endocrine and metabolic disorders
Hyperosmolar Hyperglycemic State (HHS)
Treatment of Hyperosmolar Hyperglycemic State
IV 0.9% saline Correction of any hypokalemia IVinsulin(as long as serum potassium is≥3.3 mEq/L [≥3.3 mmol/L]) ( Treatment references ). Treatment is 0.9% (isotonic) saline solution; 1000 mL is given in the first hour. Smaller boluses (500 mL) can be given if there is risk for exacerbation of heart failure or volume overload. Additional boluses may be needed for patients who are hypotensive. After the first hour, intravenous fluids should be adjusted based on hemodynamic and electrolyte status but should generally be continued at a rate of 250 to 500 mL/hour. A corrected sodium should be calculated. If the corrected sodium is<135 mEq/L (<135 mmol/L), then isotonic saline can be continued. If the corrected sodium is normal or elevated, then 0.45% saline (half normal) should be used. Dextroseshould be added once the glucose level reaches 250 to 300 mg/dL (13.9 to 16.7 mmol/L). The rate of infusion of IV fluids should be adjusted depending on blood pressure, cardiac status, and the balance between fluid input and output. Insulin is given at 0.1 unit/kg IV bolus followed by a 0.1 unit/kg/hour infusion after the first liter of saline has been infused and hypokalemia has been corrected. Hydration alone can sometimes precipitously decrease plasma glucose, so Target plasma glucose is between 250 and 300 mg/dL (13.9 to 16.7 mmol/L). After recovery from the acute episode, patients are usually switched to adjusted doses of subcutaneousinsulin. Potassium replacement is similar to that in Hypokalemia prevention : 40 mEq/hour for serum potassium 1.Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. In: Feingold KR, Anawalt B, Blackman MR, et al., eds. Endotext. South Dartmouth (MA): MDText.com, Inc.; May 9, 2021. 2.French EK, Donihi AC, Korytkowski MT: Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients.BMJ365:l1114, 2019. doi: 10.1136/bmj.l1114 