What are the initial management steps for hyperosmolar hyperglycemic state (HHS)?

From the Guidelines

The initial management of hyperosmolar hyperglycemic state (HHS) should focus on aggressive fluid resuscitation, insulin therapy, electrolyte replacement, and identifying and treating the underlying cause, as outlined in the most recent guidelines 1. The management goals include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis.

• Begin with immediate intravenous fluid resuscitation using isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour, then adjust based on hemodynamic status, as recommended by recent studies 1.
• After starting fluid therapy, initiate insulin as a continuous IV infusion at 0.1 units/kg/hr, which is lower than the dose used for diabetic ketoacidosis, to achieve a gradual decrease of 50-70 mg/dL per hour in blood glucose levels.
• Monitor blood glucose hourly and adjust insulin accordingly, and once glucose reaches 250-300 mg/dL, switch to 5% dextrose with 0.45% saline to prevent hypoglycemia while continuing insulin.
• Potassium replacement is crucial; maintain serum potassium between 4-5 mEq/L by adding KCl to IV fluids when levels fall below 5.0 mEq/L, as emphasized in the guidelines 1.
• Phosphate replacement may be necessary if levels are severely depleted, and throughout treatment, monitor vital signs, mental status, fluid input/output, electrolytes, and glucose closely.
• Identify and treat the precipitating cause, which may include infection, medication non-adherence, stroke, or myocardial infarction, to address the underlying cause of HHS. This comprehensive approach addresses the severe dehydration, hyperglycemia, and electrolyte abnormalities that characterize HHS, which carries a higher mortality rate than diabetic ketoacidosis, and is supported by the most recent and highest quality studies 1.

From the Research

Initial Management Steps for Hyperosmolar Hyperglycemic State (HHS)

The initial management steps for HHS involve several key components, including:

• Monitoring of the response to treatment, with regular measurement or calculation of serum osmolality to monitor the response to treatment, aiming to reduce osmolality by 3-8 mOsm/kg/h 2, 3
• Fluid and insulin administration, using i.v. 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration, withholding insulin until the blood glucose level is no longer falling with i.v. fluids alone (unless ketonaemic) 2, 3, 4
• Delivery of care, involving the diabetes specialist team as soon as possible, and nursing patients in areas where staff are experienced in the management of HHS 2, 3

Key Interventions

Key interventions in the management of HHS include:

• Intravenous (IV) 0.9% sodium chloride to restore circulating volume, with caution in elderly patients 3, 5, 4
• Fixed rate intravenous insulin infusion (FRIII) once osmolality stops falling with fluid replacement, unless there is ketonaemia 3
• Glucose infusion (5% or 10%) once glucose <14 mmol/L 3
• Potassium replacement according to potassium levels 3, 5, 4

Aims of Therapy

The aims of therapy in HHS include:

• Improving clinical status and replacing fluid losses by 24 h 3
• Gradual decline in osmolality (3.0-8.0 mOsm/kg/h) to minimize the risk of neurological complications 3
• Blood glucose 10-15 mmol/L in the first 24 h 3
• Preventing hypoglycaemia, hypokalaemia, and other complications such as VTE, osmotic demyelination, fluid overload, and foot ulceration 3, 4

Resolution Criteria

The resolution criteria for HHS include:

• Osmolality <300 mOsm/kg 3
• Hypovolaemia corrected (urine output ≥0.5 ml/kg/h) 3
• Cognitive status returned to pre-morbid state 3
• Blood glucose <15 mmol/L 3