Hyperosmolar hyperglycemic state

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – intravenous fluid therapy

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1st line –

intravenous fluid therapy

In the setting of severe volume deficit and shock, and in the absence of cardiac compromise, patients should receive 0.9% sodium chloride or balanced crystalloid at a rate of 500-1000 mL/hour over the first 2-4 hours, aiming to replace 50% of estimated fluid deficit in first 8-12 hours.[1][47] Choice and rate of fluid replacement after restoration of intravascular volume depends on hydration status assessment (blood pressure, heart rate, fluid input and output, and sodium levels), and estimated deficits should be replaced within 24-48 hours.[1]

Older adults, or patients with heart failure or end-stage kidney disease on dialysis, should be treated cautiously, with smaller boluses of isotonic solutions (e.g., 250 mL boluses) and frequent assessment of hemodynamic status.[2][55] In such patients, the use of a standard fluid replacement protocol may be associated with treatment-related complications including volume overload, mechanical ventilation, and longer length of stay.[55]

Plus – supportive care ± intensive care unit (ICU) admission

Plus – identify and treat any precipitating factors

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Plus –

identify and treat any precipitating factors

Treatment recommended for ALL patients in selected patient group

Diagnosis of precipitating factors (e.g., infection, causative drugs) and appropriate treatment with antibiotics and removal of the offending drug should be initiated.[1]

Examples of causative drugs include: corticosteroids; thiazide diuretics; beta-blockers; pentamidine; phenytoin and atypical antipsychotics (in particular, clozapine and olanzapine).[26][27][28][29][30][32][33]

Consider – vasopressor

with baseline serum potassium <3.5 mEq/L

Plus – potassium therapy with frequent serum measurements

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Plus –

potassium therapy with frequent serum measurements

Treatment recommended for ALL patients in selected patient group

Insulin therapy, correction of acidosis, volume expansion, and increased urinary loss of potassium decrease serum potassium. Within 48 hours of admission, potassium levels typically decline by 1-2 mEq/L in patients with diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), and mixed DKA/HHS. To prevent hypokalemia, potassium replacement should be started after serum levels fall below 5 mEq/L with the aim of maintaining a potassium level of 4-5 mEq/L.

Potassium should be added to maintenance fluid therapy for patients who are normokalemic or hypokalemic.[47] If baseline serum potassium is <3.5 mEq/L insulin therapy should be delayed and potassium should be replaced until >3.5 mEq/L (guidelines suggest replacement with 10-20 mEq potassium per liter of infusion fluid).[1]

Serial potassium measurements should be monitored every 2-4 hours, and potassium replacement should then be given as needed to maintain a potassium level of 4-5 mEq/L.[1]

Plus – insulin therapy once serum potassium measurement >3.5 mEq/L

Consider – phosphate therapy

with baseline serum potassium 3.5 to 5.0 mEq/L

Plus – insulin therapy

Plus – potassium therapy with frequent serum measurements

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Plus –

potassium therapy with frequent serum measurements

Treatment recommended for ALL patients in selected patient group

Potassium should be added to maintenance fluid therapy for patients who are normokalemic or hypokalemic.[47]

If baseline serum potassium level is between 3.5 and 5.0 mEq/L potassium replacement should be started (guidelines suggest replacement with 10-20 mEq potassium per liter of infusion fluid).[1] Serial potassium measurements should be monitored every 2-4 hours, and potassium replacement should then be given as needed to maintain a potassium level of 4-5 mEq/L.[1]

Potassium replacement is not needed once the level is >5.0 mEq/L, but potassium levels should be checked every 2 hours in this situation.[1][47]

Consider – phosphate therapy

with baseline serum potassium >5.0 mEq/L

Plus – insulin therapy

Consider – monitoring of serum potassium

Consider – phosphate therapy

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