Hyperosmolar hyperglycemia state (HHS) is a diabetic emergency. Volume resuscitation is key, as is a basal rate of insulin. Have you ever noticed a rising sodium level despite treatment? Don't worry. This is normal.
Why? The oversimplified schematic shows that glucose is initially an effective solute (it remains in the serum more), which draws water with it. Giving a patient isotonic fluids and insulin makes glucose enter cells, causing water to follow.
This unmasks the existing hypernatremia. You may need to convert to hypotonic fluid after adequate fluid resuscitation, slowly correcting the free water deficit.
Read a more detailed explanation about HHS in EMCrit's “Internet Book on Critical Care” at http://bit.ly/3XmU5pS.
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Dr. Linis the founder, CEO, and editor-in-chief of Academic Life in Emergency Medicine (https://www.ALiEM.com) and a professor of emergency medicine at the University of California San Francisco with interests in health professions education and digital scholarship. Follow her on Instagram@MichelleLinMDand on Twitter@M_Lin.