.9% with
potassium.
Aim to achieve a positive balance of 3 to 6 litres by 12 hours, and replace
the remaining estimated fluid losses within the next 12 to 24 hours.
Monitor therapy by calculating serum osmolality at 0 hours (i.e. the time of
diagnosis), 3 hours, 6 hours, 12 hours and then 12 hourly till resolution of
metabolic abnormalities. (Send blood sample for U&Es to the lab.)
Aim to reduce serum osmolality by about 5 mOsmol (range 3 - 8 mOsmol)
per hour.
An initial rise in sodium is expected and is not itself an indication for
hypotonic fluids.
If plasma sodium is increasing but osmolality is falling at an appropriate
rate, continue Sodium Chloride 0.9% with potassium.
If plasma sodium is increasing and osmolality is increasing (or not falling
adequately), check fluid balance. If positive balance is inadequate,
increase the rate of infusion of sodium chloride.
Only switch to 0.45% Sodium Chloride 0.9% with potassium if the
osmolality is not declining despite adequate fluid replacement.
If the osmolality is falling too rapidly, then reduce the rate of intravenous
fluids.
If the patient becomes fluid overloaded, then contact the critical care team
for escalation to Level 2 care for monitoring of central venous pressure
and cardiovascular state during further fluid resuscitation.
The rate of fall of sodium should not exceed 10 mmol/L over 24 hours.

4.3.b Potassium
Aim to keep potassium levels between 3.5 and 5.5 mmol by the use of Sodium
chloride 0.9% with added potassium as follows:
Serum Potassium
> 5 mmol
3.5 to 5 mmol
< 3.5 mmol

Fluid to be used
Sodium chloride 0.9% 1 litre with no added
potassium
Sodium chloride 0.9% 1 litre with 20 mmol
potassium
Sodium chloride 0.9% 1 litre with 40 mmol
potassium

Only pre-mixed preparations of saline and potassium are available.

Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Management of Hyperosmolar Hyperglycaemic State 2013

4.3.c Insulin
Set up a syringe driver with 50 units of soluble insulin (Humulin S) in 50 ml
Sodium Chloride 0.9% (i.e. 1 unit /ml).
Start the infusion rate at 2 ml/hr (i.e. 2 units/hr).
A fresh insulin solution should be prepared every 8 hours for immediate
use.
Measure capillary blood glucose hourly.
Aim for capillary blood glucose levels between 10 15 mmol/mol.
If capillary blood glucose is above 15 mmol/mol, increase the rate of
insulin infusion by 0.5 units.
If capillary blood glucose falls below 5 mmol/mol, decrease the rate of
insulin infusion by 1 unit.
Once capillary blood glucose levels fall below 14 mmol/L, add in 10%
glucose at 125 ml/hr.
If the patient is normally on long acting insulin (Levemir or Lantus)
then this needs to be continued as usual.
Once hyperglycaemia and dehydration have resolved but the patient is not
able to eat and drink, then switch to intravenous insulin therapy as per
trust guidelines.

4.3.d Thromboprophylaxis
HHS is a hypercoagulable state due to the associated profound
dehydration, and all patients with HHS should therefore receive
thromboprophylaxis unless contraindicated.

4.4 MONITORING

Early warning score should be monitored every 30 minutes for 2 hours and
then hourly if stable.
Capillary blood glucose should be monitored every hour.
Serum electrolytes and serum osmolality should be measured at 0 hours,
3 hours, 6 hours, 12 hours and then 12 hourly till metabolic abnormalities
have resolved.
Urinary bladder catheterisation must be performed and strict hourly fluid
balance must be monitored.

Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Management of Hyperosmolar Hyperglycaemic State 2013

4.5 CONVERTING FROM INTRAVENOUS INSULIN INFUSION TO

SUBCUTANEOUS INSULIN/ ORAL HYPOGLYCAEMIC AGENTS

Not all patients will require subcutaneous insulin when the HHS has
resolved many may be able to continue on oral hypoglycaemic agents.
The patient is generally ready to be switched to a subcutaneous insulin
regimen or oral hypoglycaemic agents when he or she
Has stable blood sugar levels
Has regained normal mental status
Is eating and drinking normally

(The metabolic abnormalities may take longer than this to resolve

completely.)

If the patient was admitted on insulin, then recommence their usual insulin
regimen at the same dose.
If the patient was not on insulin previously but now requires subcutaneous
insulin, then contact the Diabetes Specialist Team for advice on insulin
doses and regimen.
When converting from intravenous insulin to a twice daily s/c insulin
regimen, do so at breakfast or tea time.
When converting from intravenous insulin to a basal + bolus regimen, do
so at breakfast, lunch or tea time. Give the long acting basal insulin with
the 1st short acting bolus of insulin.
Administer s/c insulin before the meal and discontinue the intravenous
insulin infusion 30 minutes after the meal.
Never convert to subcutaneous insulin at night time.
If the patient has stable blood sugars BUT is unable to eat and drink:
switch to intravenous insulin therapy (IVIT) as per trust guidelines.

