Treatment of Hyperglycemic Hyperosmolar State
Hyperglycemic hyperosmolar state (HHS) is a serious acute complication marked by extreme dehydration, markedly elevated blood glucose, and high serum osmolality. It requires prompt, structured first-line intervention to prevent neurological and other life-threatening complications.
Clinical Situation
The protocol addresses initial management, including the risks of overly rapid fluid or electrolyte correction, the need for thromboprophylaxis sustained throughout admission, and protective care for at-risk skin and feet.
Treatment Approach
The protocol is built around a structured intravenous fluid resuscitation regimen — with specific rate adjustments, electrolyte management, and additional supportive measures detailed in full.
Exact volumes, rates, thresholds, and modifications for cardiac or renal comorbidities are specified in the full structured protocol.
Key Clinical Targets
- Serum osmolality: gradual decline of no more than 3.0–8.0 mOsm/kg/hr
- Blood glucose: fall of no more than 5.0 mmol/L/hr
- Serum sodium: rate of fall not exceeding 10 mmol/L in 24 hours
- Urine output: at least 0.5 ml/kg/hr
References
- Commence IV 0.9% sodium chloride – 1 litre to run over 1 hour
- Using 0.9% sodium chloride solution aim to give a further 0.5–1 litre/hr depending on clinical assessment of dehydration vs. risk of precipitating heart failure.
- The target is to achieve positive fluid balance of 2–3 litres by 6 hours
- Continue IV fluid replacement to achieve positive balance of 3–6 litres by 12 hours
- Potassium should be replaced or omitted as required (see Table 2).
- Everyone with HHS should receive prophylactic low molecular weight heparin (LMWH) for the full duration of admission unless contraindicated.
- Heel protectors and an appropriate mattress should be provided for those with immobility, neuropathy, peripheral vascular disease or lower limb deformity.
- The fall in osmolality should not be more than 3.0–8.0 mOsm/kg/hr to minimise the risk of neurological complications
- The fall in glucose should not be more than 5.0 mmol/L/hr
- The rate of fall of serum sodium should not exceed 10 mmol/L in 24 hours
- Maintain accurate fluid balance chart (minimum urine output 0.5 ml/kg/hr)
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