Clinical assessment and risk stratification

Precipitating factors of hyperosmolar hyperglycaemic state (HHS) include:

  • Infection
  • Inadequate insulin or non-adherence to diabetic treatment.
  • New onset of diabetes mellitus or other physiological stress (such as trauma or surgery).
  • Other medical conditions (such as hypothyroidism or pancreatitis).
  • Drugs (such as corticosteroids, diuretics, atypical antipsychotics, and sympathomimetic drugs such as salbutamol).

Markers of Severity Indicating the Need for High Dependency / Level 2 Care:

Consider the need for admission to a high-dependency unit / level 2 environment, when one or more of the following are present:

  • osmolality greater than 350 mosmol/kg
  • sodium above 160 mEq/L
  • venous ⁄ arterial pH below 7.1
  • hypokalaemia (less than 3.5 mEq/L) or hyperkalaemia (greater than 6 mEq/L) on admission
  • Glasgow Coma Scale (GCS) less than 12 or abnormal
  • oxygen saturation below 92% on air (assuming normal baseline respiratory function)
  • systolic blood pressure below 90 mmHg
  • pulse over 100 or below 60 bpm
  • urine output less than 0.5 ml/kg/hr
  • serum creatinine >200 µmol/L
  • hypothermia
  • macrovascular event such as myocardial infarction or stroke
  • other serious co-morbidity


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