Surgical patients with diabetes and impaired glucose tolerance are susceptible to volume depletion and electrolyte imbalance leading to the hyperosmolar nonketotic syndrome. Intravenous fluids are required to replace the pre-existing volume deficient, hemorrhage, third-space losses, GI losses, and the ongoing osmotic diuresis. Appropriate attention to intravascular volume will facilitate hepatic/renal blood flow and correction of the hyperosmolar condition. Placement of a pulmonary artery catheter and/or transesophageal endoscope (TEE) may provide useful data to guide fluid management, especially in the diabetic with renal insufficiency or decreased cardiac reserve (31).
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