What To Do When Initial IV Fluid Resuscitation for Hyperglycemic Hyperosmolar State Has Not Achieved Its Target Correction Rates

Hyperglycemic hyperosmolar state (HHS) is managed in sequential steps. The first priority is intravenous fluid resuscitation to restore circulating volume and begin correcting hyperosmolality. When that initial approach has not achieved the required rates of biochemical correction — or when blood glucose has plateaued with fluid replacement alone — a structured insulin protocol becomes the next clinical priority.

When the Initial IV Fluid Step Has Not Met Its Targets

The first-line approach — intravenous 0.9% sodium chloride solution — is designed to produce a controlled, gradual correction across several parameters simultaneously. The targets it must achieve are:

A gradual decline in serum osmolality of 3.0–8.0 mOsm/kg/hr
A fall in blood glucose of no more than 5.0 mmol/L/hr
A rate of fall of serum sodium not exceeding 10 mmol/L in 24 hours
A urine output of at least 0.5 ml/kg/hr

When these parameters are not being achieved — or when blood glucose concentrations have plateaued and fluids alone are no longer sufficient — this protocol defines the next step.

Treatment Approach (Partial Overview)

Once fluid replacement is judged adequate and blood glucose has plateaued, a fixed-rate intravenous insulin infusion is commenced. Blood glucose is monitored closely throughout, and the need for additional glucose supplementation alongside the ongoing saline is assessed based on how glucose responds. When the patient becomes biochemically stable, the mode of insulin delivery is reassessed according to whether they are eating and drinking.

Specific rates, thresholds, switching criteria, and the full decision algorithm are in the complete structured regimen.

Key Clinical Target

Maintain blood glucose 10–15 mmol/L in the first 24 hours.

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References

ONLY start IV insulin once fluid replacement is adequate and glucose concentrations have plateaued.
The recommended insulin dose is a FRIII given at 0.05 units/kg/hr.
Once glucose plateaus with fluid replacement alone, commence FRIII at rate of 0.05 units/kg/hr, aiming for a target glucose of 10.0–15.0 mmol/L.
If BG falls below 14 mmol/L commence 5% or 10% glucose at 125 ml/hr AND CONTINUE 0.9% sodium chloride solution.
Variable rate insulin if not eating and drinking.
Convert to appropriate subcutaneous insulin regime when biochemically stable.
Aim to keep BG 10–15 mmol/L in first 24 hours.

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