The Hypertonic State

Feig, Peter U.; McCurdy, Donna K.

doi:10.1056/nejm197712292972608

Cited by 219 publications

(86 citation statements)

References 9 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The severity of fluid and sodium deficits, as shown in Table 2, is determined primarily by duration of hyperglycemia, level of renal function, and patient' s oral intake of solute and water (23,24,44,145,(167)(168)(169)(170)(171)(172)(173)(174)(175). The severity of dehydration and volume depletion can be estimated by clinical examination (44) using the following guidelines, with the caveat that these criteria are less reliable in patients with neuropathy and impaired cardiovascular reflexes:…”

Section: Replacement Of Fluid and Electrolytesmentioning

confidence: 99%

Management of Hyperglycemic Crises in Patients With Diabetes

et al. 2001

View full text Add to dashboard Cite

Abbreviations: AaO 2 , alveolar-to-arteriolar oxygen; AKA, alcoholic ketoacidosis; ARDS, adult respiratory distress syndrome; BUN, blood urea nitrogen; CPT, carnitine palmitoyl-transferase; CSF, cerebrospinal fluid; DKA, diabetic ketoacidosis; FFA, free fatty acid; HHS, hyperosmolar hyperglycemic state; IRI, immunoreactive insulin; PaO 2 , arteriolar partial pressure of oxygen; RDKA, recurrent DKA.A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Management of Hyperglycemic Crises in Patients With Diabetes T E C H N I C A L R E V I E R e v i e w s / C o m m e n t a r i e s / P o s i t i o n S t a t e m e n t s 132DIABETES CARE, VOLUME 24, NUMBER 1, JANUARY 2001Technical Review noted in newly diagnosed obese type 2 diabetic patients (5,26,31). Therefore, the concept that the presence of DKA in type 2 diabetes is a rare occurrence is incorrect.The most common types of infections are pneumonia and urinary tract infection, accounting for 30-50% of cases (Table 4). Other acute medical illnesses as precipitating causes include alcohol abuse, trauma, pulmonary embolism, and myocardial infarction, which can occur both in type 1 and 2 diabetes (6). Various drugs that alter carbohydrate metabolism, such as corticosteroids, pentamidine, sympathomimetic agents, and ␣-and ␤-adrenergic blockers, and excessive use of diuretics in the elderly may also precipitate the development of DKA and HHS.The recent increased use of continuous subcutaneous insulin infusion pumps that use small amounts of short-acting insulin has been associated with an incidence of DKA that is significantly increased over the incidence seen with conventional methods of multiple daily insulin injections, in spite of the fact that most of the mechanical problems with insulin pumps have been resolved (6,(32)(33)(34). In the Diabetes Control and Complications Trial, the incidence of DKA in patients on insulin pumps was about twofold higher than that in the multipleinjection group over a comparable time period (35). This may be due to the exclusive use of short-acting insulin in the pump, which if interrupted leaves no reservoir of insulin for blood glucose control.Psychological factors and poor compliance, leading to omission of insulin therapy, are important precipitating factors for recurrent ketoacidosis. In young female patients with type 1 diabetes, psychological problems complicated by eating disorders may be contributing factors in up to 20% of cases of recurrent ketoacidosis (36,37). Factors that may lead to insulin omission in younger patients include fear of weight gain with good metabolic control, fear of hypoglycemia, rebellion against authority, and stress related to chronic disease (36). Noncompliance with insulin therapy has been found to be the leading precipitating cause for DKA in urban African-Americans and medically indigent patients (5,26). In addition, a recent study showed that diabetic patients without health insurance or with Medicaid alone had hospitali...

show abstract

Section: Replacement Of Fluid and Electrolytesmentioning

confidence: 99%

Management of Hyperglycemic Crises in Patients With Diabetes

et al. 2001

View full text Add to dashboard Cite

show abstract

“…Gain in extracellular solutes other than sodium salts, such as glucose, is the main exception to this rule. Hypertonicity in hyperglycemia should be evaluated in two steps: (1) At presentation, the degree of hypertonicity, which results from extracellular accumulation of solute (glucose) [9] and loss of water through osmotic diuresis [10,11] , determines the severity of the presenting clinical manifestations is calculated by the tonicity formula [1,5] ; (2) The prescription of the tonicity (i.e., sodium plus potassium concentration) of the replacement solutions should be based on [Na]Corrected [12] , reflecting the fact that correction of hyperglycemia without any further changes in the external balances of water and monovalent cations leads to rise in [Na], but decrease in serum effective osmolality [12] . Monitoring of the clinical status and serum chemistries is imperative during treatment of severe HHS [12] .…”

Section: Discussionmentioning

confidence: 99%

“…Hypertonicity resulting from excessive losses of body water through the kidneys, the respiratory tract, the skin, the gastrointestinal tract and/or gain in body solute, causes neurological manifestations that may become life threatening [1,2] . Hypernatremia [3] and hyperglycemia [4] are the two common causes of hypertonicity.…”

Section: Introductionmentioning

confidence: 99%

Prolonged hypernatremia triggered by hyperglycemic hyperosmolar state with coma: A case report

Vigil

Ganta

Sun

et al. 2015

WJN

View full text Add to dashboard Cite

A man with past lithium use for more than 15 years, but off lithium for two years and not carrying the diagnosis of diabetes mellitus or nephrogenic diabetes insipidus (NDI), presented with coma and hyperglycemic hyperosmolar state (HHS). Following correction of HHS, he developed persistent hypernatremia accompanied by large volumes of urine with low osmolality and no response to desmopressin injections. Urine osmolality remained < 300 mOsm/kg after injection of vasopressin. Improvement in serum sodium concentration followed the intake of large volumes of water plus administration of amiloride and hydrochlorothiazide. Severe hyperglycemia may trigger symptomatic lithium-induced NDI years after cessation of lithium therapy. Patients with newonset diabetes mellitus who had been on prolonged lithium therapy in the past require monitoring of their serum sodium concentration after hyperglycemic episodes regardless of whether they do or do not carry the diagnosis of NDI.

show abstract

“…Serum tonicity, or effective osmolarity, is the part of total serum osmolarity attributable to extracellular solutes that don't rapidly enter cells and therefore cause steady state osmotic fluid shifts from the intracellular into the extracellular compartment when their extracellular concentration is high [9]. The clinical manifestations of hypertonicity result primarily from reductions in the volume of brain cells [10] and are neurological (headache, coma, seizures, and death).…”

Section: Changes In Serum Tonicity In Hyperglycemic Syndromes From Gamentioning

confidence: 99%

“…Although these two mechanisms have additive effects on tonicity, they have opposing effects on . A gain in extracellular glucose content, without any change in body water or monovalent cations, causes hypertonicity [9]. An increase in serum glucose concentration leads to osmotic transfer of intracellular water into the extracellular compartment resulting in dilution of extracellular solutes and hyponatremia [16].…”

Section: Changes In Serum Tonicity In Hyperglycemic Syndromes From Gamentioning

confidence: 99%