HHS with Ketonaemia (Not Acidotic): Management After Initial IV Saline and Insulin Infusion Fail to Reach Targets
Clinical scenario
Hyperglycaemic hyperosmolar state with marked hypovolaemia — serum osmolality ≥ 320 mOsm/kg and blood glucose ≥ 30 mmol/L — alongside blood ketones (3β-hydroxybutyrate) above 1.0 and up to 3.0 mmol/L, or urine ketones below 2+, and no acidosis (venous pH > 7.3 and bicarbonate > 15.0 mmol/L).
Previous treatment & why it was insufficient
First-line therapy — IV 0.9% sodium chloride solution with a fixed rate intravenous insulin infusion (FRIII) — aimed for a controlled fall in blood glucose to 10–15 mmol/L and clearance of blood ketones. This protocol addresses the next step when those goals are not being met.
Approach at this stage
Management involves specific adjustments to both the insulin infusion rate and the intravenous fluid composition, guided by the observed rate of glucose fall and the trajectory of plasma osmolality. The complete criteria and substitution rules are in the structured protocol.
Clinical goal: A safe, controlled fall in plasma glucose of no more than 5.0 mmol/L/hr.
References
- If there is HHS and ketonaemia (blood ketones 3β-hydroxybutyrate >1.0 – ≤3.0 mmol/L or urine ketones < 2+) and not acidotic (venous pH >7.3 and bicarbonate >15.0 mmol/L) then use 0.05 units/kg/hr
- If glucose is dropping too quickly (i.e. by >5.0 mmol/L/hr), then reduce the FRIII rate by 50%
- 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.
- The fall in glucose should not be more than 5.0 mmol/L/hr
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