Diabetic medicine : a journal of the British Diabetic Association · 2026
Hyperosmolar hyperglycaemic state: A systematic review of management guidelines and their evidence.
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Lin Rose, Wootton Elizabeth, Gaca Michele, Venkatesh Balasubramanian, Bellomo Rinaldo, Ekinci Elif
Аннотация
BACKGROUND: Hyperosmolar hyperglycaemic state (HHS) is an endocrine emergency associated with increased morbidity and mortality. HHS management is largely varied in clinical practice due to a lack of high-quality evidence. This systematic review aims to compare international guidelines and their underlying evidence base in HHS management.
METHODS: Searching MEDLINE, Embase and Emcare databases and reviewing references of relevant papers identified 363 papers, of which seven met the inclusion criteria.
RESULTS: The features of HHS include hypovolaemia, hyperglycaemia and hyperosmolality, but criteria for diagnosis vary from glucose ≥33.3 mmol/L and osmolality ≥320 mOsm/kg (American Diabetes Association [ADA] and Diabetes Canada [DC]) to glucose ≥30.0 mmol/L with osmolality ≥320 mOsm/kg (Joint British Diabetes Society [JBDS]). The ADA and DC guidelines recommend correction of serum osmolality <3 mOsm/kg/h, whereas the JBDS accepts an osmolality change of 3-8 mOsm/kg/h. ADA guidelines suggest 0.9% normal saline at 15-20 mL/kg/h or 1-1.5 L/h, whereas JBDS guidelines suggest replacing ~50% of the estimated fluid loss within the first 12 h. The ADA and DC guidelines recommend a fixed rate insulin infusion of 0.1 units/kg/h. The JBDS guidelines recommend 0.05 units/kg/h, increasing by 1.0 units/h as required.
CONCLUSIONS: These guidelines are consensus-based rather than evidence-based because no randomised controlled trials exist. Further research specific to HHS is required to standardise diagnosis and optimise management.
METHODS: Searching MEDLINE, Embase and Emcare databases and reviewing references of relevant papers identified 363 papers, of which seven met the inclusion criteria.
RESULTS: The features of HHS include hypovolaemia, hyperglycaemia and hyperosmolality, but criteria for diagnosis vary from glucose ≥33.3 mmol/L and osmolality ≥320 mOsm/kg (American Diabetes Association [ADA] and Diabetes Canada [DC]) to glucose ≥30.0 mmol/L with osmolality ≥320 mOsm/kg (Joint British Diabetes Society [JBDS]). The ADA and DC guidelines recommend correction of serum osmolality <3 mOsm/kg/h, whereas the JBDS accepts an osmolality change of 3-8 mOsm/kg/h. ADA guidelines suggest 0.9% normal saline at 15-20 mL/kg/h or 1-1.5 L/h, whereas JBDS guidelines suggest replacing ~50% of the estimated fluid loss within the first 12 h. The ADA and DC guidelines recommend a fixed rate insulin infusion of 0.1 units/kg/h. The JBDS guidelines recommend 0.05 units/kg/h, increasing by 1.0 units/h as required.
CONCLUSIONS: These guidelines are consensus-based rather than evidence-based because no randomised controlled trials exist. Further research specific to HHS is required to standardise diagnosis and optimise management.