From the Guidelines
Inpatient management of hyperosmolar hyperglycemic state (HHS) requires aggressive fluid resuscitation, insulin therapy, electrolyte replacement, and addressing the underlying cause, with the goal of restoring circulatory volume and tissue perfusion, resolving hyperglycemia, and correcting electrolyte imbalance and acidosis, as recommended by the most recent guidelines 1.
Key Components of Management
- Begin with immediate IV fluid resuscitation using 0.9% normal saline at 15-20 mL/kg/hr for the first hour (typically 1-2 L), then adjust based on hemodynamic status and serum sodium.
- After initial volume expansion, start IV regular insulin as a continuous infusion at 0.1 units/kg/hr, which is lower than for diabetic ketoacidosis, as continuous intravenous insulin is the standard of care for critically ill and mentally obtunded individuals with DKA or HHS 1.
- Monitor blood glucose hourly and adjust insulin to achieve a glucose reduction of 50-70 mg/dL per hour.
- When glucose reaches 250-300 mg/dL, switch to 5% dextrose with 0.45% saline to prevent rapid osmolality changes while continuing insulin.
- Replace potassium when levels fall below 5.2 mEq/L, aiming to maintain levels above 4 mEq/L, and monitor phosphate and magnesium levels and replace as needed.
Additional Considerations
- Thromboprophylaxis is essential as HHS increases thrombosis risk.
- Identify and treat the precipitating cause, commonly infection, medication non-adherence, or acute illness.
- The gradual correction approach prevents cerebral edema, which can occur with rapid osmolality changes.
- Continue monitoring for complications including acute kidney injury, cerebral edema, and rhabdomyolysis throughout treatment.
Evidence-Based Recommendations
The management approach is based on the most recent guidelines from the Diabetes Care journal, which emphasizes individualization of treatment based on careful clinical and laboratory assessment 1. The use of continuous intravenous insulin is supported by recent studies, which have shown 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 2, 3.
From the Research
Inpatient Management of Hyperosmolar Hyperglycemic State (HHS)
The inpatient 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, aiming to reduce osmolality by 3-8 mOsm/kg/h 4
- Fluid and insulin administration, using i.v. 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration, withholding insulin until the blood glucose level is no longer falling with i.v. fluids alone (unless ketonaemic) 4, 5
- Delivery of care, with involvement of the diabetes specialist team as soon as possible and nursing in areas where staff are experienced in the management of HHS 4
Key Components of HHS Management
Some of the key components of HHS management include:
- Clinical assessment and monitoring, with aims of therapy including improvement of clinical status, replacement of fluid losses, gradual decline in osmolality, and prevention of hypoglycaemia and hypokalaemia 5
- Interventions, including intravenous 0.9% sodium chloride to restore circulating volume, fixed rate intravenous insulin infusion, glucose infusion, and potassium replacement according to potassium levels 5
- Identification and treatment of underlying precipitants, with HHS resolution criteria including osmolality <300 mOsm/kg, hypovolaemia corrected, cognitive status returned to pre-morbid state, and blood glucose <15 mmol/L 5
Treatment Considerations
Treatment considerations for HHS include:
- Fluid resuscitation and correction of electrolyte abnormalities, with close monitoring to avoid overcorrection of osmolality, sodium, and other electrolytes 6
- Admission to an intensive care unit, due to the critical illness and significant morbidity and mortality associated with HHS 6, 7
- Control of dehydration, with particular attention paid to the control of dehydration in the treatment of HHS 7
- Management of concurrent illnesses, with early clinical diagnosis and prompt treatment improving the outcome 8