From the Guidelines
In treating Hyperosmolar Hyperglycemic State (HHS), glucose should be lowered gradually at a rate of 50-75 mg/dL per hour using intravenous insulin therapy, as recommended by the most recent guidelines 1.
Key Considerations
- The goal is to correct severe hyperglycemia while carefully managing fluid status and electrolyte imbalances to prevent complications during treatment.
- Aggressive fluid resuscitation with normal saline should be initiated at 1-1.5 L in the first hour, then 250-500 mL/hour depending on hemodynamic status and electrolyte levels.
- Once glucose reaches 250-300 mg/dL, switch to 5% dextrose with continued insulin to prevent too rapid a decline.
- Potassium replacement is crucial when levels fall below 5.2 mEq/L.
Rationale
- Lowering glucose too rapidly can cause cerebral edema and neurological complications due to rapid shifts in osmolality, as noted in previous studies 1.
- The use of continuous intravenous insulin infusion is the most effective method for achieving specific glycemic goals and avoiding hypoglycemia in the critical care setting, according to recent guidelines 1.
Implementation
- Start with an IV insulin bolus of 0.1 units/kg followed by a continuous infusion at 0.1 units/kg/hour.
- Adjust the insulin rate based on hourly glucose measurements to maintain the target reduction rate.
- Monitor electrolyte levels and adjust potassium replacement as needed.
- Regularly assess the patient's hemodynamic status and adjust fluid resuscitation accordingly.
From the Research
Lowering Glucose in HHS
To manage Hyperosmolar Hyperglycaemic State (HHS), it is crucial to understand the appropriate rate of glucose lowering. The following points outline the recommendations:
- The aim is to achieve a gradual decline in osmolality, with a target reduction of 3.0-8.0 mOsm/kg/h to minimize the risk of neurological complications, as stated in 2.
- Blood glucose levels should be reduced to 10-15 mmol/L in the first 24 hours, as recommended in 2.
- Insulin therapy should be initiated once osmolality stops falling with fluid replacement, unless there is ketonaemia, as suggested in 2.
- The use of intravenous 0.9% sodium chloride solution is recommended as the principal fluid to restore circulating volume and reverse dehydration, as stated in 3 and 2.
- It is essential to monitor the response to treatment, including regular measurement or calculation of serum osmolality, as recommended in 3 and 2.
Key Considerations
When managing HHS, the following considerations are crucial:
- Identification and treatment of underlying precipitants, as emphasized in 2 and 4.
- Prevention of hypoglycaemia, hypokalaemia, and other complications, as recommended in 2.
- Close monitoring of the patient's clinical status, including urine output, cognitive status, and blood glucose levels, as suggested in 2.
- Involvement of the diabetes specialist team as soon as possible, as recommended in 3.