Medication Summary
Aggressive rehydration with intravenous (IV) fluids, including 0.9% isotonic saline, is indicated in every patient with hyperosmolar hyperglycemic state (HHS). Insulin therapy and repletion of electrolytes (especially potassium) are the other cornerstones of management. [38] Antipyretics, antiemetic, and antibiotics are added when appropriate to control fever and vomiting and to treat an underlying infection if one is suspected.
Frequent monitoring of electrolyte and glucose concentrations is indicated when patients are treated with IV fluids. Volume overload is the only other potential problem associated with IV fluid replacement; therefore, regular assessment of the hydration status is indicated.
Antidiabetics, Insulins
Class Summary
Although many patients with hyperosmolar hyperglycemic state (HHS) respond to fluids alone, intravenous (IV) insulin in dosages similar to those used in diabetic ketoacidosis (DKA) can facilitate correction of hyperglycemia. Insulin used without concomitant vigorous fluid replacement increases the risk of shock.
Regular insulin (Humulin R, Novolin R)
Regular insulin has a rapid onset of action (within 0.5-1 hours), and a short duration of action (4-6 hours). Peak effects occur within 2-4 hours. Insulin is used to reduce blood glucose levels and decrease ketogenesis. Some authors favor lower bolus and infusion dosages, with the rationale that fluids are the cornerstone of therapy and that HHS is more a disorder of insulin resistance than it is one of insulin deficiency. Furthermore, lowering serum glucose and serum osmolarity overly rapidly can result in complications.
Insulin aspart (NovoLog)
Insulin aspart has a rapid onset of action (5-15 minutes) and a short duration of action (3-5 hours). Peak effects occurs within 30-90 minutes.
Insulin glulisine (Apidra)
Insulin glulisine has a rapid onset of action (5-15 minutes) and a short duration of action (3-5 hours).
Insulin lispro (Humalog)
Insulin lispro has a rapid onset of action (5-15 minutes) and a short duration of action (4 hours).
Alkalizing agents
Class Summary
No evidence is found that sodium bicarbonate provides any benefit to patients with HHS. It may be considered if a patient has significant acidosis (pH < 7.0), particularly if inotropic agents are required to maintain blood pressure.
Sodium bicarbonate (NaHCO3)
Sodium bicarbonate neutralizes hydrogen ions and raises urinary and blood pH.
Electrolytes Supplements, Parenteral
Class Summary
Electrolytes are given to replenish electrolyte supplies depleted by the presence of a high blood glucose level.
Potassium chloride (Klor-Con, K-Tab, Micro-K)
In virtually all cases of HHS, supplemental potassium is necessary because the serum level drops secondary to insulin therapy and correction of metabolic acidosis. Do not start IV potassium until the initial serum level is ascertained, as the initial level may be high related to hemoconcentration. Administer it cautiously, with attention to proper dosing and concentration. If the patient can tolerate oral medications or has a gastric tube in place, potassium chloride can be given orally in doses of up to 60 mEq, with dosing based on frequently obtained laboratory values.
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Glucose metabolism chart
