HHS. Hyperglycaemic Hyperosmolar State Care Pathway 1 Presenta8on to 6 hours. Page 1 of 2 AFFIX PATIENT LABEL ! INFORM DIABETES TEAM OF ADMISSION!

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1 Hyperglycaemic Hyperosmolar State Care Pathway 1 Presenta8on to 6 hours Page 1 of 2 Time of Arrival Loca8on Date / / Diagnosis the characteris8c features of a person with HHS are a) Hypovolaemia b) Marked hyperglycaemia (30 mmol/l or more) without significant hyperketonaemia (less than 3 mmol/l), ketonuria (2+ or less) or acidosis (H + <45 mmol/l, HCO 3 - > 15 mmol/l) c) Osmolality usually 320 mosmol/kg or more HHS AFFIX PATIENT LABEL A mixed picture of HHS and DKA may occur Aims GRADUAL normalisa<on of dehydra<on and metabolic abnormali<es 1. Reduce the serum osmolality by 3 8 mosmol/kg per hour 2. Reduce the plasma glucose by less than 5 mmol/l per hour Plasma osmolality is calculated as (2 x Na + ) + glucose + urea regular assessment is mandatory! INFORM DIABETES TEAM OF ADMISSION! 1. Immediate ac<ons 0 to 60 minutes Record 8me of arrival Assess severity (guidance note 1) including detailed volume status assessment Commence IV 0.9% Sodium Chloride - 1 litre over 1 hour (more rapid replacement may be required when SBP <90 and slower replacement considered when heart failure a concern) Only commence insulin (0.05 units/kg/hr) if significant ketonaemia (> 1 mmol/l) or ketonuria (> 2+) Check capillary blood glucose, capillary or urinary ketones, U&Es, venous blood gas, lactate, calculate osmolality (2 x Na + + glucose + urea) and FBC. Record relevant details in flow sheet (overleaf) Insert urinary catheter and monitor hourly urine output Commence prophylac8c LMWH (pa8ents are at high risk of arterial and venous thrombosis) Record es8mated water loss (guidance note 3) Other interven<ons to be considered ECG and consider cardiac monitor Record GCS score CRP MSSU IV an8bio8cs (if sepsis suspected) Blood cultures Central line Chest X- ray Record foot risk (guidance note 5) If deteriora<ng, consultant or senior physician called 2. Management 60 minutes to 6 hours Aim for gradual decline in osmolality (3 8 mosmol/kg/hr) and achieve posi8ve fluid balance of 2 3 L by 6 hours Aim to give L/hr 0.9% Sodium Chloride (depending on clinical fluid balance assessment) Measure glucose and U&Es hourly and calculate osmolality 1h 2h 3h 4h 5h 6h Adjust fluid administra8on based on clinical assessment and hourly assessment of osmolality (guidance note 2) Potassium replacement follow guidance note 4 If blood glucose falling less than 5 mmol/l check fluid balance. If posi8ve balance inadequate increase rate of 0.9% Sodium Chloride infusion. If posi8ve balance adequate start IV insulin at 0.05 units/kg/hr (or increase rate to 0.1 units/kg/hr if already running) Aim to keep glucose between mmol/l. If glucose falls below 14 mmol/l commence 10% glucose at 125 ml/hr AND CONTINUE sodium chloride solu8on Joint Bri8sh Diabetes Socie8es HHS protocol August 2012 NHS Lothian version 3 F. Gibb and S. Ritchie 01/04/2014

