Hyperosmolar Hyperglycemic State (HHS) — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] HHS diagnosis (four criteria)
   Does it meet the HHS diagnostic criteria? (Four HHS criteria: 1) glucose ≥33.3 mmol/L (600 mg/dL); 2) effective serum osmolality >320 mOsm/kg (effective osm = 2×Na + glucose in mmol/L); 3) no significant ketosis (β-hydroxybutyrate <3.0 mmol/L or urine ketones ≤2+); 4) no acidosis (pH ≥7.3, HCO3 ≥15 mmol/L). The degree of altered consciousness correlates with osmolality.)
   • Meets HHS → HHS management (correct slowly)
   • More like DKA or mixed → DKA-predominant / mixed
2. [End] DKA-predominant / mixed
   Predominantly ketoacidosis or mixed DKA/HHS: manage along the DKA pathway (fluids + insulin + potassium + find the trigger); if hyperosmolarity is marked, insulin may start after adequate fluids, lowering osmolality slowly.
3. [End] HHS management (correct slowly)
   HHS develops and is corrected slowly: 1) Aggressive fluids — start 0.9% sodium chloride to correct volume (adults are often ~9 L deficient over 48 h); after volume restored, switch to 0.45% by corrected sodium, and add dextrose when glucose falls to ~13.9 mmol/L. 2) Potassium — check and replace once urine output returns and K <5.2; hold insulin if K <3.3. 3) Insulin — after fluids and potassium, low-dose infusion 0.05 U/kg/h (lower than DKA). 4) Lower glucose and osmolality slowly (effective osmolality drop ≤3 mOsm/kg/h) to prevent cerebral edema. 5) Find and treat the trigger (infection, MI, etc.), monitor electrolytes, watch for thrombosis.

Source guidelines & references

• 2024 ADA/EASD consensus on hyperglycemic crises in adults. Diabetes Care 2024

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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