What is the treatment for hyperosmolar symptoms?

Treatment of Hyperosmolar Symptoms

The treatment of hyperosmolar symptoms requires aggressive fluid resuscitation, careful insulin administration, and electrolyte management, with initial focus on isotonic saline at 15-20 mL/kg/hr followed by insulin therapy once fluid resuscitation has begun. 1, 2

Initial Assessment and Management

Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr to restore circulatory volume and tissue perfusion 1
• Total body water deficit in hyperosmolar hyperglycemic state (HHS) is typically 9 liters (approximately 100-200 mL/kg) 1
• After the first hour, continue fluid replacement based on hemodynamic status, typically at 4-14 mL/kg/hr 3
• Fluid replacement should correct estimated deficits within the first 24 hours 1

Insulin Therapy

• Once hypokalemia is excluded and after fluid resuscitation has begun, administer an intravenous bolus of regular insulin at 0.15 U/kg body weight, followed by a continuous infusion at 0.1 U/kg/hr 1, 4
• If plasma glucose does not fall by 50-75 mg/dL in the first hour, double the insulin infusion rate 3, 1
• When blood glucose reaches 250-300 mg/dL, add dextrose to IV fluids while continuing insulin infusion at a reduced rate to prevent hypoglycemia 1, 2
• Maintain glucose levels at 250-300 mg/dL until hyperosmolarity and mental status improve 1

Electrolyte Management

• Monitor serum potassium levels every 2-4 hours as insulin therapy can cause hypokalemia 3
• Once renal function is assured and serum potassium is known, add 20-40 mEq/L potassium to the infusion 1
• Begin potassium replacement when serum levels fall below 5.2 mEq/L, provided the patient has adequate urine output 3
• Phosphate replacement (20-30 mEq/L potassium phosphate) may be considered in patients with cardiac dysfunction, anemia, respiratory depression, or serum phosphate <1.0 mg/dL 1

Monitoring and Ongoing Management

• Check blood glucose every 1-2 hours until stable 3
• Monitor electrolytes, blood urea nitrogen, creatinine, and osmolality every 2-4 hours 1
• Induced change in serum osmolality should not exceed 3 mOsm/kg/hr to prevent cerebral edema 1
• Monitor for signs of cerebral edema, such as lethargy, behavioral changes, seizures, incontinence, pupillary changes, bradycardia, and respiratory arrest 1, 2

Treatment of Precipitating Factors

• Identify and treat underlying causes such as infection, medication non-compliance, or new-onset diabetes 3, 2
• Obtain bacterial cultures of urine, blood, and other sites as needed and administer appropriate antibiotics if infection is suspected 1
• Stressful events (e.g., illness, trauma, surgery) frequently aggravate glycemic control and may precipitate hyperosmolar state 2

Transition to Subcutaneous Insulin and Discharge Planning

• Once hyperosmolar state has resolved, transition to subcutaneous insulin 1
• Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin to prevent rebound hyperglycemia 1
• A structured discharge plan should be tailored to the individual patient to reduce length of hospital stay and readmission rates 1

Prevention of Future Episodes

• Educate patients on monitoring blood glucose and recording insulin administered 3
• Review sick-day management with patients, including when to contact healthcare providers 3
• Advise patients never to discontinue insulin during illness and to seek professional advice early 3
• Adequate supervision and help from staff or family may prevent many of the admissions for HHS due to dehydration among elderly individuals 2

Special Considerations

• Be aware of euglycemic diabetic ketoacidosis risk in patients taking SGLT2 inhibitors 3
• Cerebral edema is a rare but potentially fatal complication, particularly in children and young adults 2
• Prevention measures for cerebral edema include gradual replacement of sodium and water deficits in hyperosmolar patients 2
• Hypoxemia and, rarely, noncardiogenic pulmonary edema may complicate treatment 2

Common Pitfalls to Avoid

• Overly rapid correction of hyperosmolality can lead to cerebral edema 1, 2
• Premature termination of intravenous insulin therapy can lead to recurrence of hyperosmolarity 5
• Insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin can cause rebound hyperglycemia 5
• Failure to monitor and replace potassium can lead to dangerous hypokalemia during insulin treatment 4