A)
Pathology: Occurs predominantly with Type II DM and relative
insulin deficiency
B) Clinical Findings:
1) Precipitating Factors:
Volume depletion, extrinsic osmotic load (TPN, enteral feeding without
adequate free water), intercurrent illness (infection, MI CVA, GI
bleed, pancreatitis), peritoneal dialysis, drugs (diuretics, cimetidine,
corticosteroids, dilantin, beta-blockers). Approx. 50% of patients
have no prior history of diabetes
2) Manifestations: Similar
to DKA but without Kussmaul's respirations and acetone halitosis
3) Diagnosis: Hyperglycemia
with glucose > 600 mg/dl and may be > 2000 mg/dl; mild anion
gap acidosis with ketosis; high serum osmolality; hyponatremia with
1.6 mEq/l decrease for each 100 mg/dl glucose increase above normal.
A normal serum Na+ with inc glucose indicates a severe water deficit.
C) Management (Identify and treat precipitating
event)
1) Volume resuscitation for
hypovolemia with NS. Hyperosmolality correction with hypotonic fluids
(D5 1/2NS or D5W) only after correction of hypovolemic state
2) Hyperglycemia treated with
hydration alone will typically lower plasma glucose to less than
500 mg/dl. Insulin therapy should begin after volume replacement
and begun with a low dose regimen (0.1 u/kg/hr or regular insulin)
3) K+ replacement prn. Acidosis
typically resolves with volume repletion.
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