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Hyperosmolar hyperglycaemic state — MCCQE Part 1 MCQ

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HardAltered Level of ConsciousnessHyperosmolar hyperglycaemic stateMCCQE Part 1

A 79-year-old woman with type 2 diabetes is brought in with lethargy after several days of poor oral intake and polyuria. Glucose is 48 mmol/L, measured osmolality is high, pH is 7.36, bicarbonate is 22 mmol/L, and serum ketones are minimal. She is hypotensive and her creatinine has doubled. What is the most appropriate next step in management?

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Correct answer: E — Start cautious isotonic fluid resuscitation and insulin after initial fluids

This is hyperosmolar hyperglycaemic state, where severe dehydration and hyperosmolality require careful fluid replacement before or alongside low-dose insulin. Giving insulin first can worsen intravascular depletion and precipitate osmotic shifts. Bicarbonate is not indicated without severe acidosis. Oral sulfonylureas are inappropriate in an unstable hyperosmolar emergency.

Reference: Diabetes Canada Clinical Practice Guidelines