Version July 2025
This algorithm summarizes our suggested approach to the management of HHS in adults.
HHS diagnostic criteria: Hyperglycemia (glucose ≥600 mg/dL [33.3 mmol/L]), serum osmolality >300 mOsm/kg, arterial pH >7.3, serum bicarbonate >18 mEq/L, and minimal ketonuria (<2+) or ketonemia (BOHB <3 mmol/L). Normal laboratory values vary; check local laboratory reference ranges for all electrolytes.
If acidosis and/or at least moderate ketonemia/ketonuria are present, presentation is consistent with DKA or mixed DKA/HHS. Refer to UpToDate content on the treatment of DKA in adults.
For monovalent ions (eg, K+), 1 mEq/L = 1 mmol/L.
BOHB: beta-hydroxybutyrate; BUN: blood urea nitrogen; DKA: diabetic ketoacidosis; HHS: hyperosmolar hyperglycemic state; IV: intravenous; K+: potassium; KCl: potassium chloride; Na+: sodium; NaCl: sodium chloride; STAT: intervention should be performed emergently; SUBQ: subcutaneous.
* After history and physical examination, obtain capillary glucose and serum or urine ketones. Begin 1 L of 0.9% NaCl (or buffered crystalloid) over 1 hour, and draw arterial blood gas (or mixed venous blood gas), complete blood count with differential, urinalysis, serum glucose, BUN, electrolytes, chemistry profile, and creatinine levels STAT. Obtain electrocardiogram and, if needed, chest radiograph and specimens for bacterial cultures.
¶ Serum Na+ should be "corrected" for hyperglycemia (for each 100 mg/dL increase in glucose above 100 mg/dL, add 2 mEq to sodium value for corrected serum sodium value).
