In hyperosmolar hyperglycemic state, what is a key initial management step?

• A. Initiate insulin therapy immediately
• B. Aggressive IV fluid resuscitation with isotonic saline
• C. Administer potassium-sparing diuretics
• D. Start oral rehydration

Answer: (B)

In hyperosmolar hyperglycemic state, the immediate challenge is severe dehydration from osmotic diuresis, which drops intravascular volume and impairs organ perfusion. The best first step is aggressive IV fluid resuscitation with isotonic saline because it quickly restores circulating volume, improves renal perfusion, and starts to reduce serum osmolality as glucose is excreted by the kidneys. Insulin therapy is important, but it is started after adequate fluid resuscitation to avoid worsening hypoperfusion and dangerous shifts in osmolality. Potassium must be checked and corrected because insulin and fluids will drive potassium into cells, potentially causing dangerous hypokalemia. The use of potassium-sparing diuretics would worsen potassium balance, and oral rehydration alone cannot meet the needs of a patient with severe dehydration and possible altered mental status. After initial fluid resuscitation and stabilization, insulin therapy can be initiated as glucose approaches the 200–250 mg/dL range, with ongoing fluid management guided by perfusion, electrolytes, and urine output.