This protocol covers the management of hyperglycemic hyperosmolar state (HHS) in patients presenting with marked hypovolaemia, a serum osmolality of at least 320 mOsm/kg, significantly elevated blood glucose, and mild ketonaemia — in the absence of acidosis.
The patient meets criteria for HHS with marked hypovolaemia and serum osmolality ≥ 320 mOsm/kg. Blood glucose is ≥ 30 mmol/L. Blood ketones (3β-hydroxybutyrate) are > 1.0 mmol/L and ≤ 3.0 mmol/L, or urine ketones are below 2+. Venous pH is above 7.3 and bicarbonate above 15.0 mmol/L — the patient is not acidotic.
Management begins with intravenous fluid resuscitation and prompt initiation of a fixed rate intravenous insulin infusion, titrated according to hourly blood glucose and ketone measurements. Additional protective measures are started at the same time. The full sequence, rates, and supportive steps are detailed in the structured regimen below.
A controlled fall in blood glucose to a target of 10–15 mmol/L and clearance of blood ketones.