4.6 FURTHER MANAGEMENT AND DISCHARGE POLICY

The patient must be referred to the Diabetes Specialist Team as early as

possible.
The patient must be referred to the Diabetes Specialist Nurses as soon as
possible.
The patient must be referred to a dietician.
Check that the patient has arrangements in place for early outpatient
follow up with the Diabetes Specialist Nurses.
Ensure that the patient has outpatient follow up with the Diabetologists
after discharge.

Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Management of Hyperosmolar Hyperglycaemic State 2013

5.0

Roles and Responsibilities

It is the responsibility of all doctors and nurses looking after patients with
suspected HHS to follow this policy.
It is the responsibility of the Diabetes directorate leads to ensure all
relevant clinical staff are aware of the policy.
It is the responsibility of Pharmacy to ensure the guideline is put onto the
intranet after ratification by Clinical and Cost effectiveness Group, and that
all pharmacists are aware of the policy.

6.0

Associated documentation and references

1 - The management of the hyperosmolar hyperglycaemic state (HHS) in
adults with diabetes, Joint British Diabetes Inpatient Care Group, August
2012

7.0

Training & Resources

Training and reference sources will be provided to all doctors and nurses
working within A&E, AMU and Diabetes.
There will be a link to the policy on the hospital intranet.

8.0

Monitoring and Audit

The table below demonstrates how the Trust will monitor compliance with
the HHS guideline

Minimum
requirement to be
monitored

Process for
monitoring
e.g. audit

Responsible
individual/
group/
committee

Frequency of
monitoring

Responsible
individual/
group/
committee for
review of results

Responsible
individual/
group/
committee for
development
of action plan

Responsible
individual/group/
committee for
monitoring of
action plan and
Implementation

Guideline is
followed in
patients with HHS

Audit

Diabetes and
Endocrinology
Directorate and
Pharmacy

Annual

Diabetes and
Endocrinology
Directorate

Diabetes and
Endocrinology
Directorate
lead and
Diabetology
pharmacist

Diabetes and
Endocrinology
Directorate lead
and Diabetology
pharmacist

9.0

Equality and Diversity

The Trust is committed to an environment that promotes equality and
embraces diversity in its performance as an employer and service
provider. It will adhere to legal and performance requirements and will
mainstream equality and diversity principles through its policies,
procedures and processes. This policy should be implemented with due
regard to this commitment.

Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Management of Hyperosmolar Hyperglycaemic State 2013

To ensure that the implementation of this policy does not have an adverse
impact in response to the requirements of the Race Relations
(Amendment Act) the Disability Discrimination Act 2005, and the Equality
Act 2006 this policy has been screened for relevance during the policy
development process and a full impact assessment conducted where
necessary prior to consultation. The Trust will take remedial action when
necessary to address any unexpected or unwarranted disparities and
monitor practice to ensure that this policy is fairly implemented.
This policy and procedure can be made available in alternative formats on
request including large print, Braille, moon, audio and different languages.
To arrange this please refer to the Trust translation and interpretation
policy in the first instance.
The Trust will endeavour to make reasonable adjustments to
accommodate any employee/patient with particular equality and diversity
requirements in implementing this policy and procedure. This may include
accessibility of meeting/appointment venues, providing translation,
arranging an interpreter to attend appointments/meetings, extending policy
timeframes to enable translation to be undertaken, or assistance with
formulating any written statements.

9.1

Recording and Monitoring of Equality & Diversity

The Trust understands the business case for equality and diversity and will
make sure that this is translated into practice. Accordingly, all policies and
procedures will be monitored to ensure their effectiveness.
Monitoring information will be collated, analysed and published on an
annual basis as part of our Single Equality and Human Rights scheme.
The monitoring will cover all strands of equality legislation and will meet
statutory employment duties under race, gender and disability. Where
adverse impact is identified through the monitoring process the Trust will
investigate and take corrective action to mitigate and prevent any negative
impact.
The information collected for monitoring and reporting purposes will be
treated as confidential and it will not be used for any other purpose.

Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Management of Hyperosmolar Hyperglycaemic State 2013

Glossary of Terms used within Policy

List all terms used within the policy and provide a summary of what the
term means
HONK HyperOsmolar Non-Ketotic hyperglycaemia, a term which has now been
replaced by Hyperosmolar Hyperglycaemic State (HHS)
DKA diabetic ketoacidosis, a condition characterised by raised plasma glucose
(>11 mmol/L), significant ketosis (plasma ketones > 3 mmol/L and/ or urine
ketones > 2+) and acidosis (arterial pH <7.3 and/or plasma bicarbonate <15
mmol/L)
FBC full blood count
CRP C reactive protein
U&E urea and electrolytes
LFT liver function test
Cardiac markers Troponin T
MSSU mid stream sample of urine
CXR chest x ray
GCS Glasgow Coma Scale
AVPU a scale used to assess conscious level based on the whether an
individual is alert, responds to voice or pain, or is unresponsive
Basal Bolus Regimen an insulin regimen consisting of once/ twice daily long
acting or intermediate acting basal insulin along with a bolus of short acting
insulin at mealtimes.
Diabetes Specialist Team team consisting of the Diabetes Inpatient Specialist
Nurse, the on-call Diabetes registrar and the on-call Diabetes Consultant

Clinical Effectiveness Manager. Policy for the development of Trust Policies, Protocols and Guidelines.
Management of Hyperosmolar Hyperglycaemic State 2013