Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – intravenous fluid therapy

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ACUTE
|
all patients
1st line – 

intravenous fluid therapy

In the setting of severe volume deficit and shock, and in the absence of cardiac compromise, patients should receive 0.9% sodium chloride at a rate of 15 to 20 mL/kg/hour or 1 to 2 L during the first hour.[2]​​[44]​​ Once hypotension is corrected, fluid resuscitation should be continued with 0.9% sodium chloride at 250 to 500 mL/hour.[44]

Older adults, or patients with heart failure or end-stage kidney disease on dialysis, should be treated cautiously, with smaller boluses of isotonic solutions (e.g., 250 mL boluses) and frequent assessment of hemodynamic status.[3][54]​​ In such patients, the use of a standard fluid replacement protocol may be associated with treatment-related complications including volume overload, mechanical ventilation, and longer length of stay.[54]

Plus – supportive care ± intensive care unit (ICU) admission

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ACUTE
|
all patients
Plus – 

supportive care ± intensive care unit (ICU) admission

Treatment recommended for ALL patients in selected patient group

Glucose should be checked every 1-2 hours until hyperglycemia is corrected.[2]​​ Electrolytes, BUN, venous pH, and creatinine should be checked every 2-4 hours, until resolution of HHS. Urinary output should be monitored.

Diagnosis of precipitating factors (e.g., infection or causative medications) and appropriate treatment with antibiotics and removal of the offending medication should be initiated.[2]​​​

Patients with hemodynamic, cardiovascular, or respiratory instability or altered mental status may require ICU admission with frequent blood pressure and hemodynamic monitoring, a central venous catheter and/or Swan-Ganz catheterization, and continuous percutaneous oximetry.

Oxygenation and airway protection are crucial. Intubation and mechanical ventilation are commonly required, with constant monitoring of respiratory parameters.

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Consider – vasopressor

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ACUTE
|
all patients
Consider – 

vasopressor

Treatment recommended for SOME patients in selected patient group

If hypotension persists after forced hydration, a vasopressor agent should be started.[55]

Patients requiring vasoactive drugs (vasopressor and/or inotrope) need continuous monitoring in a critical care setting.

Consult a specialist for guidance on suitable vasopressor regimens.

Plus – potassium therapy with frequent serum measurements

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ACUTE
|
all patients
|
with baseline serum potassium ≤3.3 mEq/L
Plus – 

potassium therapy with frequent serum measurements

Treatment recommended for ALL patients in selected patient group

Insulin therapy, correction of acidosis, volume expansion, and increased urinary loss of potassium decrease serum potassium. Within 48 hours of admission, potassium levels typically decline by 1 to 2 mEq/L in patients with diabetic ketoacidosis (DKA), HHS, and mixed DKA/HHS. To prevent hypokalemia, potassium replacement should be started after serum levels fall below 5 mEq/L with the aim of maintaining a potassium level of 4 to 5 mEq/L.

Potassium should be added to maintenance fluid therapy for patients who are normokalemic or hypokalemic.[44]​ If baseline serum potassium is ≤3.3 mEq/L insulin therapy should be delayed and potassium should be replaced until >3.3 mEq/L (guidelines suggest replacement with 20 to 30 mEq potassium per liter of infusion fluid, though in practice we recommend 10 to 20 mmol per liter).[2]​​

Serial potassium measurements should be monitored every 2-4 hours, and the infusion adjusted once a serum potassium >3.3 mEq/L to maintain serum potassium between 4 and 5 mEq/L.[2]​​

Plus – insulin therapy once serum potassium measurement >3.3 mEq/L

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ACUTE
|
all patients
|
with baseline serum potassium ≤3.3 mEq/L
Plus – 

insulin therapy once serum potassium measurement >3.3 mEq/L

Treatment recommended for ALL patients in selected patient group

A continuous intravenous infusion of regular insulin is usually recommended if the serum potassium is >3.3 mEq/L.

Insulin can be started with a bolus followed by continuous infusion.

Local protocols should be followed. If the serum glucose does not fall by at least 10% in the first hour, then a further bolus of intravenous insulin should be administered, while continuing the previous insulin infusion rate. Once the blood glucose reaches 300 mg/dL or less, the insulin infusion should be reduced, while maintaining the blood glucose between 200 and 300 mg/dL, until the patient is mentally alert.[2]​​

Primary options

insulin regular: consult local protocol for dose guidelines

Consider – phosphate therapy

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ACUTE
|
all patients
|
with baseline serum potassium ≤3.3 mEq/L
Consider – 

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine phosphate replacement has not resulted in clinical benefits to patients.[4] In the presence of severe hypophosphatemia (<1 mg/dL) in patients with cardiac dysfunction (e.g., with signs of left ventricular dysfunction), symptomatic anemia, or respiratory depression (e.g., decreased oxygen saturation), careful phosphate therapy may be indicated to avoid cardiac, respiratory, and skeletal muscle dysfunction.[2]​​

Plus – insulin therapy

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ACUTE
|
all patients
|
with baseline serum potassium 3.4 to 5.2 mEq/L
Plus – 

insulin therapy

Treatment recommended for ALL patients in selected patient group

A continuous intravenous infusion of regular insulin is usually recommended if the serum potassium is >3.3 mEq/L.

