From the Guidelines
Treatment for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
The treatment for HHNS involves restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis.
- The primary goal is to address dehydration and electrolyte imbalances through aggressive fluid management.
- Continuous intravenous insulin is the standard of care for critically ill and mentally obtunded individuals with HHNS, as it helps to reduce glucose levels and osmolality.
- Basal insulin should be administered 2-4 hours before stopping intravenous insulin to prevent recurrence of hyperglycemia and rebound hyperglycemia 1.
- There is no significant difference in outcomes between intravenous human regular insulin and subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate HHNS.
- The use of bicarbonate is generally not recommended, as it has been shown to make no difference in the resolution of acidosis or time to discharge 1.
From the Research
Treatment Overview
The treatment for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) involves several key components, including:
- Aggressive fluid replacement with isotonic or hypotonic NaCl solutions to correct dehydration and restore intravascular volume 2, 3, 4
- Administration of insulin to lower blood glucose levels, typically starting with a bolus of 10 to 15 units of regular human insulin followed by a continuous infusion of approximately 0.1 U/kg/h 2
- Replacement of electrolytes, particularly potassium, to address significant depletion 2, 4
- Management of precipitating illnesses or factors that contributed to the development of HHNS 2, 3, 5
Fluid Replacement
The choice of initial fluid for infusion is a topic of debate, with some studies suggesting the use of 0.9% NaCl until vital signs have stabilized, followed by substitution with 0.45% NaCl 2. Others recommend aggressive fluid replacement with isotonic or hypotonic NaCl solutions as the first priority 3.
Insulin Therapy
Insulin administration is a critical component of HHNS treatment. The initial bolus is typically followed by a continuous infusion, which is adjusted based on the patient's response to treatment 2. Once blood glucose levels approach 13.9 to 16.7 mmol/L (250 to 300 mg/dl), 5% dextrose may be added to the intravenous fluids and the rate of insulin infusion reduced 2.
Electrolyte Replacement
Significant depletion of potassium and other electrolytes requires replacement during treatment 2, 4. Careful monitoring of electrolyte levels is necessary to ensure adequate replacement and prevent complications.
Management of Precipitating Illnesses
Identifying and treating the underlying causes of HHNS, such as infections or other acute illnesses, is essential for effective management and reducing mortality 2, 3, 5.