Fluid administration and restoration of electrolyte disturbances

Mean fluid deficit amounts to 9-10 L. The administered fluid is isotonic solution of NaCl (0.9 percent) and only when Na+ concentration is > 155 mmol/L is hypotonic solution of NaCl (0.45 percent) preferred (if this is not readily available, it can be prepared by adding four ampoules of NaCl in one L of water for injection).

Generally, it is essential to monitor urine output, vital signs and cerebral function. In elderly people it is also useful to monitor central venous pressure (to avoid fluid overload).

The frequently high Na+ values subside with hydration and administration of hypotonic solutions (when the value is very high). The frequently normal K+ values decrease with hydration and insulin administration. For this reason K+ should be administered very early (with the first litres of administered fluids), on condition that diuresis is adequate. The concentrations in the blood should be monitored with repeated measurements.

2. Correction of hyperglycaemia with insulin administration (lower doses than needed in DKA). The dose of insulin is proposed at 3-5 units per hour, aiming at a gradual drop of plasma glucose (not more than 150 mg/dl [8.3 mmol/L] per hour) for avoidance of cerebral oedema or peripheral shock.

3. Management of underlying diseases (septicaemia is common, as well as strokes, cardiac episodes, etc.).

4. Prevention of thromboembolic episodes. Thromboembolic episodes are frequent, due to the hyperglycaemia and dehydration and can even be fatal, as is the case in thrombosis of superior mesenteric artery. For this reason administration of anticoagulants in small doses is usually proposed.

5. Close monitoring in an intensive care unit. The patient under discussion died four days later, despite her admission to an Intensive Care Unit. Her metabolic disturbances were successfully managed, but her brain function deteriorated.

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