Hyperosmolar hyperglycemic state medical therapy: Difference between revisions

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{{Hyperosmolar hyperglycemic state}}
{{Hyperosmolar hyperglycemic state}}
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{HS}}


==Overview==
==Overview==
Hyperosmolar hyperglycemic state (HHS) is a [[medical emergency]] and acute complication of [[diabetes mellitus]]. The basic principles guiding therapy include rapid restoration of adequate [[circulation]] and [[perfusion]], correction of [[hyperosmolality]], [[electrolytes]] balance, [[hyperglycemia]], identifying and treating the underlying precipitating cause and close monitoring to prevent and treat complications if they develop. The mainstay of therapy for HHS is medical therapy including intravenous [[insulin]], [[fluids|fluids,]] and [[potassium]] replacement therapy.


==Medical Therapy==
==Medical Therapy==
=== <u>Basic principles</u> ===
=== <u>Basic principles</u> ===
The basic principles of hyperosmolar hyperglycemic state treatment are:
The basic principles of hyperosmolar hyperglycemic state treatment are:
Line 19: Line 16:
* Careful monitoring to detect and treat complications.
* Careful monitoring to detect and treat complications.


The [[American Diabetes Association|American Diabetes Association (ADA)]] recommends the following therapy for hyperosmolar hyperglycemic state:<ref name="pmid2699725">{{cite journal |vauthors=Radhakrishna Pillai M, Balaram P, Bindu S, Hareendran NK, Padmanabhan TK, Nair MK |title=Interleukin 2 production in lymphocyte cultures: a rapid test for cancer-associated immunodeficiency in malignant cervical neoplasia |journal=Cancer Lett. |volume=47 |issue=3 |pages=205–10 |year=1989 |pmid=2699725 |doi= |url=}}</ref><ref name="urlDiabetes Care">{{cite web |url=http://care.diabetesjournals.org/content/32/7/1335?ijkey=34356f79daf21d51f95018c32e74e6df627e513c&keytype2=tf_ipsecsha |title=Diabetes Care |format= |work= |accessdate=}}</ref><ref name="pmid21978840">{{cite journal |vauthors=Nyenwe EA, Kitabchi AE |title=Evidence-based management of hyperglycemic emergencies in diabetes mellitus |journal=Diabetes Res. Clin. Pract. |volume=94 |issue=3 |pages=340–51 |year=2011 |pmid=21978840 |doi=10.1016/j.diabres.2011.09.012 |url=}}</ref><ref name="pmid19564476">{{cite journal| author=Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN| title=Hyperglycemic crises in adult patients with diabetes. | journal=Diabetes Care | year= 2009 | volume= 32 | issue= 7 | pages= 1335-43 | pmid=19564476 | doi=10.2337/dc09-9032 | pmc=2699725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19564476  }} </ref>


