What is the management of Hyperosmolar Hyperglycemic State (HHS)?

From the Guidelines

To effectively manage Hyperosmolar Hyperglycemic State (HHS), I recommend implementing a comprehensive approach that prioritizes restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis, with continuous intravenous insulin as the standard of care in critically ill and mentally obtunded individuals. The management of HHS requires a careful clinical and laboratory assessment to individualize treatment, as the condition can range from euglycemia or mild hyperglycemia and acidosis to severe hyperglycemia, dehydration, and coma 1. The primary goals of management include restoring circulatory volume and tissue perfusion, resolving ketoacidosis, and correcting electrolyte imbalance and acidosis. It is also essential to treat any correctable underlying cause of HHS, such as sepsis, myocardial infarction, or stroke.

Key Management Strategies

• Restoration of circulatory volume and tissue perfusion through aggressive fluid management
• Resolution of ketoacidosis and correction of electrolyte imbalance and acidosis
• Treatment of any correctable underlying cause of HHS
• Continuous intravenous insulin as the standard of care in critically ill and mentally obtunded individuals 1
• Consideration of subcutaneous rapid-acting insulin analogs in patients with mild or moderate HHS, with adequate fluid replacement, frequent POC blood glucose monitoring, and treatment of any concurrent infections 1

Prevention of Complications

• Gradual replacement of sodium and water deficits to prevent cerebral edema
• Maintenance of a glucose level of 250-300 mg/dl until hyperosmolarity and mental status improve and the patient becomes clinically stable 1
• Monitoring for hypoxemia and noncardiogenic pulmonary edema, and prompt treatment if necessary

Conclusion is not allowed, so the answer will continue without a conclusion section, and the response will be based on the provided evidence and general medicine knowledge.

The use of bicarbonate in patients with HHS is generally not recommended, as several studies have shown that it makes no difference in the resolution of acidosis or time to discharge 1. Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2-4 hours before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia 1. Recent studies have reported that the administration of a low dose of basal insulin analog in addition to intravenous insulin infusion may prevent rebound hyperglycemia without increased risk of hypoglycemia 1.

From the Research

Management of Hyperosmolar Hyperglycemic State (HHS)

The management of HHS involves several key steps, including:

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

Fluid and Insulin Administration

• Use i.v. 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration 3
• Fluid replacement alone will cause a fall in blood glucose (BG) level 3
• Withhold insulin until the BG level is no longer falling with i.v. fluids alone (unless ketonaemic) 3
• Early use of insulin (before fluids) may be detrimental 3

Delivery of Care

• The diabetes specialist team should be involved as soon as possible 3
• Patients should be nursed in areas where staff are experienced in the management of HHS 3
• Particular attention should be paid mainly to the control of dehydration 4
• The patient with HHS should always be admitted to the intensive care unit 4

Treatment Considerations

• Replacement of the mostly substantial fluid deficit with several liters of a physiological crystalloid solution is the first and most important step 5
• Serum potassium concentrations need to be carefully monitored to guide its substitution 5
• Regular insulin or rapid acting insulin analogues can be initially administered as an i.v. bolus followed by continuous infusion 5
• Insulin should be switched to subcutaneous injections only after correction of the acidosis and stable glucose concentrations within an acceptable range 5
• Monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes 6