2 HHS pa8ent data flow chart First 12 hours Presentation After 1 hour After 2 hours After 3 hours After 4 hours Time (use 24hr clock) Mental status (AVPU) Respiratory rate SaO 2 (%) OBSERVATIONS Inspired O 2 (%) Temperature ( C) BP (mmhg) Heart rate / / / / / Hourly urine output (ml/hr) Total cumulative urine output (ml) SEWS Glucose (mmol/l) lab [L], gas [G], BM [B] Sodium (mmol/l) BIOCHEMISTRY Urea (mmol/l) Serum osmolality * (mosmol/kg) Potassium (mmol/l) Bicarbonate (mmol/l) Hydrogen ion (mmol/l) Insulin (units infused in past hour) FLUIDS & INSULIN 0.9% Saline (ml infused in past hour) 0.45% Saline (ml infused in past hour) 10% Glucose (ml infused in past hour) KCL (mmol infused in past hour) Total fluid input (litres) Fluid balance since admission (litres) Staff nurse responsible for care (initial) Doctor responsible for care (initial)! HIGHLIGHTED BOXES ARE MANDATORY! *Calculated osmolality = 2 x Na + + glucose + urea

3 HHS GOALS OF TREATMENT Aner 6 hours, begin using Care Pathway 2 but con8nue recording data in this flow chart up to 12 hours Normalise the osmolality Replace fluid and electrolyte losses Normalise blood glucose Preven8on of arterial or venous thrombosis Prevent other complica8ons (e.g. Cerebral oedema / osmo8c demyelina8on) Prevent foot ulcera8on After 5 hours After 6 hours After 7 hours After 8 hours After 9 hours After 10 hours After 11 hours After 12 hours / / / / / / / / FLOW CHART FOR NEXT 12 HOURS IS IN CARE PATHWAY 2

4 Hyperglycaemic Hyperosmolar State Care Pathway 1 Presenta8on to 6 hours Page 2 of 2 Fluid (Potassium) prescrip<on sheet FLUID VOL (ml) RATE PRINT NAME SERIAL NO TIME BEGUN POTASSIUM DOSE SIGNATURE BATCH NO (mmol) A Sodium Chloride 0.9% 500 ml 1L / hr B Sodium Chloride 0.9% 500 ml 1L / hr C D E F G H I Once Blood Glucose <14 mmol/l start Glucose 10% J Glucose 10% K Glucose 10% L Intravenous Insulin Prescrip<on TIME INSULIN RATE (units/hr) TYPE OF INSULIN PRINT NAME SIGNATURE NEW PRINCIPLES Measure or calculate osmolality (2Na+ + glucose + urea) frequently to monitor treatment response. Use IV 0.9% sodium chloride solu8on as the principle fluid to restore circula8ng volume and reverse dehydra8on. Only switch to 0.45% sodium chloride solu8on if the osmolality is not declining despite adequate posi8ve fluid balance. An ini8al rise in sodium is expected and is not in itself an indica8on for hypotonic fluids. Thereaner, the rate of fall of plasma sodium should not exceed 10 mmol/l in 24 hours. The fall in blood glucose should be no more than 5 mmol/l/hr. Low dose IV insulin (0.05 units/kg/hr) should be commenced once the blood glucose is no longer falling with IV fluids alone OR immediately if there is significant ketonaemia (3β- hydroxy butyrate greater than 1mmol/L). Assess foot risk score on admission.

