T i n j a u a np u s t a k a

PENATALAKSANAAN KETOASIDOSIS DIABETIK (KAD)

Wi r aGo t e r a , De waGd eAg u n gBu d i y a s a Ba g i a n / S M FI l muP e n y a k i t Da l a m, F K Un u d / RS UPS a n g l a hDe n p a s a r Ema i l : wi r a g o t e r a @y a h o o . c o m
ABS TRACT Di a b e t i c Ke t o a s i d o s i s(DKA)i sme t a b o l i cd i s t u r b a n c ed i s o r d e rt h a tb es i g n e db yt r i a sh y p e r g l y c e mi a ,a c i d o s i s ,a n d k e t o s i s ,wh i c ho n eo fv e r ys e r i o u sa c u t eme t a b o l i cc o mp l i c a t i o no fd i a b e t e sme l l i t u s .I nI n d o n e s i at h ei n c i d e n c ewa sn o ts o h i g hc o mp a r et h a nt h ewe s t e r nc o u n t r i e s , b u tt h emo r t a l i t yi ss t i l lh i g h . I ny o u n ga g et h emo r t a l i t yc a nb ep r e v e n t e db ye a r l y d i a g n o s i s ,r a t i o n a la n dp r o mp tt r e a t me n ta c c o r d i n gt oi t sp a t h o p h y s i o l o g y .S u c c e s f u l lo fDKA t r e a t me n tn e e d sc o r r e c t i o no f d e h i d r a t i o n , h y p e r g l y c e mi a , a c i d o s i s , a n de l e c t r o l y t ed i s t u r b a n c e , i d e n t i c a t i o no fc o mo r b i dp r e c i p i t a t i o nf a c t o r ,a n dt h emo s t i mp o r t a n to n ewa sc o n t i n u e mo n i t o r i n g . Th et r e a t me n twe r ea d e q u a t eo fu i dt h e r a p y , s u f c i e n ti n s u l i nt h e r a p h y , t h e r a p yo f p o t a s s i u m, b i c a r b o n a t e , p h o s p h a t , ma g n e s i u m, h y p e r c h l o r e mi cc o n d i t i o n , a n da n t i b i o t i ca d mi n i s t r a t i o na c c o r d i n gt oi n d i c a t i o n . Th ei mp o r t a n to n ewa sa l s oa wa r n e s sf o rt h e r a p yc o mp l i c a t i o n ss ot h a tt h et h e r a p yn o tt o ma k ewo r s e n i n gc o n d i t i o no ft h e p a t i e n t s . Ke y wo r d s : d i a b e t i c , k e t o a c i d o s i s , ma n a g e me n t

P ENDAHULUAN Ke t o a s i d o s i sd i a b e t i k (KAD) a d a l a hk e a d a a n d e k o mp e n s a s i k e k a c a u a nme t a b o l i ky a n gd i t a n d a i o l e h t r i a sh i p e r g l i k e mi a ,a s i d o s i s ,d a nk e t o s i s ,t e r u t a ma 1 d i s e b a b k a no l e hd e s i e n s i i n s u l i na b s o l u t a t a ur e l a t i f . KAD d a n Hiperosmolar Hyperglycemia State (HHS ) a d a l a h2 k o mp l i k a s ia k u tme t a b o l i kd i a b e t e sme l l i t u s y a n gp a l i n gs e r i u sd a n me n g a n c a m n y a wa . Ke d u a k e a d a a nt e r s e b u td a p a tt e r j a d ip a d aDi a b e t e sM e l l i t u s (DM ) t i p e1 d a n2, me s k i p u nKAD l e b i hs e r i n gd i j u mp a i 2 p a d aDM t i p e1.KAD mu n g k i nme r u p a k a nma n i f e s t a s i a wa ld a r iDM t i p e1 a t a u mu n g k i n me r u p a k a na k i b a t d a r ip e n i n g k a t a nk e b u t u h a ni n s u l i np a d a DM t i p e1 p a d ak e a d a a ni n f e k s i ,t r a u ma ,i n f a r k mi o k a r d ,a t a u 3 k e l a i n a nl a i n n y a .

