Management of Hyperosmolar Hyperglycemic State
Patients with hyperosmolar hyperglycemic state (HHS) should be admitted to an intensive care unit and managed by a multidisciplinary team that includes the diabetes specialist team, with nursing staff experienced in HHS management. 1, 2
Initial Care Setting and Team Composition
- HHS patients require ICU-level care, particularly those presenting with altered mental status or severe dehydration 1
- The diabetes specialist team must be involved as soon as possible after diagnosis 2
- Patients should be nursed in areas where staff have specific experience managing HHS, as this condition is prone to management errors due to lack of familiarity 3, 2
- Emergency physicians initiate treatment but should rapidly involve critical care and endocrinology specialists 4, 5
Why Specialized Management is Critical
HHS carries a higher mortality rate than diabetic ketoacidosis and presents unique management challenges 2:
- The condition develops over many days (not hours like DKA), resulting in more extreme dehydration and metabolic disturbances 2
- Complications include myocardial infarction, stroke, seizures, cerebral edema, and central pontine myelinolysis 2
- Rapid changes in osmolality during treatment may precipitate central pontine myelinolysis, requiring careful monitoring to ensure osmolality decreases by no more than 3 mOsm/kg/h 1, 2
Specific Monitoring Requirements During Treatment
Blood must be drawn every 2-4 hours for serum electrolytes, glucose, blood urea nitrogen, creatinine, and osmolality 1, 6. This intensive monitoring requires:
- Experienced physicians who can interpret trends and adjust therapy accordingly 7
- Staff capable of frequent assessment of cardiac, renal, and mental status, particularly in patients with renal or cardiac compromise 1
- Continuous evaluation of fluid input/output and hemodynamic parameters 1
Common Management Pitfalls Requiring Expertise
Several critical errors occur frequently in HHS management 7:
- Premature use of insulin before adequate fluid resuscitation, which may be detrimental 2
- Premature termination of intravenous insulin therapy 7
- Insufficient timing or dosing of subcutaneous insulin before discontinuing intravenous insulin 7
- Overly rapid correction of osmolality, sodium, and other electrolytes 4
Role of Different Specialists
Emergency physicians provide initial assessment, diagnosis, and stabilization with fluid resuscitation 4, 5. Critical care physicians manage the ICU-level monitoring and adjust treatment protocols based on frequent laboratory assessments 1, 4. Endocrinology/diabetes specialists guide insulin therapy, transition to subcutaneous insulin, and develop discharge planning to prevent recurrence 6, 2.
The multidisciplinary approach is non-negotiable because HHS patients are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation 7. Collaborative working through clinical practice groups improves outcomes by standardizing the approach to fluid replacement, insulin therapy, and electrolyte management 3.