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

From the Guidelines

The management of Hyperosmolar Hyperglycemic State (HHS) requires aggressive fluid replacement, insulin therapy, and electrolyte correction, with continuous intravenous insulin infusion being the most effective method for achieving specific glycemic goals and avoiding hypoglycemia in the critical care setting, as recommended by the most recent guidelines 1.

Key Components of HHS Management

• Aggressive fluid replacement using normal saline at 15-20 mL/kg/hr for the first hour, then adjusting based on hemodynamic status
• Insulin therapy with continuous intravenous insulin infusion at 0.1 units/kg/hr after initial fluid resuscitation, avoiding bolus insulin to prevent rapid osmolality shifts
• Electrolyte correction, particularly potassium replacement when levels fall below 5.5 mEq/L and serum is adequate
• Addressing the underlying trigger, such as infection, medication non-adherence, stroke, etc., while monitoring for complications like thromboembolism

Transition to Subcutaneous Insulin

• Transition to subcutaneous insulin when the patient is stable, alert, and eating, with a basal insulin dose administered 2-4 hours before stopping intravenous insulin to prevent recurrence of ketoacidosis and rebound hyperglycemia 1
• Estimating the combined basal and nutritional subcutaneous insulin requirements based on the average amount of insulin infused during the 12 hours before transition, as suggested by recent studies 1

Importance of Prompt Management

• HHS carries a higher mortality rate than DKA (10-20%) due to extreme dehydration, hyperosmolality, and the typically older patient population with comorbidities, making prompt and careful management essential
• Recent guidelines emphasize the importance of individualized treatment based on careful clinical and laboratory assessment, as well as the need for clear communication with outpatient providers to facilitate safe transition of care 1

From the Research

Management of Hyperosmolar Hyperglycemic State (HHS)

The management of HHS involves several key components, including:

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

Treatment Considerations

Treatment of HHS involves:

• Fluid resuscitation and correction of electrolyte abnormalities 3
• Monitoring of patients to avoid overcorrection of osmolality, sodium, and other electrolytes 3
• Admission to an intensive care unit, as these patients are critically ill 3
• Identification and treatment of underlying precipitants, such as infections, certain medications, and nonadherence to therapy 4, 5
• Vigorous correction of dehydration, requiring an average of 9 L of 0.9% saline over 48 hours in adults 5

Specific Treatment Guidelines

Specific treatment guidelines for HHS include:

• Use of intravenous (IV) 0.9% sodium chloride to restore circulating volume, with fluid losses of 100-220 ml/kg, and caution in elderly patients 4
• Commencement of fixed rate intravenous insulin infusion (FRIII) once osmolality stops falling with fluid replacement, unless there is ketonaemia 4
• Start of glucose infusion (5% or 10%) once glucose <14 mmol/L 4
• Potassium replacement according to potassium levels 4
• Aim to improve clinical status, replace fluid losses, and achieve a gradual decline in osmolality (3.0-8.0 mOsm/kg/h) to minimize the risk of neurological complications 4