The insulin can be started with a bolus followed by a continuous infusion. Local protocols should be followed. If the serum glucose does not fall by at least 10% in the first hour, then a further bolus of intravenous insulin should be administered, while continuing the previous insulin infusion rate. Once the blood glucose reaches 300 mg/dL or less, the insulin infusion should be reduced, while maintaining the blood glucose between 200 and 300 mg/dL, until the patient is mentally alert.[2]​​

Primary options

insulin regular: consult local protocol for dose guidelines

Plus – potassium therapy with frequent serum measurements

Back
ACUTE
|
all patients
|
with baseline serum potassium 3.4 to 5.2 mEq/L
Plus – 

potassium therapy with frequent serum measurements

Treatment recommended for ALL patients in selected patient group

Insulin therapy, correction of acidosis, volume expansion, and increased urinary loss of potassium decrease serum potassium. Within 48 hours of admission, potassium levels typically decline by 1 to 2 mEq/L in patients with DKA, HHS, and mixed DKA/HHS.

Potassium should be added to maintenance fluid therapy for patients who are normokalemic or hypokalemic.[44]​​

If baseline serum potassium level is between 3.4 to 5.2 mEq/L potassium replacement should be started (guidelines suggest replacement with 20 to 30 mEq potassium per liter of infusion fluid).[2]​​

Potassium replacement is not needed once the level is >5.3 mEq/L, but potassium levels should be checked every 2 hours.[2]​​[44]

Consider – phosphate therapy

Back
ACUTE
|
all patients
|
with baseline serum potassium 3.4 to 5.2 mEq/L
Consider – 

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine phosphate replacement has not resulted in clinical benefits to patients.[4] In the presence of severe hypophosphatemia (<1 mg/dL) in patients with cardiac dysfunction (e.g., with signs of left ventricular dysfunction), symptomatic anemia, or respiratory depression (e.g., decreased oxygen saturation), careful phosphate therapy may be indicated to avoid cardiac, respiratory, and skeletal muscle dysfunction.[2]​​

Plus – insulin therapy

Back
ACUTE
|
all patients
|
with baseline serum potassium ≥5.3 mEq/L
Plus – 

insulin therapy

Treatment recommended for ALL patients in selected patient group

A continuous intravenous infusion of regular insulin is usually recommended if the serum potassium is >3.3 mEq/L.

The insulin can be started with a bolus followed by a continuous infusion.

Local protocols should be followed. If the serum glucose does not fall by at least 10% in the first hour, then a further bolus of intravenous insulin should be administered, while continuing the previous insulin infusion rate. Once the blood glucose reaches 300 mg/dL or less, the insulin infusion should be reduced, while maintaining the blood glucose between 200 and 300 mg/dL, until the patient is mentally alert.[2]​​

Primary options

insulin regular: consult local protocol for dose guidelines

Consider – monitoring of serum potassium

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ACUTE
|
all patients
|
with baseline serum potassium ≥5.3 mEq/L
Consider – 

monitoring of serum potassium

Treatment recommended for SOME patients in selected patient group

Supplemental potassium is not required if the serum potassium is ≥5.3 mEq/L, but serum potassium should be checked every 2-4 hours because insulin therapy and fluid administration reduces potassium levels.[2]​​

Consider – phosphate therapy

Back
ACUTE
|
all patients
|
with baseline serum potassium ≥5.3 mEq/L
Consider – 

phosphate therapy

Treatment recommended for SOME patients in selected patient group

Routine phosphate replacement has not resulted in clinical benefits to patients.[4] In the presence of severe hypophosphatemia (<1 mg/dL) in patients with cardiac dysfunction (e.g., with signs of left ventricular dysfunction), symptomatic anemia, or respiratory depression (e.g., decreased oxygen saturation), careful phosphate therapy may be indicated to avoid cardiac, respiratory, and skeletal muscle dysfunction.[2]​​

ONGOING

HHS resolved and patient able to tolerate oral intake

1st line – subcutaneous insulin therapy

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ONGOING
|
HHS resolved and patient able to tolerate oral intake
1st line – 

subcutaneous insulin therapy

Management and monitoring should continue until resolution of HHS. Criteria for resolution of HHS are normal plasma glucose <250 mg/dL, normal plasma effective osmolality <300 mOsm/kg, and normalization of hemodynamic and mental status.[2]​​

Once HHS is resolved transition to subcutaneous insulin is initiated. Subcutaneous insulin should be given 2 hours before the termination of insulin infusion.

Intermediate or long-acting insulin is recommended for basal requirements and short-acting insulin for prandial glycemic control.

Patients already on insulin treatment prior to admission may be continued on the same dose.

Primary options

insulin glargine

or

insulin detemir

or

insulin NPH

-- AND --

insulin lispro

or

insulin aspart

or

insulin glulisine

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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