Hyperosmolar Hyperglycemic State (HHS) Management

Algorithm Steps

1. ▶

   Start

   Suspected HHS

   Patient with severe hyperglycemia, altered mental status, minimal ketosis

   1. ◆

      Decision

      Confirm HHS Diagnosis

      All 4 criteria required

      • Glucose ≥600 mg/dL (33.3 mmol/L)
      • Effective osmolality >300 mOsm/kg OR total >320 mOsm/kg
      • β-hydroxybutyrate <3.0 mmol/L OR urine ketones ≤2+
      • pH ≥7.3 AND bicarbonate ≥15 mmol/L
      1. ●

         Action

         1. Fluid Resuscitation

         Cornerstone of HHS therapy - prioritize over insulin

         • Initial: 0.9% NaCl 15-20 mL/kg/hr (or 1-1.5L) in first hour
         • 2024 update: Balanced crystalloids (LR/PlasmaLyte) preferred when available
         • Subsequent: Based on corrected sodium and hemodynamics
         • If corrected Na+ high/normal: 0.45% NaCl 250-500 mL/hr
         • If corrected Na+ low: Continue 0.9% NaCl 250-500 mL/hr
         • Goal: Positive fluid balance 3-6L in first 12 hours
         • Smaller boluses (250mL) in elderly/CHF/CKD
         1. ●

            Action

            2. Insulin Therapy

            Start AFTER initial fluid bolus - use LOWER dose than DKA

            • Regular insulin 0.05 units/kg/hr IV infusion (HALF the DKA dose)
            • HHS requires less aggressive insulin than DKA
            • Target glucose decline: ≤90-120 mg/dL/hr (slower than DKA)
            • When glucose reaches 250-300 mg/dL: Reduce to 0.02-0.05 units/kg/hr
            • Add dextrose (D5) when glucose <300 mg/dL
            • Rapid glucose/osmolality drop risks cerebral edema
            1. ◆

               Decision

               3. Potassium Status

               Check K+ before and during insulin

               1. ●

                  Action

                  K+ <3.3 mEq/L

                  HOLD insulin until K+ ≥3.3

                  • Give 20-40 mEq KCl/L IV fluid
                  • Recheck K+ every 1-2 hours
                  • Resume insulin when K+ ≥3.3 mEq/L
                  1. ●

                     Action

                     4. Continuous Monitoring

                     Close laboratory and clinical monitoring

                     • Glucose: every 1 hour
                     • BMP (Na, K, Cl, HCO3, Cr): every 2-4 hours
                     • Osmolality: every 2-4 hours
                     • Fluid balance and urine output
                     • Mental status assessment
                     • Identify and treat precipitating cause
                     1. ◆

                        Decision

                        HHS Resolution Criteria?

                        2024 Consensus criteria for resolution

                        • Serum osmolality ≤310 mOsm/kg
                        • Patient alert and oriented
                        • Glucose <250 mg/dL (13.9 mmol/L)
                        1. ●

                           Action

                           Transition to SubQ Insulin

                           When resolution criteria met and patient eating

                           • Start basal-bolus insulin 1-2 hours BEFORE stopping IV insulin
                           • Calculate total daily dose based on IV insulin requirements
                           • 50% basal, 50% prandial distribution
                           • Do NOT stop IV insulin until SubQ on board
                           1. ✓

                              Outcome

                              HHS Resolved

                              Discharge planning, diabetes education, follow-up

                        2. ●

                           Action

                           Continue IV Treatment

                           If criteria not met

                           • Continue IV fluids and insulin
                           • Reassess every 2-4 hours
                           • Evaluate for complications
                           • Search for unresolved precipitant
                     2. ⚠

                        Warning

                        ICU Care Required

                        Severe HHS, hemodynamic instability, altered consciousness

               2. ●

                  Action

                  K+ 3.3-5.3 mEq/L

                  Continue insulin, replace K+

                  • Add 20-30 mEq KCl per liter IV fluid
                  • Maintain K+ 4-5 mEq/L
                  • Monitor every 2-4 hours
               3. ●

                  Action

                  K+ >5.3 mEq/L

                  Continue insulin, hold K+ replacement

                  • Do not add K+ to IV fluids
                  • Recheck every 2 hours
                  • Begin replacement when K+ <5.3 mEq/L
         2. ⚠

            Warning

            ⚠️ Osmolality Warning

            Avoid rapid correction of osmolality

            • Target decrease: 3 mOsm/kg/hr
            • Rapid correction risks cerebral edema
            • Monitor mental status closely