5 Hyperglycaemic Hyperosmolar State Care Pathway 2 6 hours to day 3 Page 1 of 2 Time pathway started Loca8on Date / / Aims a) Ensure clinical and biochemical parameters are improving b) Con8nue IV fluid replacement (posi8ve balance of 3-6 litres by 12 hours and replacement of es8mated losses by 24 hours) c) Assess for complica8ons of treatment d) Con8nue trea8ng underlying precipitant(s) e) Avoid hypoglycaemia HHS AFFIX PATIENT LABEL 1. Management from 6 to 12 hours Aim for gradual decline in osmolality (3 8 mosmol/kg/hr) and achieve posi8ve balance of 3 6 litres by 12 hours Measure and record glucose hourly; U&Es and calculated osmolality 2 hourly. Ensure results are recorded in the data flow chart. Refer to guidance note 2 if osmolality is not falling at the desired rate. If blood glucose falling less than 5 mmol/l check fluid balance. If posi8ve balance inadequate increase rate of 0.9% Sodium Chloride infusion. If posi8ve balance adequate start IV insulin at 0.05 units/kg/hr (or increase rate to 0.1 units/kg/hr if already running) Aim to keep glucose between mmol/l. If glucose falls below 14 mmol/l commence 10% glucose at 125 ml/hr AND CONTINUE sodium chloride solu8on Adjust insulin infusion by 1 unit/hr increments or decrements to achieve desired blood glucose Potassium replacement follow guidance note 4. Assess for complica8ons and ensure senior review if pa8ent (or biochemistry) not improving 2. Management from 12 to 24 hours Aim for gradual decline in osmolality (3 8 mosmol/kg/hr) and replace es8mated fluid losses by 24 hours Review fluid balance to date and es8mate fluid deficit to be replaced in the hour period Es8mated minimum fluid loss at presenta8on (guidance note 3) litres Fluid replaced to 12 hours litres Residual volume to be replaced between hours litres Measure and record glucose hourly; U&Es and calculated osmolality 4 hourly (2 hourly if not improving) Follow guidance note 2 if osmolality is not falling at the required rate. Adjust insulin (if running) as previously described. Replace potassium as indicated in guidance note 4. Assess for complica8ons and ensure senior review if pa8ent (or biochemistry) not improving 3. Management from 24 hours to 3 days Pa8ent should be steadily recovering, beginning to eat and drink, biochemistry back to normal Ensure clinical and biochemical parameters are improving Con8nue IV fluids and variable rate insulin un8l ea8ng and drinking then convert to subcutaneous insulin Encourage mobilisa8on Daily U&Es (minimum) Remove catheter when appropriate Assess for complica8ons and sepsis Daily foot checks Con8nue LMWH un8l discharge (and possibly beyond in very high risk pa8ents) Joint Bri8sh Diabetes Socie8es HHS protocol August 2012 NHS Lothian version 3 F. Gibb and S. Ritchie 01/04/2014

6 HHS pa8ent data flow chart 13 to 24 hours After 13 hours After 14 hours After 15 hours After 16 hours After 17 hours Time (use 24hr clock) Mental status (AVPU) Respiratory rate SaO 2 (%) OBSERVATIONS Inspired O 2 (%) Temperature ( C) BP (mmhg) Heart rate / / / / / Hourly urine output (ml/hr) Total cumulative urine output (ml) SEWS Glucose (mmol/l) lab [L], gas [G], BM [B] Sodium (mmol/l) BIOCHEMISTRY Urea (mmol/l) Serum osmolality (mosmol/kg) Potassium (mmol/l) Bicarbonate (mmol/l) Hydrogen ion (mmol/l) Insulin (units infused in past hour) FLUIDS & INSULIN 0.9% Saline (ml infused in past hour) 0.45% Saline (ml infused in past hour) 10% Glucose (ml infused in past hour) KCL (mmol infused in past hour) Total fluid input (litres) Fluid balance since admission (litres) Staff nurse responsible for care (initial) Doctor responsible for care (initial)! HIGHLIGHTED BOXES ARE MANDATORY!

7 HHS GOALS OF TREATMENT Normalise the osmolality Replace fluid and electrolyte losses Normalise blood glucose Preven8on of arterial or venous thrombosis Prevent other complica8ons (e.g. Cerebral oedema / osmo8c demyelina8on) Prevent foot ulcera8on After 18 hours After 19 hours After 20 hours After 21 hours After 22 hours After 23 hours After 24 hours / / / / / / /

8 Hyperglycaemic Hyperosmolar State Care Pathway 2 From 6 hours to 3 days Page 2 of 2 Fluid (Potassium) prescrip<on sheet FLUID VOL (ml) RATE PRINT NAME SERIAL NO TIME BEGUN POTASSIUM DOSE SIGNATURE BATCH NO (mmol) A B C D E F G H I Once Blood Glucose <14 mmol/l start Glucose 10% J Glucose 10% K Glucose 10% L Intravenous Insulin Prescrip<on TIME INSULIN RATE (units/hr) TYPE OF INSULIN PRINT NAME SIGNATURE PLEASE USE SUPPLEMENTARY HHS FLUID/INSULIN CHART IF REQUIRED

