From the Guidelines
The treatment for Hyperosmolar Hyperglycemic State (HHS) should prioritize aggressive fluid replacement, insulin therapy, and addressing underlying causes, with continuous intravenous insulin being the standard of care for critically ill patients, as recommended by the most recent guidelines 1.
Key Components of Treatment
- Aggressive fluid replacement with intravenous fluids, typically 0.9% normal saline, administered rapidly at 1-1.5 L in the first hour, followed by continued fluid resuscitation based on hemodynamic status.
- Insulin therapy with regular insulin given intravenously, starting with a 0.1 units/kg bolus followed by a continuous infusion at 0.1 units/kg/hour, titrated to reduce glucose by 50-70 mg/dL per hour.
- Potassium replacement with potassium chloride 20-40 mEq/L in IV fluids when levels fall below 5.2 mEq/L.
- Switch to 5% dextrose-containing fluids while continuing insulin once blood glucose reaches 250-300 mg/dL to prevent hypoglycemia.
- Phosphate replacement may be necessary if levels are severely depleted.
Monitoring and Underlying Cause Identification
- Continuous monitoring of vital signs, mental status, fluid balance, electrolytes, and glucose is essential.
- The underlying cause of HHS, often infection, medication non-compliance, or new-onset diabetes, must be identified and treated.
Rationale for Approach
The aggressive approach is necessary because HHS carries a mortality rate of 10-20%, primarily due to profound dehydration that can lead to vascular complications and thrombosis, as highlighted in recent guidelines 1.
Insulin Administration
Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia, as noted in 1.
Fluid Management
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, as reported in 1.
From the Research
Treatment Overview
The treatment for Hyperosmolar Hyperglycemic State (HHS) involves a multi-step approach to address the underlying causes and manage the symptoms. The key components of treatment include:
- Fluid replacement to restore circulating volume and reverse dehydration 2, 3, 4, 5, 6
- Insulin administration to control blood glucose levels 2, 4, 5, 6
- Electrolyte replacement to correct imbalances 2, 4, 5, 6
- Monitoring of the patient's response to treatment and adjustment of the treatment plan as needed 2, 3, 5, 6
Fluid Replacement
Fluid replacement is a critical component of HHS treatment. The recommended approach includes:
- Using 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration 2, 6
- Administering an average of 9 L of 0.9% saline over 48 hours in adults 5
- Correcting dehydration at a rate of no more than 3 mOsm per hour to avoid cerebral edema in children and adolescents 5
Insulin Administration
Insulin administration is also an essential part of HHS treatment. The recommended approach includes:
- Withholding insulin until the blood glucose level is no longer falling with intravenous fluids alone (unless ketonaemic) 2
- Administering 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 5
- Commencing fixed rate intravenous insulin infusion (FRIII) once osmolality stops falling with fluid replacement unless there is ketonaemia 6
Electrolyte Replacement
Electrolyte replacement is crucial to correct imbalances and prevent complications. The recommended approach includes:
- Replacing potassium according to potassium levels 6
- Monitoring and correcting other electrolyte imbalances as needed 2, 4, 5
Monitoring and Adjustment
Monitoring the patient's response to treatment and adjusting the treatment plan as needed is critical to ensure optimal outcomes. The recommended approach includes: