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endo.hhs.core.v1PRODUCTION
endo.hhs.core.v1

Hyperosmolar hyperglycemic state (adult)

endocrinologyacuteadult
Hard-required inputs
0 / 10
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm HHS criteria (glucose ≥600, eff osm >300, pH >7.30, BHB <3.0, AMS) and exclude pure DKA / mixed DKA-HHS (ADA/EASD 2024 consensus; ADA 2026 §16)

Inputs
4
Actions
0
Advance rule
Set
Advance when

HHS criteria met per ADA/EASD 2024 consensus

Patient inputs (11)

Elderly substrate; silent precipitants (MI/sepsis); drug list per Beers 2023 (Scott 2015 UK audit)

Infection #1 (UTI/pneumonia/sepsis), MI/stroke, drug (steroid/SGA/thiazide) (JBDS-IP 2023; Pasquel 2014)

≥600 mg/dL diagnostic threshold (ADA 2026 §16); switch to dextrose-containing IVF when <300 (JBDS-IP 2023)

Effective osmolality >300 mOsm/kg defines HHS (ADA/EASD 2024 consensus)

BHB <3.0 distinguishes from DKA; ≥3.0 → mixed DKA-HHS (ADA/EASD 2024 consensus)

pH >7.30 in pure HHS; lower → mixed DKA-HHS (ADA/EASD 2024 consensus; Kitabchi 2009)

Corrected Na trend drives ½NS switch; ODS-prevention rate ceiling (JBDS-IP 2023; Adrogué-Madias NEJM 2000)

Total-body K depleted but serum may be normal/high; replete before insulin (ADA 2026 §16; Kitabchi 2009)

Pre-renal AKI universal in HHS; gates dosing (Pasquel 2014; KDIGO 2024)

Fluid + insulin dosing weight-based; total deficit often 6–9 L (JBDS-IP 2023; Kitabchi 2009)

Beers 2023: thiazides, steroids, SGAs, phenytoin, beta-blockers precipitate HHS (JBDS-IP 2023; Scott 2015)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningeffective_osm_gt_350_with_AMS_JBDS_2023
    Effective osmolality >350 mOsm/kg with coma or seizure (ADA/EASD 2024 consensus; JBDS-IP 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverek_lt_3_3_hold_insulin_hhs_ADA_2026
    K <3.3 mEq/L on initial labs (ADA 2026 §16; Kitabchi 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereosm_falling_too_fast_JBDS_2023
    Effective osmolality falling >8 mOsm/kg/h OR glucose >90 mg/dL/h (JBDS-IP 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremixed_dka_hhs_ADA_EASD_2024
    Glucose ≥600 + osm >320 + BHB ≥3.0 + pH <7.30 (ADA/EASD 2024 consensus)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresepsis_precipitant_qsofa_2_SSC_2026
    qSOFA ≥2 (RR ≥22, SBP ≤100, AMS) at presentation (Sepsis-3 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresilent_MI_or_stroke_precipitant_JBDS_2023
    New ECG/troponin abnormality OR focal neuro deficit (JBDS-IP 2023; Pasquel 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefree_water_deficit_severe_JBDS_2023
    Calculated free-water deficit >10 mL/kg with effective osmolality >340 mOsm/kg (JBDS-IP 2023; Kitabchi 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypernatremia_post_correction_JBDS_2023
    Corrected sodium rising above 150 mEq/L despite NS resuscitation (JBDS-IP 2023; Adrogué-Madias NEJM 2000)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehhs_no_VTE_prophylaxis_JBDS_2023
    HHS admission without VTE prophylaxis ordered within 24h (JBDS-IP 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebeers_list_precipitant_active_Beers_2023
    Active prescription for Beers 2023-list HHS precipitant — thiazide diuretic, atypical antipsychotic (olanzapine, clozapine, quetiapine), high-dose corticosteroid, phenytoin, or beta-blocker — identified on admission medication reconciliation (JBDS-IP 2023; Scott 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

HHS acute — JBDS-IP 06 (2nd ed 2023) fluid-first + delayed low-dose insulin
axis: hhs_acute_jbds_fluid_firststep 1 - Stage 1 — Fluid resuscitation (first 1h) (JBDS-IP 2023)
Selected step "Stage 1 — Fluid resuscitation (first 1h) (JBDS-IP 2023)" — HHS confirmed (glucose ≥600, eff osm >320, pH >7.30) per ADA/EASD 2024 consensus
  • 0.9% sodium chloride
    first line
    crystalloid
    1 L IV over 1h (no bolus); aim positive balance 3–6 L by 12h, 6–9 L by 24h (JBDS-IP 2023) • IV • continuous
    triggers: hhs_confirmed
    JBDS-IP 06 (2nd ed 2023) — fluids alone often drop glucose by 50–100 mg/dL/h and reduce osmolality before any insulin (Kitabchi 2009)
    rxcui 9863

ed playbook — drug actions (6)

