Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Begin fluids; correct K+; start low-dose insulin infusion.
- Monitor osmolality, Na+, K+, glucose; avoid rapid shifts; add dextrose as glucose approaches 250–300.
- Treat precipitant; transition to SC insulin and education at recovery.
Clinical Synopsis & Reasoning
HHS features profound hyperglycemia, hyperosmolality, and minimal ketosis. Begin cautious isotonic fluids, correct potassium, then start insulin at lower rates than DKA; avoid rapid osmotic shifts. Search for precipitants (infection, MI, stroke, medications).
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Serum osmolality, glucose, ketones, ABG/VBG | Diagnosis | Effective osmolality >320 mOsm/kg; minimal acidosis | Differentiate from DKA |
| Electrolytes (K+, Na+, phosphate) and renal function | Safety | Hypokalemia risk with insulin | Frequent labs |
| Infection/MI/stroke workup | Precipitant | Common triggers | Treat source |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| AMS/shock | High mortality | ICU; cautious fluids/insulin |
| Na+ >150 and high osmolality | Cerebral edema risk | Slow correction; frequent labs |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Balanced crystalloids then 0.45% NaCl based on corrected Na+ | Fluids | Hours | Gradual osmolality correction | Avoid rapid drop |
| Regular insulin 0.05 U/kg/h (no bolus) after K+ ≥3.3 | Insulin | Hours | Lower glucose and osmolality | Add dextrose when glucose 250–300 |
| Potassium/magnesium/phosphate repletion | Electrolytes | Hours | Prevent arrhythmias/weakness | Protocols apply |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- ADA/Endocrine Society HHS guidance — Link