EP I DEM I OLOGI Da t ak o mu n i t a sd i Ame r i k aS e r i k a t ,Ro c h e s t e r , me n u n j u k k a nb a h wa i n s i d e n KAD s e b e s a r 8/ 10 0 0 p a s i e n DM p e rt a h u nu n t u ks e mu ak e l o mp o ku mu r , s e d a n g k a nu n t u kk e l o mp o ku mu rk u r a n gd a r i 30t a h u n 1 s e b e s a r 13, 4/ 10 0 0p a s i e n DM p e rt a h u n . S u mb e r l a i n me n y e b u t k a ni n s i d e n KAD s e b e s a r4, 6 8/ 10 0 0 4, 5 p a s i e nDM p e rt a h u n . KAD d i l a p o r k a nb e r t a n g g u n g j a wa bu n t u kl e b i hd a r i 10 0 . 0 0 0p a s i e ny a n gd i r a wa t p e r 6 t a h u nd iAme r i k aS e r i k a t . Wa l a u p u nd a t ak o mu n i t a s d iI n d o n e s i ab e l u m a d a ,a g a k n y ai n s i d e n KAD d i I n d o n e s i at i d a ks e b a n y a kd in e g a r ab a r a t ,me n g i n g a t p r e v a l e n s iDM t i p e1 y a n gr e n d a h .La p o r a ni n s i d e n KAD d iI n d o n e s i au mu mn y ab e r a s a ld a r id a t ar u ma h 1 s a k i t d a nt e r u t a map a d ap a s i e nDM t i p e2.

126

J Peny Dalam, Volume 11 Nomor 2 Mei 2010

An g k ak e ma t i a np a s i e nd e n g a n KAD d in e g a r a ma j uk u r a n gd a r i5% p a d ab a n y a ks e n t e r ,b e b e r a p a 2 5 s u mb e rl a i n me n y e b u t k a n 5 10 %, 2 10 %, a t a u9 10 % 1. S e d a n g k a nd i k l i n i kd e n g a ns a r a n as e d e r h a n a d a np a s i e nu s i al a n j u t a n g k ak e ma t i a nd a p a t me n c a p a i 25 50 %. An g k ak e ma t i a n me n j a d il e b i ht i n g g ip a d a b e b e r a p ak e a d a a ny a n gme n y e r t a i KAD, s e p e r t i s e p s i s , s y o kb e r a t , i n f a r kmi o k a r da k u t y a n gl u a s , p a s i e nu s i a l a n j u t ,k a d a rg l u k o s ad a r a ha wa ly a n gt i n g g i ,u r e mi a d a nk a d a rk e a s a ma nd a r a hy a n gr e n d a h .Ke ma t i a n p a d ap a s i e nKAD u s i amu d au mu mn y ad a p a t d i h i n d a r i d e n g a nd i a g n o s i sc e p a t ,p e n g o b a t a ny a n gt e p a td a n r a s i o n a ls e s u a id e n g a np a t o s i o l o g i n y a .P a d ap a s i e n k e l o mp o ku s i al a n j u t , p e n y e b a bk e ma t i a nl e b i hs e r i n g 1 d i p i c uo l e hf a k t o rp e n y a k i t d a s a r n y a . Me n g i n g a tp e n t i n g n y ap e n g o b a t a nr a s i o n a ld a n t e p a tu n t u k me n g h i n d a r ik e ma t i a np a d ap a s i e n KAD u s i amu d a , ma k at u l i s a ni n i a k a nme mb i c a r a k a nt e n t a n g p e n a t a l a k s a n a a n KAD d i s e r t a id e n g a n k o mp l i k a s i a k i b a t p e n a t a l a k s a n a a n n y a . S e b a g a i p e n d a h u l u a na k a n d i j e l a s k a ns e c a r ar i n g k a st e n t a n gf a k t o rp e n c e t u sd a n k r i t e r i ad i a g n o s i sKAD. P ATOF I S I OLOGIKETOAS I DOS I SDI ABETI K KAD d i t a n d a i o l e ha d a n y a h i p e r g l i k e mi a , a s i d o s i s me t a b o l i k ,d a np e n i n g k a t a nk o n s e n t r a s ik e t o ny a n g b e r e d a r d a l a ms i r k u l a s i . Ke t o a s i d o s i s me r u p a k a na k i b a t d a r ik e k u r a n g a na t a ui n e f e k t i t a si n s u l i ny a n gt e r j a d i b e r s a ma a nd e n g a np e n i n g k a t a nh o r mo nk o n t r a r e g u l a t o r (g l u k a g o n , k a t e k o l a mi n , k o r t i s o l , d a ngrowthh ormon) . Ke d u ah a l t e r s e b u t me n g a k i b a t k a np e r u b a h a np r o d u k s i d a np e n g e l u a r a ng l u k o s ad a n me n i n g k a t k a nl i p o l i s i s d a n p r o d u k s ib e n d a k e t o n . Hi p e r g l i k e mi a t e r j a d i a k i b a tp e n i n g k a t a np r o d u k s ig l u k o s ah e p a rd a ng i n j a l (g l u k o n e o g e n e s i sd a ng l i k o g e n o l i s i s )d a np e n u r u n a n u t i l i s a s ig l u k o s ap a d aj a r i n g a np e r i f e r .P e n i n g k a t a n g l u k o n e o g e n e s i sa k i b a td a r it i n g g i n y ak a d a rs u b s t r a t n o n k a r b o h i d r a t (a l a n i n , l a k t a t , d a ng l i s e r o l p a d ah e p a r , d a ng l u t a mi np a d ag i n j a l ) d a nd a r i p e n i n g k a t a na k t i v i t a s e n z i mg l u k o n e o g e n i k (f o s f o e n o lp i r u v a tk a r b o k s i l a s e / P EP CK, f r u k t o s e1, 6b i f o s f a t , d a np i r u v a t k a r b o k s i l a s e ) . P e n i n g k a t a np r o d u k s ig l u k o s ah e p a r me n u n j u k k a n
P e n a t a l a k s a n a a n Ke t o a s i d o s i sDi a b e t i k(KAD) Wira Gotera, Dewa Gd e Agung Bud iyasa