==== Fluid therapy ====
* Initial [[Intravenous fluids|fluid therapy]] is aimed towards expansion of the [[intravascular]], [[interstitial]], and [[intracellular]] volume, all of which are reduced in [[Hyperglycemic crises resident survival guide|hyperglycemic crises]].
* [[Fluid]] restoration also leads to increased [[renal]] [[perfusion]] and improves [[renal]] function.
* The following options may be used for [[fluid]] restoration:
** [[Saline solution|Isotonic saline]] (0.9% [[Sodium chloride|NaCl]]) is infused at a rate of 15–20 ml/kg/h or 1–1.5 L during the first hour. It may also be [[Infusion|infused]] at a rate of 250-500 ml/h if [[serum]] [[sodium]] is low.
** Subsequent choice for [[Intravenous fluids|fluid]] replacement depends on [[hemodynamics]], the volume status of the body ([[Signs and Symptoms|signs and symptoms]] of [[dehydration]]), [[serum electrolyte]] levels, and [[urinary]] output.<ref name="urlDiabetic Ketoacidosis: Evaluation and Treatment - American Family Physician">{{cite web |url=http://www.aafp.org/afp/2013/0301/p337.html |title=Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician |format= |work= |accessdate=}}</ref>
** Half [[normal saline]] (0.45% [[Sodium chloride|NaCl]] ) [[Infusion|infused]] at 250–500 ml/h is beneficial if the corrected [[serum]] [[sodium]] is normal or increased.<ref name="urlDiabetic Ketoacidosis: Evaluation and Treatment - American Family Physician" /><ref name="pmid3138479">{{cite journal |vauthors=Kageyama Y, Kawamura J, Ajisawa A, Yamada T, Iikuni K |title=A case of pseudohypoparathyroidism type 1 associated with gonadotropin resistance and hypercalcitoninaemia |journal=Jpn. J. Med. |volume=27 |issue=2 |pages=207–10 |year=1988 |pmid=3138479 |doi= |url=}}</ref>
* Successful progress with fluid replacement is judged by, [[blood pressure]] monitoring, measurement of [[fluid]] input/output, laboratory values, and clinical examination.
* [[Intravenous fluids|Fluid]] replacement usually leads to successful treatment of volume deficit within the first 24 hours.
* In patients with [[renal]] or [[cardiac]] compromise, monitoring of [[serum]] [[osmolality]] and frequent assessment of [[cardiac]], [[renal]], and [[mental status]] must be performed during [[fluid resuscitation]] to avoid [[iatrogenic]] [[fluid overload]].
* Aggressive [[rehydration]] with subsequent resolution of the [[hyperosmolar]] state has been shown to be linked to a better response to low dose [[insulin]]. 
* Once the [[plasma]] [[glucose]] is ∼ 300 mg/dl, 5% [[dextrose]] should be added to replacement [[Intravenous fluids|fluids]] to allow continued [[insulin]] administration. 
==== '''Insulin therapy''' ====
* Adequate fluids must be given before administering [[insulin]]. If [[insulin]] is given before [[fluids]], it will cause water to move intracellularly causing worsening of [[hypotension]] and death.
* [[Insulin]] therapy helps control [[hyperglycemia]] and [[hyperkalemia]] in hyperosmolar hyperglycemic state.<ref name="urlManagement of Diabetic Ketoacidosis - American Family Physician">{{cite web |url=http://www.aafp.org/afp/1999/0801/p455.html |title=Management of Diabetic Ketoacidosis - American Family Physician |format= |work= |accessdate=}}</ref>


