Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content +++ Key Features +++ Essentials of Diagnosis ++ Hyperglycemia, serum glucose > 600 mg/dL (33.3 mmol/L) Serum osmolality > 310 mOsm/kg No acidosis; blood pH > 7.3 Serum bicarbonate > 15 mEq/L Normal anion gap (< 14 mEq/L) +++ General Considerations ++ Frequently occurs with mild or occult diabetes mellitus Infection, myocardial infarction, stroke, or recent operation is often a precipitating event Drugs (phenytoin, diazoxide, corticosteroids, and diuretics) or procedures associated with glucose loading such as peritoneal dialysis can also precipitate the syndrome Acute kidney dysfunction develops from hypovolemia, leading to increasingly higher blood glucose concentrations Underlying chronic kidney disease or heart failure is common, and the presence of either worsens the prognosis +++ Demographics ++ Rarer than diabetic ketoacidosis even in older age groups Affects middle-aged to elderly +++ Clinical Findings +++ Symptoms and Signs ++ Onset may be insidious over days or weeks, with weakness, polyuria, and polydipsia The lack of features of ketoacidosis may retard recognition until dehydration becomes more profound than in ketoacidosis Fluid intake is usually reduced from inappropriate lack of thirst, nausea, or inaccessibility of fluids to bedridden patients Lethargy and confusion develop as serum osmolality exceeds 310 mOsm/kg Convulsions and coma can occur if osmolality exceeds 320–330 mOsm/kg Physical examination shows profound dehydration, lethargy, or coma without Kussmaul respirations +++ Differential Diagnosis ++ Diabetic ketoacidosis Cerebrovascular accident or head trauma Hypoglycemia Sepsis Diabetes insipidus +++ Diagnosis +++ Laboratory Tests ++ Severe hyperglycemia (serum glucose 800–2400 mg/dL [44.4 to 133.2 mmol/L]) When dehydration is less severe, dilutional hyponatremia as well as urinary sodium losses may reduce serum sodium to 120–125 mEq/L As dehydration progresses, serum sodium can exceed 140 mEq/L, producing serum osmolality readings of 330–440 mOsm/kg Ketosis and acidosis are usually absent or mild Prerenal azotemia with blood urea nitrogen elevations > 100 mg/dL (35.7 mmol/L) typical +++ Treatment +++ Medications +++ Fluid Replacement ++ Fluid replacement paramount to correct fluid deficits of 6–10 L In hypovolemic oliguric hypotension, initiate fluid resuscitation with isotonic 0.9% saline Otherwise, hypotonic (0.45%) saline preferred because of hyperosmolality As much as 4–6 L of fluid may be required in first 8–10 h Once blood glucose reaches 250 mg/dL (13.9 mmol/L), add 5% dextrose to either water, 0.45% saline solution, or 0.9% saline solution at a rate to maintain serum glucose levels of 250–300 mg/dL (13.9 to 16.7 mmol/L) to reduce risk of cerebral edema Goal of fluid therapy is to restore urinary output to ≥ 50 mL/h +++ Insulin ++ Less insulin is required than in diabetic ketoacidotic coma Fluid replacement alone can reduce hyperglycemia by increasing glomerular filtration and renal excretion of glucose... GET ACCESS TO THIS RESOURCE Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth Get Free Access Through Your Institution Contact your institution's library to ask if they subscribe to McGraw-Hill Medical Products. Access My Subscription GET ACCESS TO THIS RESOURCE Subscription Options Pay Per View Timed Access to all of AccessMedicine 24 Hour $34.95 (USD) Buy Now 48 Hour $54.95 (USD) Buy Now Best Value AccessMedicine Full Site: One-Year Individual Subscription $995 USD Buy Now View All Subscription Options