9 Hyperglycaemic Hyperosmolar State Supplementary fluid / insulin prescrip8on Use this chart if no further space on Care Pathway 2 fluid prescrip8on sheet AFFIX PATIENT LABEL Fluid (Potassium) prescrip<on sheet FLUID VOL (ml) RATE PRINT NAME SERIAL NO TIME BEGUN POTASSIUM DOSE SIGNATURE BATCH NO (mmol) A B C D E F G Once Blood Glucose <14 mmol/l start Glucose 10% H Glucose 10% I Glucose 10% J K Intravenous Insulin Prescrip<on TIME INSULIN RATE (units/hr) TYPE OF INSULIN PRINT NAME SIGNATURE

10 SECTION 1. SEVERITY ASSESSMENT Hyperglycaemic Hyperosmolar State Guidance notes Pa8ents with HHS are generally very unwell on presenta8on and require regular assessment. Seek senior advice (and consider HDU review) if severity markers present or if deteriora8ng despite treatment Osmolality greater than 350 mosmol/kg Sodium greater than 160 mmol/l or H other + greater serious than co- morbidity 80 mmol/l Hypokalaemia (<3.5 mmol/l) or Hyperkalaemia (> 6mmol/L) GCS less than 12 Oxygen satura8on below 92% (if normal respiratory baseline) Systolic BP < 90 mmhg Pulse over 100 or below 60 bpm Urine output less than 0.5 ml/kg/hr Serum crea8nine >200 µmol/l Hypothermia Macrovascular event or other serious co- morbidity SECTION 2. INTERPRETING AND RESPONDING TO OSMOLALITY RESULTS If osmolality falling at the required rate of 3 8 mosmol/l con8nue 0.9% Sodium Chloride If plasma Na + increasing but osmolality declining at appropriate rate con8nue 0.9% Sodium Chloride If plasma Na + increasing AND osmolality increasing (or declining <3 mosmol/kg/hr) check fluid balance if or posi8ve other serious balance co- morbidity inadequate increase rate of 0.9% Sodium Chloride. If fluid balance adequate consider switch to 0.45% Sodium Chloride If osmolality falling at rate exceeding 8 mosmol/kg/hr consider reducing infusion rate of IV fluids and/or IV insulin (if already commenced) SECTION 3. ESTIMATED MINIMUM FLUID AND ELECTROLYTE LOSSES (AT PRESENTATION) Weight (kg) Water (litres) Sodium (mmol) Potassium (mmol) SECTION 4. POTASSIUM REPLACEMENT If potassium above 5.5 mmol/l no addi8onal KCL. or If other potassium serious between co- morbidity 3.5 and 5.5 prescribe 20 mmol/l KCL per infusion fluid. If potassium below 3.5 mmol/l seek senior advice. SECTION 5. FOOT RISK ASSESSMENT Risk category Criteria Ac8on ACTIVE Presence of active ulceration, spreading infection, critical ischaemia, gangrene or unexplained hot, red, swollen foot with or without the presence of pain. Rapid referral to Multidisciplinary Foot Team. HIGH RISK Previous ulceration or amputation or more than one risk factor present e.g. loss of sensation or signs of peripheral vascular disease with callus or deformity. Use foam heel protectors to reduce heel ulcer risk. MEDIUM RISK LOW RISK One risk factor present e.g. loss of sensation or signs of peripheral vascular disease without callus or deformity. No risk factors present e.g. no loss of sensation, no signs of peripheral vascular disease and no other risk factors. Annual podiatry input no urgent action required. Annual screening no urgent action required. Joint Bri8sh Diabetes Socie8es HHS protocol August 2012 NHS Lothian version 3 F. Gibb and S. Ritchie 01/04/2014