p a t o g e n e s i su t a ma y a n gb e r t a n g g u n gj a wa bt e r h a d a p k e a d a a nh i p e r g l i k e mi ap a d ap a s i e nd e n g a nKAD. S e l a n j u t n y a ,k e a d a a nh i p e r g l i k e mi ad a nk a d a r k e t o n y a n g t i n g g i me n y e b a b k a n d i u r e s i so s mo t i k y a n ga k a nme n g a k i b a t k a nh i p o v o l e mi ad a np e n u r u n a n glomerular ltration rate. Ke a d a a n y a n g t e r a k h i r a k a n me mp e r b u r u kh i p e r g l i k e mi a .M e k a n i s me y a n g me n d a s a r ip e n i n g k a t a np r o d u k s ib e n d ak e t o nt e l a h d i p e l a j a r is e l a ma i n i . Ko mb i n a s id e s i e n s ii n s u l i n d a np e n i n g k a t a nk o n s e n t r a s ih o r mo nk o n t r a r e g u l a t o r me n y e b a b k a na k t i v a s ih o r mo nl i p a s ey a n gs e n s i t i f p a d aj a r i n g a nl e ma k .P e n i n g k a t a na k t i v i t a si n ia k a n me me c a ht r i g l i s e r i d me n j a d ig l i s e r o ld a na s a ml e ma k b e b a s(f ree f atty acid / F F A) .Di k e t a h u ib a h wag l i s e r o l me r u p a k a ns u b s t r a tp e n t i n gu n t u kg l u k o n e o g e n e s i s p a d ah e p a r , s e d a n g k a np e n g e l u a r a na s a ml e ma kb e b a s y a n gb e r l e b i h a nd i a s u ms i k a ns e b a g a i p r e k u r s o ru t a ma d a r i k e t o a s i d . P a d a h e p a r ,a s a m l e ma k b e b a s d i o k s i d a s i me n j a d ib e n d a k e t o n y a n g p r o s e s n y a d i s t i mu l a s i t e r u t a ma o l e h g l u k a g o n .P e n i n g k a t a n k o n s e n t r a s i g l u k a g o nme n u r u n k a nk a d a rmalonyl coenz yme A (Co A)d e n g a nc a r ame n g h a mb a t k o n v e r s i p i r u v a t me n j a d i acetyl Co A me l a l u ii n h i b i s iacetyl Co A carb ox ylase, e n z i mp e r t a may a n gd i h a mb a t p a d as i n t e s i s a s a ml e ma k b e b a s . Malonyl Co A me n g h a mb a t camitine palmitoyltransf erase I (CP TI ) ,e n z i m u n t u kt r a n s e s t e r i k a s i d a r if atty acyl Co A me n j a d if atty acyl camitine, y a n g me n g a k i b a t k a no k s i d a s ia s a m l e ma k me n j a d ib e n d a k e t o n . CP T Id i p e r l u k a nu n t u kp e r p i n d a h a na s a m l e ma kb e b a sk e mi t o k o n d r i at e mp a td i ma n aa s a m l e ma kt e r o k s i d a s i . P e n i n g k a t a na k t i v i t a sf atty acyl Co Ad a n CP T Ip a d a KAD me n g a k i b a t k a np e n i n g k a t a n 6 k e t o n g e n e s i s . F AKTOR P ENCETUSKETOAS I DOS I SDI ABETI K T e r d a p a ts e k i t a r 20 % p a s i e n KAD y a n gb a r u d i k e t a h u ime n d e r i t a DM u n t u kp e r t a ma k a l i n y a .P a d a p a s i e n KAD y a n gs u d a hd i k e t a h u iDM s e b e l u mn y a , 80 %d a p a t d i k e n a l i a d a n y af a k t o rp e n c e t u s , s e me n t a r a 1, 6 20 %l a i n n y at i d a kd i k e t a h u i f a k t o rp e n c e t u s n y a . 127

