What are the treatment guidelines for hyperosmolar hyperglycemic state (HHS)?

From the Guidelines

The treatment of hyperosmolar hyperglycemic state (HHS) should prioritize aggressive fluid replacement, insulin therapy, electrolyte correction, and addressing underlying causes, with the goal of minimizing morbidity, mortality, and improving quality of life. According to the most recent and highest quality study 1, management goals include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis.

Key Components of Treatment

• Aggressive fluid replacement with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour, followed by 250-500 mL/hr depending on hemodynamic status, with a goal to replace 50% of estimated fluid deficit within the first 12 hours
• Insulin therapy should begin with an IV bolus of regular insulin at 0.1 units/kg followed by continuous infusion at 0.1 units/kg/hr, titrating to achieve glucose reduction of 50-70 mg/dL/hr
• Potassium replacement is essential when levels fall below 5.3 mEq/L, typically requiring 20-30 mEq/L in IV fluids
• Phosphate replacement may be necessary if levels are below 1 mg/dL
• Continuous cardiac monitoring is important due to risk of arrhythmias during treatment
• Thromboprophylaxis with low molecular weight heparin should be considered given the hypercoagulable state

Transition to Subcutaneous Insulin

After resolution of HHS, transition to subcutaneous insulin is recommended, with administration of basal insulin 2–4 h prior to the intravenous insulin being stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1. It is also essential to investigate precipitating factors such as infection, medication non-adherence, stroke, or myocardial infarction to prevent recurrence.

Prevention of Complications

Prevention measures that might decrease the risk of cerebral edema in high-risk patients include gradual replacement of sodium and water deficits in patients who are hyperosmolar, and the addition of dextrose to the hydrating solution once blood glucose reaches 250 mg/dl 1.

From the Research

Treatment Guidelines for Hyperosmolar State

The treatment guidelines for hyperosmolar state involve several key steps, including:

• Intensive monitoring of the patient and laboratory values, especially glucose, sodium, and potassium levels 2, 3, 4, 5
• Vigorous correction of dehydration, requiring an average of 9 L of 0.9% saline over 48 hours in adults 2, 3, 5
• Potassium replacement should begin after urine output is established 2, 3, 5
• Administration of intravenous insulin, with an initial bolus of 0.1-0.15 units per kg of body weight, followed by a continuous infusion of 0.1 units per kg per hour 2, 6, 3, 5
• Identification and treatment of underlying and precipitating causes are necessary 2, 6, 3, 4, 5

Fluid Replacement and Insulin Therapy

The use of fluid replacement and insulin therapy is critical in the treatment of hyperosmolar state, with the following key points:

• Fluid replacement should be administered at a rate of 100-220 ml/kg, with caution in elderly patients 5
• Fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement, unless there is ketonaemia 5
• Glucose infusion (5% or 10%) should be started once glucose <14 mmol/L 5

Monitoring and Prevention of Complications

Monitoring and prevention of complications is also crucial in the treatment of hyperosmolar state, including:

• Monitoring of osmolality, sodium, and potassium levels to avoid overcorrection 4
• Prevention of hypoglycaemia, hypokalaemia, and other complications such as vascular occlusions, rhabdomyolysis, and disseminated intravascular coagulopathy 2, 4, 5
• Identification and treatment of underlying precipitants to prevent future episodes 2, 6, 3, 4, 5