Fever not improving after 24 to 48 hours on antibiotics
Infection not responding as expected
Recheck needed
Chest pain, severe shortness of breath, or leg swelling
May indicate blood clot or heart attack
Emergency evaluation required
Seizure or loss of consciousness
Call 911 immediately
Do not drive yourself
Follow up appointments
Endocrinologist within 1 to 2 weeks
Insulin dose adjustments
Possible transition to oral diabetes medications
Family doctor within 1 week
Review all medications for those that may have contributed
Ongoing diabetes management
Diabetes education program
Sick day rules reinforcement
Glucose monitoring technique
Dietary counseling
References
Guidelines and key sources
Primary guidelines
American Diabetes Association Standards of Care in Diabetes 2026
Section 16 Diabetes Care in the Hospital
Section 6 Glycemic Goals Hypoglycemia and Hyperglycemic Crises
Joint British Diabetes Societies (JBDS) Inpatient Care Group guideline for HHS
Lower dose insulin protocol recommendation
UK guideline for management of HHS in adults
Key evidence sources
Lovegrove and Dubbs, Endocrinology and Metabolism Clinics of North America 2026
Comprehensive HHS review including epidemiology and pathophysiology
Pasquel and Umpierrez, Diabetes Care 2014
Historic review of clinical presentation diagnosis and treatment of HHS
Long et al, Journal of Emergency Medicine 2021
Diagnosis and management of critically ill adult patient with HHS
Rosager et al, Diabetes Care 2024
Danish cohort study on incidence and characteristics of HHS
Zeitler et al, Journal of Pediatrics 2011
Hyperglycemic hyperosmolar syndrome in children pathophysiological considerations and treatment guidelines
Lin et al, Diabetic Medicine 2026
Systematic review of management guidelines and their evidence for HHS
Mortality and outcomes evidence
Sun et al, Medical Science Monitor 2026
Predictors of in-hospital mortality in isolated HHS
Pasquel et al, Diabetes Care 2020
Clinical outcomes in isolated versus combined DKA and HHS
Karslioglu French et al, BMJ 2019
Review of acute decompensated diabetes including DKA and HHS in adults
Coding standards
ICD-10 E11.01 type 2 diabetes mellitus with hyperosmolarity with coma
ICD-10 E11.00 type 2 diabetes mellitus with hyperosmolarity without coma
SNOMED CT hyperosmolar hyperglycemic state concept
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.