Hyperglycemic Hyperosmolar State (HHS)

1. Diagnostic Criteria for HHS

• Serum Glucose: > 600 mg/dL
• Serum Osmolality: > 320 mOsm/kg
• pH > 7.3
• Bicarbonate > 15 mmol/L
• Minimal or no ketonemia/ketonuria

2. Initial Management of HHS

A. Fluid Resuscitation

• Initial Bolus: 0.9% NaCl, 10-20 mL/kg over 1-2 hours.
• Deficit Replacement: 0.45-0.75% NaCl, with the goal of correcting dehydration over 24-48 hours.

B. Insulin Therapy

• Begin when blood glucose reduction plateaus with fluids.
• Low-Dose Insulin Infusion: 0.025-0.05 units/kg/hour.
• Avoid bolus insulin to prevent rapid osmolar shifts.

C. Electrolyte Management

• Potassium Replacement: As for DKA, based on serum potassium levels.
• Phosphate Replacement: Only in cases of severe hypophosphatemia.

3. Monitoring and Complications

• Close monitoring of blood glucose and electrolytes.
• Watch for rhabdomyolysis or acute kidney injury.