Initial fluid resuscitation should be aimed at reestablishing adequate tissue perfusion and decreasing serum glucose. Replacement of intravascular fluid losses alone can account for reductions in serum glucose on average 35-70 mg/h or up to 80 percent initial values. The expansion of intravascular volume decreases serum osmolarity, inhibits counterregulatory hormones, and improves renal excretion of glucose.
The average fluid deficit in HHNS is in the range of 20 to 25 percent of total body water (TBW) or 8 to 12 L. In the elderly, about 50 percent of body weight is due to TBW. By using patient's usual current weight in kilograms, normal TBW and water deficit can be calculated. One-half of the fluid deficit should be replaced over the initial 12 h and the balance over the next 24 h. The actual rate of fluid administration should be individualized for each patient based on the presence of renal and cardiac impairment. Initial rates of 500 to 1500 mL/h during the first 2 h, followed by rates of 250 to 500 mL/h are usually well tolerated. In fact, the initial liter of fluid can usually be infused "wide open" without risk of adverse sequelae in almost all patients. Patients with cardiac disease may require the more conservative rate of volume repletion. Renal and cardiovascular function should be carefully monitored. Central venous and urinary tract catheterization should be considered in patients with preexisting renal or cardiac disease.
Most authors agree that the use of isotonic saline (0.9% NaCl) is the most appropriate initial crystalloid for the replacement of intravascular volume. It is hypotonic to the patient's serum osmolarity and will more rapidly restore plasma volume. Once hypotension, tachycardia, and urinary output improve, half-normal saline (0.45% NaCl) can be used to replace the remaining free water deficit.
A limited number of reports of cerebral edema occurring during or soon after the resuscitation phase of patients with both DKA and HHNS have been described. 1011 Most cases have occurred in children, and the mechanism is unclear. If changes in mental status occur during treatment, fluid should be stopped and head computed tomography obtained. Mannitol (1 g/kg IV bolus) can be given but effectiveness is unclear.
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