Overview of management of adults with hyperosmolar hyperglycaemia

Hyperosmolar hyperglycaemia is a medical emergency requiring specialist management. Institutions should have local protocols for management of hyperosmolar hyperglycaemia. Follow local protocols and involve the multidisciplinary diabetes service, or phone the nearest tertiary hospital or major healthcare service for specialist endocrinology advice. When uncertain about how to proceed, phone for specialist advice early.

Note: Follow local protocols and involve the multidisciplinary diabetes service when managing hyperosmolar hyperglycaemia.

If phoning for advice regarding initial management, see Information to assist initial management of diabetic ketoacidosis or hyperosmolar hyperglycaemia for information that may aid the discussion.

Management of patients with hyperosmolar hyperglycaemia should be individualised because these patients are usually older and more complex, often with multiple comorbidities such as cardiovascular disease. The goals of management are to:

  • slowly and safely replace fluid and electrolyte losses and normalise the osmolality
  • slowly and safely normalise blood glucose concentrations
  • treat the underlying cause.

Frequent monitoring is required to guide management. Effective serum osmolality1 should be measured or calculated frequently (initially hourly) to monitor the response to treatment. Rapid change in serum osmolality must be avoided. A safe rate of fall of blood glucose concentration is between 4 to 6 mmol/L per hour. Complete normalisation of electrolytes and osmolality may take up to 72 hours.

Note: Rapid change in serum osmolality must be avoided in patients with hyperosmolar hyperglycaemia.

Treating the underlying cause of hyperosmolar hyperglycaemia involves:

  • thorough investigation for and management of concurrent infection or conditions (eg pancreatitis, stroke, myocardial infarction)
  • identification and management of precipitating factors, such as:
    • inadequate or omitted doses of antihyperglycaemic drugs (eg insulin)
    • discontinuing antihyperglycaemic drugs
    • starting drugs that induce hyperglycaemia (see Drug-induced hyperglycaemia).

Patients with hyperosmolar hyperglycaemia have a very high risk of developing arterial and venous thrombosis. Use anticoagulant prophylaxis (see information on prevention of venous thromboembolism).

Note: Patients with hyperosmolar hyperglycaemia have a very high risk of developing arterial and venous thrombosis.
1 Effective serum osmolality (mOsm/kg) = (2 × [sodium concentration + potassium concentration]) + blood glucose concentration + urea concentration (all concentration units in mmol/L) Return