  1. 1. 0.9% NaCl
    1 L IV over 1h (no bolus) • IV • over 1h
    trigger: HHS confirmed (ADA/EASD 2024)
    JBDS-IP 06 (2nd ed 2023) fluid-first
  2. 2. KCl
    K<3.3: hold insulin + 20–40 mEq/h; K 3.3–5.2: 20–30 mEq/L in fluids • IV • continuous in fluids
    trigger: K result back
    Total-body K depletion universal (Kitabchi 2009; ADA 2026 §16)
  3. 3. continued NS
    500 mL/h × 2h then 250–500 mL/h • IV • continuous
    trigger: After hour 1
    Slow rehydration (JBDS-IP 2023)
  4. 4. regular insulin IV (delayed)
    0.05 U/kg/h; NO bolus • IV • continuous
    trigger: Glucose plateau OR BHB >1 (mixed DKA-HHS) (JBDS-IP 2023)
    Half DKA rate (JBDS-IP 2023; Pasquel 2014)
  5. 5. enoxaparin VTE prophylaxis
    40 mg SC daily (30 if CrCl<30) • SC • daily
    trigger: Admission
    HHS hyperviscosity = thrombosis risk (JBDS-IP 2023; Scott 2015)
  6. 6. broad-spectrum antibiotics (if sepsis)
    Per source (e.g., cefepime 2g IV q8h + vancomycin) • IV • per agent
    trigger: qSOFA ≥2 or evident infection (Sepsis-3 2016)
    Sepsis is #1 trigger (Pasquel 2014; SSC 2026)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Glucose ≥600 mg/dL (ADA 2026 §16; Kitabchi 2009); AMS in elderly diabetic (JBDS-IP 2023; Scott 2015 UK audit); Effective osmolality >300 mOsm/kg without ketoacidosis (ADA/EASD 2024 consensus).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hyperosmolar hyperglycemic state (adult)** (endo.hhs.core.v1).
Phenotype framing: Exclude pure DKA, mixed DKA-HHS, hyperglycemia-induced AMS without HHS, primary stroke/CNS process (ADA/EASD 2024 consensus; Kitabchi 2009)
Scope: Confirm HHS criteria (glucose ≥600, eff osm >300, pH >7.30, BHB <3.0, AMS) and exclude pure DKA / mixed DKA-HHS (ADA/EASD 2024 consensus; ADA 2026 §16)

No severity triggers fired against current inputs.

Plan

Regimen axis: **HHS acute — JBDS-IP 06 (2nd ed 2023) fluid-first + delayed low-dose insulin** — step "Stage 1 — Fluid resuscitation (first 1h) (JBDS-IP 2023)".
1. 0.9% sodium chloride 1 L IV over 1h (no bolus); aim positive balance 3–6 L by 12h, 6–9 L by 24h (JBDS-IP 2023) IV continuous (crystalloid, first line) — JBDS-IP 06 (2nd ed 2023) — fluids alone often drop glucose by 50–100 mg/dL/h and reduce osmolality before any insulin (Kitabchi 2009)

Setting playbook (ed) — Recognize HHS, start fluids before insulin (JBDS-IP 2023), identify precipitant (sepsis/MI/stroke), triage to ICU
2. 0.9% NaCl 1 L IV over 1h (no bolus) IV over 1h — HHS confirmed (ADA/EASD 2024) (JBDS-IP 06 (2nd ed 2023) fluid-first)
3. KCl K<3.3: hold insulin + 20–40 mEq/h; K 3.3–5.2: 20–30 mEq/L in fluids IV continuous in fluids — K result back (Total-body K depletion universal (Kitabchi 2009; ADA 2026 §16))
4. continued NS 500 mL/h × 2h then 250–500 mL/h IV continuous — After hour 1 (Slow rehydration (JBDS-IP 2023))
5. regular insulin IV (delayed) 0.05 U/kg/h; NO bolus IV continuous — Glucose plateau OR BHB >1 (mixed DKA-HHS) (JBDS-IP 2023) (Half DKA rate (JBDS-IP 2023; Pasquel 2014))
6. enoxaparin VTE prophylaxis 40 mg SC daily (30 if CrCl<30) SC daily — Admission (HHS hyperviscosity = thrombosis risk (JBDS-IP 2023; Scott 2015))
7. broad-spectrum antibiotics (if sepsis) Per source (e.g., cefepime 2g IV q8h + vancomycin) IV per agent — qSOFA ≥2 or evident infection (Sepsis-3 2016) (Sepsis is #1 trigger (Pasquel 2014; SSC 2026))