Absolute insulin eficiency Or

Stress,I nfection or insufficient insulin intake

Counterregulatory H om ones n G lucagon n Cortisol n Catecholam inee n G row th

n Lipolysis

p G lucose utiilzation

n Protolysis p Protein Synthesis

n G lycogenolysis

n G luconeogenic substrates n FFA to Liver n Ketogenesis p Alkall Reserve Ketoacidosis Lactic Acidosis n G luconeogonesis H yperglycem ia G lucosuria ( osm otic diuresis) Loss of w ater and electrolytes

D ehydration I mp a i r e dRe n a l F u n c t i o n
Ga mb a r1. Ba g a nP a t o s i o l o g i KAD13

H yperosm olarity

F a k t o rp e n c e t u st e r s e r i n gd a r i KAD a d a l a h i n f e k s i ,d a nd i p e r k i r a k a ns e b a g a ip e n c e t u s l e b i h 6-8 d a r i 50 % k a s u s KAD. P a d ai n f e k s ia k a nt e r j a d i p e n i n g k a t a ns e k r e s ik o r t i s o ld a ng l u k a g o ns e h i n g g a t e r j a d ip e n i n g k a t a nk a d a rg u l ad a r a hy a n gb e r ma k n a . F a k t o r l a i n n y a a d a l a h cereb rov ascular accid ent, alcoh ol ab use, p a n k r e a t i t i s ,i n f a r kj a n t u n g ,t r a u ma , 128

ph eoch romocytoma, o b a t , DM t i p e 1 y a n g b a r u d i k e t a h u id a nd i s k o n t i n u i t a s (k e p a t u h a n )a t a ut e r a p i 1, 2, 5-8 i n s u l i ni n a d e k u a t . Ke p a t u h a na k a np e ma k a i a ni n s u l i nd i p e n g a r u h i 5 o l e hu mu r ,e t n i sd a nf a k t o rk o mo r b i dp e n d e r i t a . F a k t o rl a i ny a n gj u g ad i k e t a h u is e b a g a ip e n c e t u s KAD a d a l a ht r a u ma ,k e h a mi l a n ,p e mb e d a h a n ,d a n

