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This is the management of hyponatraemia in a euvolaemic patient. This patient has a normal sodium level and has is noted to be clinically dehydrated. This patient likely has hyperosmolar hyperglycaemic state (HHS) which leads to severe dehydration which is managed with IV fluids (not restricting)
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Fluid restriction to 1L per day
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This is the first line fluid for management of hyperosmolar hyperglycaemic state (HHS). Compared to the serum of a patient with HHS, 0.9% is relatively hypotonic so should restore serum osmolarity to a normal level
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IV 0.9% NaCl
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This patient has hyperosmolar hyperglycaemic state (HHS) which should be addressed and treated before consideration of adjusting their long term diabetic medication
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Increase their metformin to 500mg twice daily
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This is the management for hyperkalaemia. This patient has a normal potassium level and likely has hyperosmolar hyperglycaemic state (HHS). There is evidence to suggest that patients with HHS actually tend to have worse outcomes if they are treated with the diabetic ketoacidosis (DKA) protocol such as with an insulin infusion
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Insulin and dextrose infusion
QuestionChoice
This is incorrect. This patient has hyperosmolar hyperglycaemic state (HHS) which should be treated with fluids. There is evidence to suggest that patients with HHS actually tend to have worse outcomes if they are treated with the diabetic ketoacidosis (DKA) protocol such as with an insulin infusion
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b
Sliding scale insulin infusion
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# Summary 
 
Hyperosmolar Hyperglycaemic State (HHS) is a life-threatening complication of type 2 diabetes, where patients become severely hyperglycaemic and fluid deplete over several days. It tends to present with polyuria and polydipsia, confusion and nausea, and is often triggered by intercurrent infection. Key investigations include blood glucose, ketones and a blood gas to check pH (patients with HHS should not be acidotic or have significant ketonaemia - presence of these may suggest an overlapping syndrome with diabetic ketoacidosis). Bloods including U&Es should be done and serum osmolality calculated or measured. The mainstay of treatment is fluid resuscitation to normalise osmolality and blood glucose. Foot care and venous thromboembolism prophylaxis are also important to prevent complications.
 
# Definition
 
Hyperosmolar Hyperglycaemic State (HHS) is a complication of type 2 diabetes that is usually seen in older patients with known diabetes (although it may represent a first presentation).

The key features of HHS are:

- Blood glucose ≥ 30 mmol/L
- Serum osmolality ≥ 320 mOsm/kg
- Significant hypovolaemia 
- Blood ketones ≤ 3 mmol/L
- pH ≥ 7.3 and bicarbonate  ≥15.0 mmol/L

Patients who otherwise meet the criteria for HHS but are acidotic or have high blood ketones may have a mixed picture of HHS and diabetic ketoacidosis (DKA) - these patients require an insulin infusion alongside fluid resuscitation in order to suppress ketosis. 

# Aetiology

Factors that may precipitate HHS include:

- Infection (commonly chest or urinary tract)
- Recent trauma or surgery
- Other acute events e.g. stroke or myocardial infarction
- Medications e.g. steroids

# Signs and symptoms
 
Symptoms often develop over the course of several days to short weeks, including:
 
 - Polyuria
 - Polydipsia
 - Nausea
 - Lethargy
 - Weakness
 - Confusion
 - Drowsiness
 - Loss of consciousness
 
Signs:

- Tachycardia
- Hypotension
- Altered mental state
- Sunken eyes
- Dry mucous membranes

# Investigations
 
**Bedside tests:**

- Capillary blood glucose - if 30 or higher indicates HHS
- Venous blood gas - to check acid-base status
- Capillary blood ketones - if > 3 suspect HHS/DKA overlap
- ECG - to look for precipitating events or complications e.g. ischaemic changes
- Urine dip and MSU - looking for urinary tract infection, will show glycosuria

**Blood tests:**

- Serum osmolality **(can calculate as (2xNa+) + glucose + urea)**
- Serum glucose
- U&Es - looking for AKI and electrolyte imbalances
- FBC and CRP - inflammatory markers may be raised in intercurrent infection
- LFTs - may be deranged in some triggering infections e.g. ascending cholangitis
- Bone profile - looking for other causes of confusion e.g. hypercalcaemia
- Blood cultures - if infection suspected

**Imaging:**

- Chest X-ray - as part of septic screen 
- Other imaging based on suspected triggers - e.g. CT head for suspected stroke, liver ultrasound if suspected biliary infection

# Management
 
- The key to emergency management of HHS is prompt initiation of fluid resuscitation
   - Start with 1L of 0.9% saline over 1 hour
   - Close monitoring is needed especially in elderly patients or those at risk of heart failure
   - Catheterisation may be required for close monitoring of fluid balance
- An insulin infusion is **not** required initially unless there is a mixed picture of HHS and DKA
- Potassium replacement:
	- if <3.5 or >6, senior review/ICU input required
	- 5.5-5.9 - nil potassium needed
	- 3.5-5.5 - add 40mmol/L to next bag of fluids
- Patients should be assessed for an underlying cause of HHS (e.g. sepsis, stroke) and appropriate management instigated
- Assess foot health and instigate foot care (offload heels, daily checks)
- Intensive monitoring is required with hourly bloods to check glucose, ketones, U&Es and calculate serum osmolality for the first 6 hours
   - The target is for osmolality to fall by 3-8 mOsm/kg/hr
   - If this is not achieved with 0.9% saline and fluid balance is adequate, fluids may be switched to 0.45% saline
   - If glucose plateaus and fluid balance is adequate, consider starting an insulin infusion at 0.05 units/kg/hour
- Ensure venous thromboembolism prophylaxis is prescribed (patients are high risk due to immobility and dehydration)
- Refer to the inpatient diabetes team for assessment prior to discharge

# Complications

* Hypovolemic shock
* Cerebral oedema
* Thromboembolic events
* Acute kidney injury
* Cardiac arrhythmias
* Respiratory failure
* Long-term neurological sequelae

# NICE Guidelines

[NICE CKS - Type 2 Diabetes](https://cks.nice.org.uk/topics/diabetes-type-2/)

# References
 
[Association of British Clinical Diabetologists - Management of
Hyperosmolar Hyperglycaemic State in Adults](https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Current/JBDS_06_The_Management_of_Hyperosmolar_Hyperglycaemic_State_HHS_%20in_Adults_FINAL_0.pdf)

[ABCD - HHS algorithm](https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Current/JBDS_06_HHS_care_pathway_in_adults_2022.pdf)
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Emergency Management of Hyperosmolar Hyperglycaemic State (HHS) 2
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In hyperosmolar hyperglycaemic state (HHS), intravenous 0.9% NaCl is the first-line treatment to restore fluid balance and serum osmolarity.
A known type 2 diabetic presents to the emergency department with generalised fatigue and vomiting. They have a reduced level of consciousness and are clinically dehydrated.


They are currently prescribed metformin 500mg once daily for their type 2 diabetes.


Their biochemical results may be seen below:

||||
|---------------------------|:-------:|------------------------------|
|Non-fasting Glucose|35 mmol/L|< 6.1|
|Sodium|144 mmol/L|135 - 145|
|Potassium|4.5 mmol/L|3.5 - 5.3|

 - Serum osmolarity: raised
 - Ketones: normal


What is the next best step in the management of this patient?
a