From the Guidelines
In Hyperosmolar Hyperglycemic State (HHS), serum osmolality typically exceeds 320 mOsm/kg, often ranging between 330-375 mOsm/kg, as indicated by the most recent and highest quality study 1.
Management of HHS
Management of HHS centers on aggressive fluid resuscitation, insulin therapy, and electrolyte replacement.
- Initial treatment requires rapid IV fluid administration, typically beginning with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour, then adjusted based on hemodynamic status.
- Regular insulin should be administered as an IV bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr, titrated to reduce glucose by 50-70 mg/dL/hr, as recommended by 1.
- Once glucose reaches 250-300 mg/dL, IV fluids should be changed to 5% dextrose with 0.45% saline to prevent hypoglycemia while continuing insulin.
Electrolyte Replacement
- Potassium replacement is crucial when levels fall below 5.3 mEq/L, typically given as 20-30 mEq/L in IV fluids.
- Phosphate and magnesium should also be monitored and replaced as needed, according to 1.
Monitoring and Treatment
- The underlying cause of HHS must be identified and treated, which commonly includes infection, medication non-compliance, or undiagnosed diabetes.
- Close monitoring of vital signs, mental status, fluid balance, electrolytes, and glucose levels is essential throughout treatment to prevent complications like cerebral edema from overly rapid osmolality correction, as warned by 1 and 1. The goal is to maintain a glucose level of 250–300 mg/dL until hyperosmolarity and mental status improve and the patient becomes clinically stable, as suggested by 1.
From the Research
Serum Osmolality Level in HHS
- The typical serum osmolality level in Hyperosmolar Hyperglycemic State (HHS) is ≥320 mOsm/kg 2, 3.
- Serum osmolality is calculated using the formula: (2×Na+) + glucose + urea 2.
Management of HHS
- The aims of therapy in HHS are to improve clinical status, replace fluid losses, and gradual decline in osmolality (3.0-8.0 mOsm/kg/h) to minimize the risk of neurological complications 2.
- Treatment involves:
- Intravenous (IV) 0.9% sodium chloride to restore circulating volume 4, 2.
- Fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia 2.
- Glucose infusion (5% or 10%) should be started once glucose <14 mmol/L 2.
- Potassium replacement according to potassium levels 2.
- Monitoring of the response to treatment is crucial, including regular measurement or calculation of serum osmolality to monitor the response to treatment 4.
- The diabetes specialist team should be involved as soon as possible, and patients should be nursed in areas where staff are experienced in the management of HHS 4.