J Peny Dalam, Volume 11 Nomor 2 Mei 2010

s t r e sp s i k o l o g i s .I n f e k s iy a n gd i k e t a h u ip a l i n gs e r i n g me n c e t u s k a n KAD a d a l a hi n f e k s is a l u r a nk e mi hd a n 5, 6 p n e u mo n i a . P n e u mo n i aa t a up e n y a k i tp a r ul a i n n y a d a p a t me mp e n g a r u h io k s i g e n a s id a n me n c e t u s k a n g a g a l n a p a s , s e h i n g g ah a r u ss e l a l ud i p e r h a t i k a ns e b a g a i k e a d a a ny a n gs e r i u sd a na k a nme n u r u n k a nk o mp e n s a s i 2 r e s p i r a t o r i kd a r i a s i d o s i sme t a b o l i k . I n f e k s il a i nd a p a tb e r u p ai n f e k s ir i n g a ns e p e r t i sk in lesion a t a ui n f e k s it e n g g o r o k a n . Ob a t -o b a t a n y a n g me mp e n g a r u h i me t a b o l i s me k a r b o h i d r a t s e p e r t ik o r t i k o s t e r o i d ,t h i a z i d ,p e n t a mi d i n e ,d a no b a t s i mp a t o mi me t i k (s e p e r t id o b u t a mi nd a nt e r b u t a l i n ) , d a p a t me n c e t u s k a nKAD. Ob a t -o b a t l a i ny a n gd i k e t a h u i d a p a t me n c e t u s k a nKAD d i a n t a r a n y ab e t ab l o k e r , o b a t a n t i p s i k o t i k ,d a nf e n i t o i n , P a d ap a s i e nu s i a mu d a d e n g a n DM t i p e 1,ma s a l a hp s i k o l o g i sy a n gd i s e r t a i k e l a i n a n ma k a n me mb e r i k a nk o n t r i b u s ip a d a 20 % KAD b e r u l a n g .F a k t o ry a n g me mu n c u l k a nk e l a l a i a n p e n g g u n a a ni n s u l i n p a d ap a s i e n mu d ad i a n t a r a n y a k e t a k u t a n u n t u k p e n i n g k a t a n b e r a tb a d a n d e n g a n p e r b a i k a n k o n t r o l me t a b o l i k ,k e t a k u t a n t e r j a d i n y a 4, 6, 7 h i p o g l i k e mi a ,d a ns t r e sa k i b a tp e n y a k i tk r o n i k . Na mu nd e mi k i a n ,s e r i n g k a l if a k t o rp e n c e t u s KAD t i d a kd i t e mu k a nd a ni n i d a p a t me n c a p a i 20 30 %d a r i s e mu ak a s u sKAD, a k a nt e t a p i h a l i n i t i d a kme n g u r a n g i 9, 10 d a mp a ky a n gd i t i mb u l k a na k i b a t KAD i t us e n d i r i . DI AGNOS I SKETOAS I DOS I SDI ABETI K La n g k a hp e r t a may a n gh a r u s d i a mb i l p a d ap a s i e n KAD t e r d i r i d a r i a n a mn e s i sd a np e me r i k s a a ns i ky a n g c e p a td a nt e l i t it e r u t a mame mp e r h a t i k a np a t e n s ij a l a n n a p a s ,s t a t u sme n t a l ,s t a t u sg i n j a ld a nk a r d i o v a s k u l a r , d a ns t a t u sh i d r a s i .La n g k a h -l a n g k a hi n ih a r u sd a p a t me n e n t u k a n j e n i sp e me r i k s a a n l a b o r a t o r i u m y a n g h a r u ss e g e r ad i l a k u k a n ,s e h i n g g ap e n a t a l a k s a n a a n 1 d a p a t s e g e r ad i mu l a i t a n p aa d a n y ap e n u n d a a n . Me s k i p u n g e j a l a DM y a n g t i d a k t e r k o n t r o l mu n g k i nt a mp a kd a l a m b e b e r a p ah a r i ,p e r u b a h a n me t a b o l i ky a n gk h a su n t u k KAD b i a s a n y at a mp a k d a l a m j a n g k a wa k t up e n d e k (< 24 j a m) .Umu mn y a p e n a mp a k a n s e l u r u h g e j a l a d a p a tt a mp a k a t a u
P e n a t a l a k s a n a a n Ke t o a s i d o s i sDi a b e t i k(KAD) Wira Gotera, Dewa Gd e Agung Bud iyasa

b e r k e mb a n g l e b i h a k u td a n p a s i e n d a p a tt a mp a k me n j a d i KAD t a n p a g e j a l a a t a u t a n d a KAD s e b e l u mn y a . Ga mb a r a n k l i n i s k l a s i k t e r ma s u k r i wa y a tp o l i u r i a ,p o l i d i p s i a ,d a np o l i f a g i a ,p e n u r u n a n b e r a tb a d a n ,mu n t a h ,s a k i tp e r u t ,d e h i d r a s i ,l e ma h , cloud ing of sensoria, d a na k h i r n y ak o ma . P e me r i k s a a n k l i n i st e r ma s u kt u r g o rk u l i ty a n g me n u r u n ,r e s p i r a s i Ku s s ma u l ,t a k i k a r d i a ,h i p o t e n s i ,p e r u b a h a n s t a t u s me n t a l , s y o k , d a nk o ma . Le b i hd a r i25% p a s i e nKAD me n j a d i mu n t a h -mu n t a hy a n gt a mp a ks e p e r t ik o p i . P e r h a t i a nl e b i hh a r u sd i b e r i k a nu n t u kp a s i e nd e n g a n h i p o t e r mi ak a r e n ame n u n j u k k a np r o g n o s i sy a n gl e b i h b u r u k . De mi k i a np u l ap a s i e nd e n g a n ab d ominal pain, k a r e n ag e j a l ai n id a p a tme r u p a k a na k i b a ta t a us e b u a h i n d i k a s id a r ip e n c e t u s n y a ,k h u s u s n y ap a d ap a s i e n mu d a .Ev a l u a s il e b i hl a n j u td i p e r l u k a nj i k ag e j a l ai n i t i d a k me mb a i kd e n g a nk o r e k s id e h i d r a s id a na s i d o s i s me t a b o l i k .
T a b e l 1. Kr i t e r i a d i a g n o s t i k KAD me n u r u t American Diab etes Association7 P a r a me t e r KAD Ri n g a n S e d a n g > 250 > 250 7, 25-7, 30 7, 0 0 -7, 24

