Hyperglycemic Hyperosmolar State: What to Do When Initial Insulin Infusion Fails to Control Blood Glucose
Clinical Scenario
This protocol addresses adults with hyperglycemic hyperosmolar state (HHS) who are already on intravenous therapy but whose blood glucose concentrations are not falling as expected — or whose osmolality is not declining despite ongoing fluid replacement. An escalated, structured approach is required to restore adequate glycaemic control and resolve the hyperosmolar state.
Previous Treatment — Target Not Met
The prior step — a fixed rate intravenous insulin infusion (FRIII) — was commenced with the objective of maintaining blood glucose at 10–15 mmol/L throughout the first 24 hours. This protocol becomes the next step when that target is not being achieved: glucose concentrations are not falling or the clinical response is insufficient despite that initial approach.
Next-Line Approach (partial overview)
The escalated management involves specific adjustments to the insulin infusion and, under defined circumstances, a change in the intravenous fluid being used for replacement. The criteria that trigger each adjustment, and the complete decision pathway, are set out in the full protocol.
Resolution Criteria
- Serum osmolality (measured or calculated) falls below 300 mOsm/kg
- Hypovolaemia corrected — urine output at least 0.5 ml/kg/hr
- Cognitive status returned to the pre-morbid baseline
- Blood glucose below 15 mmol/L
References
- If positive fluid balance is adequate, commence low dose IV insulin as a fixed rate intravenous insulin infusion (FRIII) at 0.05 units/kg/hr or if already running, increase rate to 0.1 units/kg/hr if glucose concentrations are not falling
- However, if the osmolality is no longer declining despite adequate fluid replacement with 0.9% sodium chloride solution AND an adequate rate of fall of plasma glucose is not being achieved, then 0.45% sodium chloride solution should be substituted.
- HHS can be considered to be resolved when the following criteria are met: when measured or calculated serum osmolality falls to <300 mOsm/kg, hypovolaemia has been corrected (urine output ≥0.5 ml/kg/hr), cognitive status has returned to the pre-morbid state and blood glucose <15 mmol/L
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