Hyperosmolar hyperglycaemic state

Manage now— do this, in order

• Go slowly — the commonest serious error is to manage HHS as though it were DKA. There is no ketoacidosis demanding urgent reversal, and the brain has adapted over weeks to a very high osmolality: rapid shifts must be avoided, guided by serial calculation of serum osmolality.
• Fluid is the treatment — 0.9% sodium chloride alone initially: 1 litre over the first hour (more rapidly if systolic below 90 mmHg), then normally 0.5–1.0 litre/hour, prescribed in mL/hour with start and finish times. Aim for a positive balance of 2–3 litres at 6 hours and 3–6 litres at 12 hours, urine output at least 0.5 mL/kg/hr, checking for pulmonary oedema before each bag. Cautious in cardiac, renal and very elderly patients — but do not under-fill: under-resuscitation is equally lethal.
• Hold the rates of correction: osmolality falling 3–8 mOsmol/kg/hour, sodium falling no more than 10 mmol/L in 24 hours, glucose falling no more than 5 mmol/L (90 mg/dL)/hour, and a glucose target after 6 hours of 10–15 mmol/L (180–270 mg/dL) — not normoglycaemia. The measured sodium normally rises as the glucose falls — that rise is expected, not a treatment failure: do not reach for 0.45% sodium chloride.
• Potassium: above 5.5 mmol/L — add none, recheck in 1 hour with cardiac monitoring; 3.5–5.5 mmol/L — potassium chloride 40 mmol/L in each litre (premixed bags), maintaining 4.0–5.0 mmol/L; below 3.5 mmol/L — cardiac monitoring, critical care input, more than 40 mmol/L through an appropriate line, and do not start insulin until potassium replacement is running.Doctor / Nurse
• Insulin is not first-line: in the first 0–60 minutes start a fixed-rate IV infusion at 0.05 units/kg/hr ONLY IF blood ketones are above 1.0 mmol/L, and only after fluid has started — otherwise no insulin. Between 1 and 6 hours: if glucose is falling by less than 5 mmol/L/hr AND the fluid balance is adequate, increase to 0.1 units/kg/hr (or start at 0.05). After 6 hours adjust by 1 unit/hour to hold glucose at 10–15 mmol/L. Never give an IV insulin bolus in HHS; if glucose falls faster than 5 mmol/L/hr, reduce or stop the infusion.Doctor / NurseNot available at your setup — Infusion pump.
• When blood glucose falls below 14 mmol/L, add 10% glucose at 125 mL/hour alongside the continuing saline — this prevents hypoglycaemia and lets a low-dose infusion keep running while any ketones clear.Doctor / Nurse
• Thromboprophylaxis is a therapeutic intervention here, not a routine: enoxaparin 40 mg SC once daily (20 mg once daily if eGFR below 30 mL/min), mechanical prophylaxis where heparin is contraindicated. Protect the feet — inspect heels, soles and interdigital spaces, keep heels off the mattress: foot infections take hold rapidly and are medical emergencies.Doctor / Nurse
• Catheterise and monitor by the clock: hourly capillary glucose; sodium, potassium, urea and recalculated osmolality hourly for 6 hours then two-hourly; hourly conscious level, urine output and cumulative balance — every value with a clock time. A falling conscious level while the biochemistry improves: exclude hypoglycaemia, then consider cerebral oedema, osmotic demyelination, stroke, sepsis and hypoxia — not more fluid.
• Treat the precipitant concurrently — it usually determines survival: cultures then early empirical antibiotics if sepsis is suspected; stop the thiazide, SGLT2 inhibitors and nephrotoxins; withhold metformin while dehydrated or in acute kidney injury. Do not give IV sodium bicarbonate (considered only below pH 6.9, implicated in cerebral oedema) and do not reflexively sedate the agitated patient — look first for hypoxia, hypoglycaemia, sepsis, pain and urinary retention.Not available at your setup — Blood culture.