Gu l ad a r a h(mg / d l ) p Ha r t e r i S e r u mb i k a r b o n a t / HCO3 15-18 10 - (< 15) (mEq / l ) Ke t o nu r i n e + + Ke t o ns e r u m + + Os mo l a l i t a ss e r u me f e k t i f v a r i a b e l v a r i a b e l (mOs m/ k g ) An i o ng a p > 10 > 12 Al e r t / P e r u b a h a ns e n s o r i a l a t a u Al e r t d r o ws y me n t a l o b t u n d a t i o n Ca t a t a n: -

Be r a t > 250 < 7, 0 0 < 10

v a r i a b e l > 12 S t u p o r / c o ma

P e n g u k u r a nk e t o ns e r u md a nu r i n e me ma k a i me t o d er e a k s i n i t r o p r u s i d a Os mo l a l i t a ss e r u m e f e k t i f(mOs m/ k g )= 2X Na(mEq / l )+ Gl u k o s a(mg / d l ) / 18 + An i o ng a p= Na (Cl +HCO3- )(mEq / l )

P ENAT ALAKS ANAAN KET OAS I DOS I SDI ABETI K P e n a t a l a k s a n a a n KAD b e r s i f a t mu l t i f a k t o r i a l s e h i n g g a me me r l u k a n p e n d e k a t a n t e r s t r u k t u ro l e h 129

d o k t e rd a np a r a me d i sy a n gb e r t u g a s . T e r d a p a tb a n y a k s e k a l ip e d o ma np e n a t a l a k s a n a a n KAD p a d al i t e r a t u r k e d o k t e r a n ,d a nh e n d a k n y as e mu ai t ut i d a kd i i k u t i s e c a r ak e t a ts e k a l id a nd i s e s u a i k a nd e n g a nk o n d i s i p e n d e r i t a . Da l a m me n a t a l a k s a n ap e n d e r i t aKAD s e t i a p r u ma hs a k i t h e n d a k n y ame mi l i k i p e d o ma na t a ud i s e b u t s e b a g a iintegrated care path way.P e d o ma ni n ih a r u s d i l a k s a n a k a n s e b a g a i ma n a me s t i n y ad a l a m r a n g k a me n c a p a it u j u a nt e r a p i .S t u d it e r a k h i r me n u n j u k k a n s e b u a h integrated care path way d a p a tme mp e r b a i k i 7 h a s i l a k h i rp e n a t a l a k s a n a a nKAD s e c a r as i g n i k a n . Ke b e r h a s i l a n p e n a t a l a k s a n a a n KAD me mb u t u h k a nk o r e k s id e h i d r a s i ,h i p e r g l i k e mi a ,a s i d o s i s d a nk e l a i n a ne l e k t r o l i t ,i d e n t i k a s if a k t o rp r e s i p i t a s i k o mo r b i d ,d a ny a n gt e r p e n t i n ga d a l a hp e ma n t a u a n 3, 7 Be r i k u ti n ib e b e r a p ah a ly a n g p a s i e nt e r u sme n e r u s . h a r u sd i p e r h a t i k a np a d ap e n a t a l a k s a n a a nKAD. 1 .Te r a p i c a i r a n P r i o r i t a su t a ma p a d ap e n a t a l a k s a n a a n KAD 8 a d a l a ht e r a p i c a i r a n .T e r a p i i n s u l i nh a n y ae f e k t i f j i k a c a i r a nd i b e r i k a np a d at a h a pa wa lt e r a p id a nh a n y a d e n g a nt e r a p i c a i r a ns a j aa k a nme mb u a t k a d a rg u l a d a r a h me n j a d il e b i hr e n d a h .S t u d ime n u n j u k k a n b a h wa s e l a ma e mp a tj a m p e r t a ma ,l e b i h d a r i 80 % p e n u r u n a nk a d a rg u l ad a r a hd i s e b a b k a no l e h 2, 11 Ol e hk a r e n ai t u ,h a lp e n t i n gp e r t a ma r e h i d r a s i . y a n gh a r u sd i p a h a mi a d a l a hp e n e n t u a nd i s i t c a i r a n y a n gt e r j a d i . Be r a t n y ak e k u r a n g a nc a i r a ny a n g t e r j a d id i p e n g a r u h io l e hd u r a s ih i p e r g l i k e mi ay a n g 11 t e r j a d i , f u n g s ig i n j a l , d a n intak ec a i r a np e n d e r i t a . Ha l i n i b i s ad i p e r k i r a k a nd e n g a np e me r i k s a a nk l i n i s 2 a t a ud e n g a nme n g g u n a k a nr u mu ss e b a g a i b e r i k u t : Fluidd ecit = (0 , 6Xb e r a t b a d a nd a l a mk g ) X (correctedNa / 140 ) CorrectedNa= Na+ (k a d a rg u l ad a r a h -5) / 3, 5 Ru mu s l a i n y a n g d a p a td i p a k a iu n t u k me n e n t u k a n d e r a j a t d e h i d r a s i a d a l a h d e n g a n me n g h i t u n go s mo l a l i t a ss e r u mt o t a ld a n corrected serum sod ium concentration. 130