Non-pharmacologic actions:
- Foley + strict I/Os (JBDS-IP 2023)
- Cardiac monitor (ADA 2026 §16)
- Central access if vasopressors (SSC 2026)
- Stop precipitating drugs (thiazides, atypicals, steroids when feasible) (Beers 2023; Scott 2015)

AVOID / contraindication checks:
- No_bolus_NS_in_HHS_first_hour_only_1L
- Hold_insulin_if_K_lt_3_3
- Delay_insulin_until_glucose_plateau_or_BHB_gt_1
- Osmolar_fall_max_3_to_8_mOsm_kg_per_h
- Glucose_fall_max_90_mg_dL_per_h_to_prevent_ODS
- VTE_prophylaxis_mandatory_in_HHS
- Overlap_basal_2h_before_stopping_IV_insulin

Monitoring

Regimen monitoring:
- glucose q1h (ADA 2026 §16; JBDS-IP 2023)
- BMP q1-2h x first 6h then q2-4h (ADA 2026 §16; Kitabchi 2009)
- corrected Na q1-2h (JBDS-IP 2023; Pasquel 2014)
- osmolality q2-4h (ADA 2026 §16; JBDS-IP 2023)
- neuro checks q1h (JBDS-IP 2023; Pasquel 2014)
- fluid balance strict I/O (ADA 2026 §16)
- telemetry (ADA 2026 §16)
- daily VTE risk review (NICE 2024)

Setting (ed) monitoring:
- POC glucose q1h (JBDS-IP 2023)
- BMP + osm q2h (JBDS-IP 2023)
- GCS q1h (JBDS-IP 2023)
- BP + telemetry continuous (ADA 2026 §16)

Follow-up plan: Endo + diabetes education; review precipitant; revise outpatient T2DM regimen per ADA 2026 §9 cardiorenal-first (SGLT2i/GLP-1 RA); medication reconciliation removing precipitating drugs (Beers 2023)
- Close-out criterion: follow-up scheduled; outpatient regimen optimized per ADA 2026

Monitoring phase: Hourly glucose, BMP q1–2h, corrected Na q1–2h, osmolality q2–4h, neuro checks q1h, strict I/Os, telemetry, daily VTE-prophylaxis review (JBDS-IP 2023; ADA 2026 §16)

Disposition

Current setting: ed — Recognize HHS, start fluids before insulin (JBDS-IP 2023), identify precipitant (sepsis/MI/stroke), triage to ICU

Disposition criteria:
- ICU mandatory for AMS / shock / mixed DKA-HHS / pregnancy (JBDS-IP 2023)
- Step-down once glucose <300 + osm <320 + alert (JBDS-IP 2023; ADA 2026 §16)

Escalation triggers (move to higher acuity):
- Shock despite 30 mL/kg → ICU + vasopressors (SSC 2026; JBDS-IP 2023)
- AMS / coma → ICU airway watch (JBDS-IP 2023)
- Mixed DKA-HHS (BHB ≥3 + AGMA) → ICU + DKA-style insulin (ADA/EASD 2024 consensus)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Effective osmolality >350 mOsm/kg with coma or seizure (ADA/EASD 2024 consensus; JBDS-IP 2023)
- [SEVERE] K <3.3 mEq/L on initial labs (ADA 2026 §16; Kitabchi 2009)
- [SEVERE] Effective osmolality falling >8 mOsm/kg/h OR glucose >90 mg/dL/h (JBDS-IP 2023)

Citations

- 2024 ADA/EASD/JBDS/AACE/DTS Hyperglycemic Crises Consensus + ADA SoC 2026 Ch 16 (Diabetes Care in the Hospital) + JBDS-IP 06 (2nd ed 2022, 2023 update) + KDIGO 2024 CKD (AKI staging) + 2025 AHA/ACC HTN (post-resolution BP) [PMID:39052901](https://pubmed.ncbi.nlm.nih.gov/39052901/)
- Cited evidence (PMID 19564476) [PMID:19564476](https://pubmed.ncbi.nlm.nih.gov/19564476/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2024 ADA/EASD/JBDS/AACE/DTS Hyperglycemic Crises Consensus + ADA SoC 2026 Ch 16 (Diabetes Care in the Hospital) + JBDS-IP 06 (2nd ed 2022, 2023 update) + KDIGO 2024 CKD (AKI staging) + 2025 AHA/ACC HTN (post-resolution BP) — PMID:39052901
  • Cited evidence (PMID 19564476) — PMID:19564476