* '''Rate of administration''': An initial [[intravenous]] dose of [[regular insulin]] (0.1 units/kg) followed by [[infusion]] of 0.1 units/kg/h [[insulin]].<ref name="urlDiabetes Care">{{cite web |url=http://care.diabetesjournals.org/content/32/7/1335?ijkey=34356f79daf21d51f95018c32e74e6df627e513c&keytype2=tf_ipsecsha |title=Diabetes Care |format= |work= |accessdate=}}</ref>
** The initial [[bolus]] of [[insulin]] may be skipped, if patients receive an hourly [[insulin]] [[infusion]] of 0.14 units/kg body weight.
** Low-dose [[insulin]] [[infusion]] protocols decrease [[plasma]] [[glucose]] concentration at a rate of 50–75 mg/dl/h.<ref name="urlDiabetes Care">{{cite web |url=http://care.diabetesjournals.org/content/32/7/1335?ijkey=34356f79daf21d51f95018c32e74e6df627e513c&keytype2=tf_ipsecsha |title=Diabetes Care |format= |work= |accessdate=}}</ref>
** '''Titration''': If [[plasma]] [[glucose]] does not decrease by 50–75 mg from the initial value in the first hour, the [[insulin]] [[infusion]] can be doubled until a steady [[glucose]] decline is achieved.
** When the [[blood]] [[glucose]] level reaches 300 mg/dl, the rate of [[insulin]] [[infusion]] should be changed to 0.02 units/kg/h - 0.05 units/kg/h and [[dextrose]] may be added to the [[Intravenous|IV]] [[fluids]] to keep the [[glucose]] between 250 - 300 mg/dl until hyperosmolality has resolved or the patient is conscious and alert.<ref name="pmid25061324">{{cite journal |vauthors=Gosmanov AR, Gosmanova EO, Dillard-Cannon E |title=Management of adult diabetic ketoacidosis |journal=Diabetes Metab Syndr Obes |volume=7 |issue= |pages=255–64 |year=2014 |pmid=25061324 |pmc=4085289 |doi=10.2147/DMSO.S50516 |url=}}</ref><ref name="pmid19564476">{{cite journal| author=Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN| title=Hyperglycemic crises in adult patients with diabetes. | journal=Diabetes Care | year= 2009 | volume= 32 | issue= 7 | pages= 1335-43 | pmid=19564476 | doi=10.2337/dc09-9032 | pmc=2699725 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19564476  }} </ref>
'''Potassium replacement'''
* [[Potassium]] replacement is started when the levels fall below the upper limit of normal (5.0-5.2 mEq/L).<ref name="pmid4633105">{{cite journal |vauthors=Beigelman PM |title=Potassium in severe diabetic ketoacidosis |journal=Am. J. Med. |volume=54 |issue=4 |pages=419–20 |year=1973 |pmid=4633105 |doi= |url=}}</ref>
* Goal is to maintain [[serum]] [[potassium]] levels within the normal range of 3.3–5.2 mEq/L.
* If [[serum]] [[potassium]] levels are < 3.3 mEq/L; hold the [[insulin]] and add 20 - 30 mEq/ hr of potassium to each litre infusion fluids.
* If [[serum]] [[potassium]] levels are > 5.2 mEq/L; do not add [[potassium]] but check for [[serum]] [[potassium]] every 2 hours.
'''Other electrolytes'''
* There is insufficient evidence that treatment with [[phosphate]], [[calcium]], and [[magnesium]] alters the outcome in the hyperosmolar hyperglycemic state.<ref name="pmid116547">{{cite journal |vauthors=Winter RJ, Harris CJ, Phillips LS, Green OC |title=Diabetic ketoacidosis. Induction of hypocalcemia and hypomagnesemia by phosphate therapy |journal=Am. J. Med. |volume=67 |issue=5 |pages=897–900 |year=1979 |pmid=116547 |doi= |url=}}</ref>
* [[Phosphate]] therapy may be given to avoid potential [[cardiac]] and [[skeletal muscle]] weakness and [[respiratory depression]] due to [[hypophosphatemia]].<ref name="pmid25061324">{{cite journal |vauthors=Gosmanov AR, Gosmanova EO, Dillard-Cannon E |title=Management of adult diabetic ketoacidosis |journal=Diabetes Metab Syndr Obes |volume=7 |issue= |pages=255–64 |year=2014 |pmid=25061324 |pmc=4085289 |doi=10.2147/DMSO.S50516 |url=}}</ref>
* [[Phosphate]] replacement may sometimes be indicated in patients with [[cardiac dysfunction]], [[anemia]], or [[respiratory depression]] and when [[serum]] [[phosphate]] concentration is <1.0 mg/dl.
* Aggressive [[phosphate]] replacement may lead to [[hypocalcemia]].
* [[Magnesium]] should be checked as it is important in preventing [[renal]] wasting of [[potassium]].
'''Vitamins'''
* Patients with hyperosmolar hyperglycemic state and [[diabetes]] are vulnerable to develop [[refeeding syndrome]].<ref name="pmid2109122">{{cite journal| author=Solomon SM, Kirby DF| title=The refeeding syndrome: a review. | journal=JPEN J Parenter Enteral Nutr | year= 1990 | volume= 14 | issue= 1 | pages= 90-7 | pmid=2109122 | doi=10.1177/014860719001400190 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2109122  }} </ref>
* The administration of [[thiamine]] can prevent [[refeeding syndrome]].
'''Identify and treat the precipitating cause'''
* Appropriate investigations can be ordered to find out and treat the precipitating cause.
* Empiric [[Antibiotic|antibiotics]] can be administered, if there is suspicion of [[sepsis]] only after taking the [[Blood culture|blood cultures]].
=== <u>Criteria for resolution</u> ===
* The following criteria must be met for labeling resolution of hyperosmolar hyperglycemic state:
** [[Plasma glucose]] < 300 mg/dl
** [[Plasma osmolality]] < 320 mOsm/kg
** Regain of normal mental status
** Regain of normal hemodynamic status


 
===Step-wise management of hyperosmolar hyperglycemic state===
 
{{familytree/start}}
 
{{familytree | | | | | | | | | | | | | | | | | B01 | | | | | | | | | | |B01=HHS treatment protocol according to ADA guidelines}}
 
{{familytree | | | | | | |,|-|-|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|.| }}
 
{{familytree | | | | | | C01 | | | | | | | | | |C02| | | | | | | | |C03|C01=Fluids|C02=Insulin|C03=Potassium}}
 
{{familytree | | | | | | |!| | | | | | | | |,|-|-|^|-|-|.| | | |,|-|-|-|+|-|-|-|-|.| }}
 
{{familytree | | | | | |D01| | | | | | | |D02| | |D03| |D04| |D05| | |D06| |D01=Hydration status|D02=0.1 u/kg/B.WT. as IV bolus|D03=0.14 u/kg/B.WT/hr as continous IV infusion|D04=K < 3.3 mEq/L|D05=K = 3.3 - 5.2 mEq/L |D06=K > 5.2 mEq/L}}
 