Os mo l a l i t a ss e r u mt o t a l = 2 X Na(mEq / l )+ k a d a rg l u k o s ad a r a h (mg / d l ) / 18 + BUN/ 2, 8 Serum sod ium concentration d a p a t d i k o r e k s i d e n g a nme n a mb a h k a n1, 6 mEq / l t i a pk e n a i k a n10 0 mg / d lk a d a rg u l ad a r a hd ia t a sk a d a rg u l a10 0 mg / d l .Ni l a icorrected serum sod ium concentration > 140d a no s mo l a l i t a ss e r u mt o t a l >330mOs m/ k ga i r 12 me n u n j u k k a nd e s i t c a i r a ny a n gb e r a t .P e n e n t u a n d e r a j a td e h i d r a s id e n g a ng e j a l ak l i n i ss e r i n g k a l i s u k a rd i k e r j a k a n , n a mu nd e mi k i a nb e b e r a p ag e j a l a k l i n i sy a n gd a p a t me n o l o n gu n t u k me n e n t u k a n 13 d e r a j a t d e h i d r a s i a d a l a h . : - 5% :p e n u r u n a n t u r g o r k u l i t , me mb r a n mu k o s ak e r i n g , t a k i k a r d i a - 10 % :capillary rell time 3 d e t i k ,ma t a c o wo n g - > 10 % :p u l s u sa r t e r ip e r i f e rl e ma h ,h i p o t e n s i , s y o k , o l i g u r i a Re s u s i t a s i c a i r a nh e n d a k n y ad i l a k u k a ns e c a r a a g r e s i f . T a r g e t n y aa d a l a hp e n g g a n t i a nc a i r a ns e b e s a r 50 % d a r ik e k u r a n g a nc a i r a nd a l a m 8 12 j a m 5, 9 p e r t a mad a ns i s a n y ad a l a m 12 16 j a mb e r i k u t n y a . Me n u r u tp e r k i r a a nb a n y a ka h l i ,t o t a lk e k u r a n g a n c a i r a np a d ap a s i e nKAD s e b e s a r 10 0ml / k g BB, a t a u 2, 5, 9 s e b e s a r5 8 l i t e r . P a d ap a s i e nd e wa s a ,t e r a p i c a i r a na wa ll a n g s u n gd i b e r i k a nu n t u ke k s p a n s i v o l u me c a i r a n i n t r a v a s k u l a rd a n e k s t r a v a s k u l a r 7, 9 d a n me n j a g ap e r f u s ig i n j a l . T e r d a p a tb e b e r a p a k o n t r o v e r s i t e n t a n gj e n i sc a i r a ny a n gd i p e r g u n a k a n . T i d a ka d au j ik l i n i ky a n g me mb u k t i k a nk e l e b i h a n 2 p e ma k a i a ns a l a hs a t uj e n i sc a i r a n . Ke b a n y a k a na h l i me n y a r a n k a np e ma k a i a nc a i r a n s i o l o g i s (Na Cl 0 , 9%)s e b a g a i t e r a p i a wa l u n t u kr e s u s i t a s i c a i r a n . Ca i r a n s i o l o g i s (Na Cl 0 , 9%) d i b e r i k a n d e n g a nk e c e p a t a n15 20ml / k g BB/ j a ma t a ul e b i h s e l a maj a mp e r t a ma (1 1, 5l i t e r ) . S e b u a hs u mb e r me mb e r i k a n p e t u n j u k p r a k t i sp e mb e r i a n c a i r a n s e b a g a ib e r i k u t :1 l i t e rp a d aj a m p e r t a ma ,1 l i t e r d a l a m2j a mb e r i k u t n y a , k e mu d i a n1 l i t e r s e t i a p4 j a m
J Peny Dalam, Volume 11 Nomor 2 Mei 2010

