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Hyperosmolar Hyperglycemic State management protocol
HHS is a life-threatening emergency with 10-20% mortality. This calculator is for TRAINED MEDICAL PROFESSIONALS only. Requires ICU-level monitoring. Higher thrombosis and mortality risk than DKA. Gradual correction essential to avoid cerebral edema.
Unlike DKA, fluids are the PRIMARY treatment in HHS. Glucose often falls 50-70 mg/dL/hr with IV fluids alone. Insulin may not be needed initially.
Replace deficit over 48 hours (vs 24 hours in DKA). Rapid correction increases risk of cerebral edema. Na should not fall >10-12 mEq/L per 24 hours.
10-20% mortality (vs <5% in DKA). Elderly patients with comorbidities. Higher thrombosis risk. Consider DVT prophylaxis early.
25-50% present with altered mental status (AMS, coma). Focal neuro deficits can occur. Resolves with treatment but indicates severity.
HHS is hypercoagulable state. High risk of DVT/PE, MI, stroke, mesenteric ischemia.
Rare but serious. From rapid osmolality changes (overly aggressive fluid resuscitation).
Elderly have impaired thirst mechanism, limited access to water (nursing homes), cognitive impairment, and more comorbidities. Takes days to weeks to develop severe dehydration.
Residual insulin is sufficient to prevent lipolysis and ketogenesis, but not enough to control glucose. Type 2 diabetics retain some beta cell function.
Start insulin if (1) glucose not falling 50-70 mg/dL/hr with fluids alone, (2) significant ketoacidosis present (mixed HHS/DKA), or (3) glucose plateaus. Use lower dose (0.05 units/kg/hr) than DKA.
Start with NS for initial resuscitation. Once hemodynamically stable, use corrected sodium to guide: If corrected Na high (>145), use 0.45% saline. If normal/low, continue NS. Add K+ 20-30 mEq/L.
Yes. Mixed presentations occur with glucose >600, osmolality >320, AND pH <7.3 with ketones. Treat as DKA (insulin required) but with HHS fluid volumes.
10-20% mortality, higher in elderly with multiple comorbidities. Mortality often from precipitating cause (MI, stroke, sepsis) rather than HHS itself. Early recognition and gradual correction improve outcomes.