{{familytree | | |,|-|-|-|+|-|-|-|.| | | | | |!| | | | |!| | | |!| | | |!| | | | |!| | | | }}
 
{{familytree | | E01 | |E02| |E03| | | |E04| | | |!| | |E05| |E06| | |E07| |E01=Severe hypovolemia|E02= Mild dehydration|E03= Cardiogenic shock|E04=0.1 u/kg/B.WT. as IV continous infusion|E05= Hold insulin and give 20-30mEq/L of potassium until K+ > 3.3mEq/L|E06= Give 20-30mEq/L in each liter of IV fluids to maintain serum K 4-5mEq/L|E07= Do not give potassium but check serum potassium every 2 hours}}
 
{{familytree | | |!| | | |!| | |!| | | | | | |!| | | | |!| | | | | | | | | | | }}
 
{{familytree | |F01 | |F02| |F03| | | | |!| | | | |!| | | | | | | | | | |F01= 0.9% Nacl (1L/hr) as IV infusion|F02= Check corrected serum sodium|F03=Hemodynamic monitoring and add pressors accordingly}}
 
{{familytree | | | | | | | |!| | | | | | | | |`|L01|-|'|L01=If serum glucose does not fall by 10 % within one hour of therapy then give 0.14 U/Kg as IV bolus and continue previous regimen}}
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
{{familytree | | | |,|-|-|-|+|-|-|-|.| | | | | | |!| | }}
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
{{familytree | | |G01| |G02| |G03| | | | |G04| G01= High serum Na (>145 mEq/L)|G02=Normal serum Na (135-145 mEq/L)|G03= Low serum Na (< 135 mEq/L)|G04= When serum glucose drops to 300 mg/dl, reduce regular insulin to 0.02-0.05 U/Kg/hour, maintain serum glucose between 200 mg/dl to 300 mg/dl until patient is alert}}
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
{{familytree | | | |!| | | |!| | | |!| | }}
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
{{familytree | | | |`|H01|'| | |H02| |H01=0.45% NaCl (250-500 ml per hour depending on hydration status|H02=0.9% NaCl (200-500 ml per hour) depending on hydration status }}
===Disease Name===
{{familytree | | | | | |!| | | | | |!| | | }}
 
{{familytree | | | | | |`|-|I01|-|'| | |I01=When serum glucose decreases to 300 mg/dl, switch to 5% dextrose with 0.45% NaCl at 150-250 ml/hour }}
* '''1 Stage 1 - Name of stage'''
{{familytree/end}}
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. ''''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 2.1 '''Specific Organ system involved 2'''
*** 2.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 2.1.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
 
* 2 '''Stage 2 - Name of stage'''
** 2.1 '''Specific Organ system involved 1 '''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) ''''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==
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[[Category:Medicine]]
[[Category:Endocrinology]]
[[Category:Up-To-Date]]
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[[Category:Emergency medicine]]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]

Overview

Hyperosmolar hyperglycemic state (HHS) is a medical emergency and acute complication of diabetes mellitus. The basic principles guiding therapy include rapid restoration of adequate circulation and perfusion, correction of hyperosmolality, electrolytes balance, hyperglycemia, identifying and treating the underlying precipitating cause and close monitoring to prevent and treat complications if they develop. The mainstay of therapy for HHS is medical therapy including intravenous insulin, fluids, and potassium replacement therapy.

Medical Therapy

Basic principles

The basic principles of hyperosmolar hyperglycemic state treatment are:

The American Diabetes Association (ADA) recommends the following therapy for hyperosmolar hyperglycemic state:[1][2][3][4]

Fluid therapy

Insulin therapy

Potassium replacement

  • Potassium replacement is started when the levels fall below the upper limit of normal (5.0-5.2 mEq/L).[9]
  • Goal is to maintain serum potassium levels within the normal range of 3.3–5.2 mEq/L.
  • If serum potassium levels are < 3.3 mEq/L; hold the insulin and add 20 - 30 mEq/ hr of potassium to each litre infusion fluids.
  • If serum potassium levels are > 5.2 mEq/L; do not add potassium but check for serum potassium every 2 hours.

Other electrolytes

Vitamins

Identify and treat the precipitating cause

  • Appropriate investigations can be ordered to find out and treat the precipitating cause.
  • Empiric antibiotics can be administered, if there is suspicion of sepsis only after taking the blood cultures.

