What are the steps for managing Hyperosmolar Hyperglycemic State (HHS) without an insulin drip?

Management of Hyperosmolar Hyperglycemic State (HHS) Without Insulin Drip

Subcutaneous insulin administration combined with aggressive fluid management is an effective alternative to intravenous insulin for managing HHS when an insulin drip is not available. 1

Initial Assessment and Stabilization (0-60 minutes)

1. Confirm diagnosis:

   • Blood glucose ≥600 mg/dL
   • Serum osmolality ≥320 mOsm/kg (calculated as 2[measured Na+] + glucose/18)
   • Minimal or absent ketones
   • Altered mental status or severe dehydration

2. Immediate laboratory tests:

   • Complete blood count
   • Comprehensive metabolic panel
   • Venous blood gases
   • Urinalysis
   • Calculate corrected sodium (for each 100 mg/dL glucose >100, add 1.6 mEq to sodium value)

3. Establish IV access and begin fluid resuscitation:

   • Start with 0.9% NaCl at a clinically appropriate rate
   • Aim to replace 50% of estimated fluid deficit in first 8-12 hours 1
   • Monitor hemodynamic status closely

Fluid Management (Hours 1-6)

1. Initial fluid choice: 0.9% NaCl (normal saline) until hemodynamic stability is achieved 1

2. Fluid rate:

   • 15-20 mL/kg/hour during the first hour (approximately 1-1.5 L in adults)
   • Then 4-14 mL/kg/hour based on hemodynamic status
   • Total fluid deficit in HHS is typically 100-220 mL/kg 2

3. Transition to hypotonic fluids:

   • Once hemodynamically stable, switch to 0.45% NaCl
   • When glucose reaches 250-300 mg/dL, add 5% dextrose to IV fluids 1

Subcutaneous Insulin Administration (Alternative to Insulin Drip)

1. Initial insulin dose:

   • For mild HHS: Give a "priming" dose of regular insulin 0.4-0.6 units/kg body weight 1
   • Half as subcutaneous injection, half as intramuscular injection

2. Maintenance insulin:

   • Regular insulin 0.1 units/kg subcutaneously or intramuscularly every hour 1
   • OR rapid-acting insulin analog 0.1 units/kg subcutaneously every 1 hour or 0.2 units/kg every 2 hours 1

3. Glucose monitoring:

   • Check blood glucose every 1-2 hours initially
   • Adjust insulin doses to achieve glucose decline of 50-75 mg/dL per hour
   • Target glucose: 200-250 mg/dL until resolution of HHS 1

Electrolyte Management

1. Potassium replacement:

   • Check serum potassium before starting insulin
   • If K+ <3.3 mEq/L: Hold insulin, give potassium replacement first
   • If K+ 3.3-5.0 mEq/L: Add 20-40 mEq potassium to each liter of IV fluid
   • If K+ >5.0 mEq/L: Do not add potassium, recheck every 2 hours 1

2. Composition of potassium replacement:

   • Use 2/3 KCl or potassium-acetate and 1/3 KPO4 1

3. Other electrolytes:

   • Monitor sodium, magnesium, phosphate
   • Correct as needed based on laboratory values

Ongoing Monitoring (Hours 6-24)

1. Laboratory monitoring:

   • Check electrolytes, glucose, BUN, creatinine every 2-4 hours until stable
   • Calculate serum osmolality regularly to monitor treatment response
   • Target osmolality reduction: 3-8 mOsm/kg/hour 3

2. Clinical monitoring:

   • Vital signs every 1-2 hours
   • Strict intake/output monitoring
   • Mental status assessment
   • Signs of fluid overload or cerebral edema

3. Adjust treatment based on response:

   • If glucose not falling by 50 mg/dL in first hour, check hydration status
   • If adequate, increase insulin dose
   • If glucose falls too rapidly, decrease insulin dose

Transition to Subcutaneous Maintenance Insulin

1. When to transition:

   • Once HHS is resolving (osmolality <300 mOsm/kg)
   • Patient is clinically stable and able to eat
   • Blood glucose <250-300 mg/dL

2. Transition protocol:

   • Start subcutaneous basal-bolus insulin regimen
   • Continue subcutaneous rapid-acting insulin for 1-2 hours after starting basal insulin
   • Initial total daily dose: 0.5-0.8 units/kg/day divided as:
     • 50% basal insulin
     • 50% prandial insulin (divided between meals)

Treatment of Precipitating Factors

1. Identify and treat underlying causes:
   • Infection (most common)
   • Medication non-adherence
   • New-onset diabetes
   • Stroke, MI, pancreatitis
   • Medications (glucocorticoids, thiazides, etc.)

Criteria for Resolution of HHS

1. Clinical improvement:

   • Mental status returns to baseline
   • Hemodynamic stability
   • Adequate urine output (≥0.5 mL/kg/hour)

2. Laboratory parameters:

   • Serum osmolality <300 mOsm/kg
   • Blood glucose <250 mg/dL
   • Electrolytes normalized

Important Cautions

1. Avoid overly rapid correction of osmolality (risk of cerebral edema and central pontine myelinolysis) 3

2. Monitor for hypoglycemia when transitioning to maintenance insulin

3. Fluid overload risk in elderly patients and those with cardiac or renal dysfunction

4. Withhold insulin until glucose stops falling with IV fluids alone (unless ketonaemic) to avoid precipitous drops in glucose 3

5. Avoid bicarbonate administration as studies show no benefit in resolution of acidosis or time to discharge 1