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Hyperosmolar hyperglycaemic state — SCE Acute Medicine MCQ

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ModerateAcute Renal and Metabolic EmergenciesHyperosmolar hyperglycaemic stateSCE Acute Medicine

A 79-year-old man with type 2 diabetes presents with confusion after a week of polyuria. Glucose is 48 mmol/L, osmolality 352 mOsm/kg, ketones 0.8 mmol/L and venous pH 7.36. Sodium is 151 mmol/L and creatinine is 206 micromol/L. What is the most appropriate next step in management?

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Correct answer: A — Cautious 0.9% sodium chloride rehydration with close osmolality monitoring

The biochemical picture is HHS: severe hyperglycaemia and hyperosmolality with minimal ketonaemia. Initial treatment prioritises careful fluid replacement and monitoring of osmolality; insulin too early can cause rapid osmotic shifts and circulatory collapse. Sodium must be interpreted in the context of hyperglycaemia and corrected gradually. The pearl is that HHS treatment is slower and more fluid-led than DKA.

Reference: JBDS HHS guideline