Criteria for resolution

  • The following criteria must be met for labeling resolution of hyperosmolar hyperglycemic state:

Step-wise management of hyperosmolar hyperglycemic state

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HHS treatment protocol according to ADA guidelines
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fluids
 
 
 
 
 
 
 
 
 
Insulin
 
 
 
 
 
 
 
 
Potassium
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hydration status
 
 
 
 
 
 
 
0.1 u/kg/B.WT. as IV bolus
 
 
0.14 u/kg/B.WT/hr as continous IV infusion
 
K < 3.3 mEq/L
 
K = 3.3 - 5.2 mEq/L
 
 
K > 5.2 mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe hypovolemia
 
Mild dehydration
 
Cardiogenic shock
 
 
 
0.1 u/kg/B.WT. as IV continous infusion
 
 
 
 
 
 
 
Hold insulin and give 20-30mEq/L of potassium until K+ > 3.3mEq/L
 
Give 20-30mEq/L in each liter of IV fluids to maintain serum K 4-5mEq/L
 
 
Do not give potassium but check serum potassium every 2 hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
0.9% Nacl (1L/hr) as IV infusion
 
Check corrected serum sodium
 
Hemodynamic monitoring and add pressors accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If serum glucose does not fall by 10 % within one hour of therapy then give 0.14 U/Kg as IV bolus and continue previous regimen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High serum Na (>145 mEq/L)
 
Normal serum Na (135-145 mEq/L)
 
Low serum Na (< 135 mEq/L)
 
 
 
 
When serum glucose drops to 300 mg/dl, reduce regular insulin to 0.02-0.05 U/Kg/hour, maintain serum glucose between 200 mg/dl to 300 mg/dl until patient is alert
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
0.45% NaCl (250-500 ml per hour depending on hydration status
 
 
 
 
0.9% NaCl (200-500 ml per hour) depending on hydration status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
When serum glucose decreases to 300 mg/dl, switch to 5% dextrose with 0.45% NaCl at 150-250 ml/hour
 
 
 
 
 
 
 
 
 

References

  1. ↑ Radhakrishna Pillai M, Balaram P, Bindu S, Hareendran NK, Padmanabhan TK, Nair MK (1989). "Interleukin 2 production in lymphocyte cultures: a rapid test for cancer-associated immunodeficiency in malignant cervical neoplasia". Cancer Lett. 47 (3): 205–10. PMID 2699725.
  2. ↑ 2.0 2.1 2.2 "Diabetes Care".
  3. ↑ Nyenwe EA, Kitabchi AE (2011). "Evidence-based management of hyperglycemic emergencies in diabetes mellitus". Diabetes Res. Clin. Pract. 94 (3): 340–51. doi:10.1016/j.diabres.2011.09.012. PMID 21978840.
  4. ↑ 4.0 4.1 Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (2009). "Hyperglycemic crises in adult patients with diabetes". Diabetes Care. 32 (7): 1335–43. doi:10.2337/dc09-9032. PMC 2699725. PMID 19564476.
  5. ↑ 5.0 5.1 "Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician".
  6. ↑ Kageyama Y, Kawamura J, Ajisawa A, Yamada T, Iikuni K (1988). "A case of pseudohypoparathyroidism type 1 associated with gonadotropin resistance and hypercalcitoninaemia". Jpn. J. Med. 27 (2): 207–10. PMID 3138479.
  7. ↑ "Management of Diabetic Ketoacidosis - American Family Physician".
  8. ↑ 8.0 8.1 Gosmanov AR, Gosmanova EO, Dillard-Cannon E (2014). "Management of adult diabetic ketoacidosis". Diabetes Metab Syndr Obes. 7: 255–64. doi:10.2147/DMSO.S50516. PMC 4085289. PMID 25061324.
  9. ↑ Beigelman PM (1973). "Potassium in severe diabetic ketoacidosis". Am. J. Med. 54 (4): 419–20. PMID 4633105.
  10. ↑ Winter RJ, Harris CJ, Phillips LS, Green OC (1979). "Diabetic ketoacidosis. Induction of hypocalcemia and hypomagnesemia by phosphate therapy". Am. J. Med. 67 (5): 897–900. PMID 116547.
  11. ↑ Solomon SM, Kirby DF (1990). "The refeeding syndrome: a review". JPEN J Parenter Enteral Nutr. 14 (1): 90–7. doi:10.1177/014860719001400190. PMID 2109122.

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