What is the initial management for a patient presenting with hyperosmolar hyperglycemic state (HHS)?

From the Guidelines

The initial management of hyperosmolar hyperglycemic state (HHS) should focus on aggressive fluid resuscitation, insulin therapy, and electrolyte correction, with the goal of restoring circulatory volume and tissue perfusion, resolving hyperglycemia, and correcting electrolyte imbalance and acidosis, as recommended by the most recent guidelines 1. The management of HHS requires individualization of treatment based on a careful clinical and laboratory assessment, as the presentation can vary from mild hyperglycemia and acidosis to severe hyperglycemia, dehydration, and coma 1. Key components of the initial management include:

• Aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr for the first hour, then adjusting based on hemodynamic status and serum sodium
• Insulin therapy with an IV insulin bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hr, titrating to achieve a glucose reduction of 50-70 mg/dL per hour
• Monitoring potassium levels closely and beginning replacement when levels fall below 5.0 mEq/L to prevent hypokalemia during insulin treatment
• Switching to 0.45% saline when serum sodium normalizes or becomes elevated
• Regular monitoring of glucose, electrolytes, renal function, and mental status
• Adding dextrose to IV fluids while continuing insulin once glucose reaches 250-300 mg/dL to prevent hypoglycemia This approach is supported by recent studies, which have shown that there is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA 1. It is also essential to treat any correctable underlying cause of HHS, such as sepsis, myocardial infarction, or stroke, and to prevent complications like cerebral edema, which can be fatal 1. Overall, the goal of initial management is to promptly address the severe dehydration, hyperglycemia, and hyperosmolality that characterize HHS, and to prevent complications and improve outcomes.

From the Research

Initial Management of Hyperosmolar Hyperglycemic State (HHS)

The initial management of a patient presenting with hyperosmolar hyperglycemic state (HHS) involves several key steps:

• Fluid resuscitation to restore circulating volume and reverse dehydration, using intravenous (IV) 0.9% sodium chloride solution as the principal fluid 2, 3, 4
• Correction of electrolyte abnormalities, including potassium replacement according to potassium levels 3, 4
• Monitoring of the response to treatment, including measurement of serum osmolality regularly to monitor the response to treatment, and aiming to reduce osmolality by 3-8 mOsm/kg/h 3, 4
• Insulin administration, with fixed rate intravenous insulin infusion (FRIII) commenced once osmolality stops falling with fluid replacement, unless there is ketonaemia 3, 4
• Glucose infusion (5% or 10%) started once glucose <14 mmol/L 4

Key Considerations

• Patients with HHS are critically ill and generally require admission to an intensive care unit 2
• The diabetes specialist team should be involved as soon as possible in the management of HHS 3, 4
• Underlying precipitants must be identified and treated simultaneously with correction of the metabolic abnormalities 5, 4
• Prevention of harm, including venous thromboembolism (VTE), osmotic demyelination, fluid overload, and foot ulceration, is an important aspect of HHS management 4