In the management of HHS, what is the correct initial priority?

• A. Start with bicarbonate therapy
• B. Aggressive IV fluids, then insulin after stabilization
• C. Insulin infusion before fluids
• D. Observational management

Answer: (B)

In Hyperosmolar Hyperglycemic State, the first priority is aggressive intravenous fluid resuscitation with isotonic saline to restore circulating volume and improve renal perfusion. Dehydration is severe, and correcting volume status helps reduce serum osmolality and allows the kidneys to clear glucose and electrolytes efficiently. Starting insulin after the patient is resuscitated helps avoid dangerous shifts in fluid and osmolality that could occur if insulin were given with ongoing hypovolemia. Potassium status must be monitored because insulin drives potassium into cells and total body potassium is often depleted; correct K+ before or with insulin to prevent dangerous hypokalemia. Bicarbonate therapy is not routinely used in HHS unless there is life-threatening acidosis (very low pH), and simply watching the patient without active fluid and electrolyte management is inadequate.