What are the typical lab findings and management of hyperosmolar hyperglycemia?

From the Guidelines

Hyperosmolar hyperglycemic state (HHS) is a life-threatening condition that requires immediate attention, and management begins with aggressive fluid resuscitation and insulin therapy to reduce glucose levels and correct electrolyte imbalances, as recommended by the most recent guidelines 1.

Typical Lab Findings

The typical lab findings for HHS include:

• Extremely elevated blood glucose (often >600 mg/dL and sometimes >1000 mg/dL)
• High serum osmolality (>320 mOsm/kg)
• Elevated BUN and creatinine indicating prerenal azotemia
• Mild metabolic acidosis (pH >7.3)
• Minimal or absent ketones
• Variable sodium levels (may be falsely low due to hyperglycemia)
• Elevated hematocrit due to hemoconcentration

Management

The management of HHS involves:

• Aggressive fluid resuscitation using isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour, then adjusted based on hemodynamic status
• Insulin therapy should be initiated with an IV insulin regular bolus of 0.1 units/kg followed by continuous infusion at 0.1 units/kg/hr, titrated to reduce glucose by 50-70 mg/dL/hr
• Once glucose reaches 250-300 mg/dL, IV fluids should be changed to 5% dextrose with 0.45% saline to prevent rapid drops in osmolality
• Potassium, phosphate, and magnesium should be monitored and replaced as needed
• The underlying cause of HHS (often infection, stroke, medication non-adherence, or new-onset diabetes) must be identified and treated
• Close monitoring of vital signs, mental status, fluid balance, electrolytes, and glucose is essential throughout treatment to prevent complications like cerebral edema from too-rapid correction of hyperosmolality, as emphasized in recent studies 1.

From the FDA Drug Label

Hyperglycemia, diabetic ketoacidosis, or hyperosmolar coma may develop if the patient takes less Humulin R U-100 than needed to control blood glucose levels Early signs of diabetic ketoacidosis include glycosuria and ketonuria Polydipsia, polyuria, loss of appetite, fatigue, dry skin, abdominal pain, nausea and vomiting and compensatory tachypnea come on gradually, usually over a period of some hours or days, in conjunction with hyperglycemia and ketonemia. Severe sustained hyperglycemia may result in hyperosmolar coma or death

The typical lab findings of hyperosmolar hyperglycemia include:

• Hyperglycemia: elevated blood glucose levels
• Glycosuria: glucose in the urine
• Ketonuria: ketones in the urine
• Electrolyte imbalances: such as hypokalemia (low potassium levels) The management of hyperosmolar hyperglycemia involves:
• Insulin therapy: to lower blood glucose levels
• Fluid replacement: to correct dehydration and electrolyte imbalances
• Monitoring: of blood glucose, electrolyte, and fluid levels 2

From the Research

Typical Lab Findings

• Severe hyperglycemia, with plasma glucose levels >600 mg/dL 3
• Hyperosmolarity, with effective plasma osmolality >320 mOsm/kg 3
• Dehydration, with significant depletion of both intracellular and extracellular fluid volumes 4
• Electrolyte imbalances, including potassium depletion 4
• Mild acidosis, with venous pH <7.4 5

Management

• Restoration of intravascular volume with intravenous fluids, typically 0.9% sodium chloride solution 6, 4
• Administration of regular insulin, with an initial bolus of 10-15 units followed by a continuous infusion of approximately 0.1 U/kg/h 4
• Monitoring of serum osmolality and adjustment of fluid and insulin administration as needed 6
• Replacement of electrolytes, including potassium, as needed 4
• Identification and treatment of precipitating causes of hyperosmolar hyperglycemic state (HHS) 4
• Involvement of a diabetes specialist team in the management of HHS 6

Key Considerations

• HHS is a medical emergency with a high mortality rate, requiring prompt and aggressive treatment 6, 7, 3
• The management of HHS differs from that of diabetic ketoacidosis (DKA), with a focus on restoring intravascular volume and correcting electrolyte imbalances 6
• Rapid changes in osmolality during treatment may precipitate central pontine myelinolysis, a rare but potentially fatal complication 6