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It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre\u2010existing\/new type 2 diabetes mellitus and increasingly affecting children\/younger adults. Mixed DKA\/HHS may occur. The JBDS HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0\u201360\u2009min, 1\u20136, 6\u201312, 12\u201324 and 24\u201372\u2009h). Clinical features of HHS include marked hypovolaemia, osmolality \u2265320\u2009mOsm\/kg using [(2\u00d7Na<jats:sup>+<\/jats:sup>)\u2009+\u2009glucose+urea], marked hyperglycaemia \u226530\u2009mmol\/L, without significant ketonaemia (\u22643.0\u2009mmol\/L), without significant acidosis (pH &gt;7.3) and bicarbonate \u226515\u2009mmol\/L. Aims of the therapy are to improve clinical status\/replace fluid losses by 24\u2009h, gradual decline in osmolality (3.0\u20138.0\u00a0mOsm\/kg\/h to minimise the risk of neurological complications), blood glucose 10\u201315\u2009mmol\/L in the first 24\u2009h, prevent hypoglycaemia\/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100\u2013220\u2009ml\/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose &lt;14\u2009mmol\/L and (4) potassium replacement according to potassium levels. HHS resolution criteria are: osmolality &lt;300\u2009mOsm\/kg, hypovolaemia corrected (urine output \u22650.5\u00a0ml\/kg\/h), cognitive status returned to pre\u2010morbid state and blood glucose &lt;15\u2009mmol\/L.<\/jats:p>","DOI":"10.1111\/dme.15005","type":"journal-article","created":{"date-parts":[[2022,11,12]],"date-time":"2022-11-12T13:14:27Z","timestamp":1668258867000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":67,"title":["Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group"],"prefix":"10.1111","volume":"40","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3123-809X","authenticated-orcid":false,"given":"Omar G.","family":"Mustafa","sequence":"first","affiliation":[{"name":"Department of diabetes King's College Hospital NHS Foundation Trust  London UK"},{"name":"King's College London  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masud","family":"Haq","sequence":"additional","affiliation":[{"name":"Maidstone and Tunbridge Wells NHS Trust  Tunbridge Wells UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7745-1852","authenticated-orcid":false,"given":"Umesh","family":"Dashora","sequence":"additional","affiliation":[{"name":"Conquest Hospital, Easdt Sussex Healthcare NHS Trust  The Ridge St Leonards on Sea UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erwin","family":"Castro","sequence":"additional","affiliation":[{"name":"Conquest Hospital, Easdt Sussex Healthcare NHS Trust  The Ridge St Leonards on Sea UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3619-9579","authenticated-orcid":false,"given":"Ketan K.","family":"Dhatariya","sequence":"additional","affiliation":[{"name":"Elsie Bertram Diabetes Centre Norfolk and Norwich University Hospitals NHS Foundation Trust  Norwich UK"},{"name":"Norwich Medicine School University of East Anglia  Norwich UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"the Joint British Diabetes Societies (JBDS) for Inpatient Care Group","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2022,12,21]]},"reference":[{"key":"e_1_2_17_2_1","doi-asserted-by":"publisher","DOI":"10.5114\/pedm.2019.85819"},{"key":"e_1_2_17_3_1","doi-asserted-by":"publisher","DOI":"10.2337\/dc19-2449"},{"key":"e_1_2_17_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpeds.2009.11.057"},{"key":"e_1_2_17_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpeds.2010.09.048"},{"key":"e_1_2_17_6_1","doi-asserted-by":"publisher","DOI":"10.7196\/SAMJ.4319"},{"key":"e_1_2_17_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0889-8529(05)70159-6"},{"key":"e_1_2_17_8_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11892-017-0857-4"},{"key":"e_1_2_17_9_1","doi-asserted-by":"publisher","DOI":"10.2337\/dc19-1168"},{"key":"e_1_2_17_10_1","doi-asserted-by":"publisher","DOI":"10.1055\/s-0043-117416"},{"issue":"1","key":"e_1_2_17_11_1","first-page":"43","article-title":"Course and prognosis of 132 patients with diabetic non ketotic hyperosmolar state","volume":"20","author":"Pinies JA","year":"1994","journal-title":"Diabete Metab"},{"key":"e_1_2_17_12_1","doi-asserted-by":"publisher","DOI":"10.1093\/med\/9780199235292.001.1"},{"key":"e_1_2_17_13_1","doi-asserted-by":"publisher","DOI":"10.1046\/j.1445-5994.2002.00255.x"},{"key":"e_1_2_17_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.diabres.2006.01.004"},{"key":"e_1_2_17_15_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00592-020-01538-0"},{"key":"e_1_2_17_16_1","doi-asserted-by":"publisher","DOI":"10.1111\/dme.13672"},{"key":"e_1_2_17_17_1","volume-title":"Practical Management of Hyperglycaemic Hyperosmolar State (HHS) in Children: Association of Children's Diabetes Clinicians Guideline","author":"Ng SM","year":"2021"},{"key":"e_1_2_17_18_1","doi-asserted-by":"publisher","DOI":"10.1111\/dme.14788"},{"key":"e_1_2_17_19_1","doi-asserted-by":"publisher","DOI":"10.1136\/pgmj.2002.004291"},{"key":"e_1_2_17_20_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41572-020-0165-1"},{"key":"e_1_2_17_21_1","unstructured":"Royal College of Physicians.National Early Warning Score (NEWS) 2: Standardising the assessment of acute\u2010illness severity in the NHS. 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