s a mp a i p a s i e nt e r e h i d r a s i . S u mb e r l a i nme n y a r a n k a n 1 1, 5l t p a d aj a mp e r t a ma , s e l a n j u t n y a250 50 0 2 ml / j a mp a d aj a mb e r i k u t n y a . P e t u n j u ki n i h a r u s l a h d i s e s u a i k a nd e n g a ns t a t u sh i d r a s ip a s i e n .P i l i h a n c a i r a ns e l a n j u t n y at e r g a n t u n gd a r is t a t u sh i d r a s i , k a d a re l e k t r o l i t s e r u m, d a np e n g e l u a r a nu r i n e . P a d a u mu mn y a , c a i r a nNa Cl 0 , 45% d i b e r i k a nj i k ak a d a r n a t r i u ms e r u mt i n g g i (> 150mEq / l ) , d a nd i b e r i k a n u n t u k me n g k o r e k s ip e n i n g k a t a nk a d a rNa +s e r u m (correctedserum sod ium) d e n g a nk e c e p a t a n4 14 ml / k g BB/ j a ms e r t aa g a rp e r p i n d a h a nc a i r a na n t a r a 3, 4, 7 i n t r ad a ne k s t r a s e l u l a rt e r j a d i s e c a r ag r a d u a l . P e ma k a i a n c a i r a n Ri n g e r La k t a t (RL) d i s a r a n k a n u n t u k me n g u r a n g i k e mu n g k i n a n t e r j a d i n y a h i p e r k l o r e mi a y a n gu mu mn y a t e r j a d i p a d a 14 p e ma k a i a nn o r ma l s a l i n e d a nb e r d a s a r k a nstrong2 ion th eory u n t u ka s i d o s i s (S t e wa r th ypoth esis) . S a mp a is a a ti n it i d a k d i d a p a t k a n a l a s a n y a n g me y a k i n k a nt e n t a n gk e u n t u n g a np e ma k a i a n RL d i b a n d i n g k a nd e n g a n Na Cl0 , 9%. J i k ak a d a rNa s e r u mr e n d a ht e t a p l a hme mp e r g u n a k a nc a i r a nNa Cl 0 , 9%. S e t e l a hf u n g s i g i n j a l d i n i l a i , i n f u s c a i r a nh a r u s me n g a n d u n g 20 30 mEq / lKa l i u m (2/ 3 KCld a n 1/ 3 KP O4)s a mp a ip a s i e ns t a b i ld a nd a p a tma k a n . Ke b e r h a s i l a n t e r a p ic a i r a n d i t e n t u k a n d e n g a n mo n i t o r i n g h e mo d i n a mi k (p e r b a i k a n t e k a n a n d a r a h ) ,p e n g u k u r a nc a i r a n ma s u kd a nk e l u a r ,d a n p e me r i k s a a nk l i n i s . P e mb e r i a n c a i r a n h a r u sd a p a t me n g g a n t i p e r k i r a a nk e k u r a n g a nc a i r a nd a l a m j a n g k a wa k t u 24 j a mp e r t a ma . P e r u b a h a no s mo l a l i t a ss e r u mt i d a k me l e b i h i3 mOs m/ k g H2O/ j a m. P a d ap a s i e nd e n g a n k e l a i n a ng i n j a l , j a n t u n ga t a uh a t i t e r u t a mao r a n gt u a , h a r u sd i l a k u k a np e ma n t a u a no s mo l a l i t a ss e r u md a n p e n i l a i a nf u n g s ij a n t u n g ,g i n j a l ,d a ns t a t u sme n t a l y a n gb e r k e s i n a mb u n g a n s e l a ma r e s u s i t a s ic a i r a n u n t u k me n g h i n d a r io v e r l o a d c a i r a n i a t r o g e n i k . Un t u ki t up e ma s a n g a n Central Venous Pressure (CVP ) mo n i t o rd a p a ts a n g a t me n o l o n g . Ke t i k a k a d a r g u l ad a r a hme n c a p a i 250mg / d l , c a i r a nd i g a n t i a t a ud i t a mb a h k a nd e n g a nc a i r a ny a n gme n g a n d u n g
P e n a t a l a k s a n a a n Ke t o a s i d o s i sDi a b e t i k(KAD) Wira Gotera, Dewa Gd e Agung Bud iyasa

d e x t r o s es e p e r t i(d e x t r o s e 5%,d e x t r o s e 5% p a d a Na Cl0 , 9%,a t a ud e x t r o s e 5% p a d a Na Cl0 , 45%) u n t u k me n g h i n d a r ih i p o g l i k e mi ad a n me n g u r a n g i k e mu n g i n a ne d e mas e r e b r a la k i b a tp e n u r u n a ng u l a 2, 3, 5, 14 d a r a hy a n gt e r l a l uc e p a t .

T a b e l 2. P e r k i r a a nj u ml a ht o t a l d e s i t a i rd a ne l e k t r o l i t p a d a p a s i e nKAD7 No 1 2 3 4 5 6 7 8 P e r k i r a a nj u ml a hd e s i t T o t a l a i r(l i t e r ) Ai r(ml / k g ) Na + (mEq / k g ) Cl - (mEq / k g ) K+ (mEq / k g ) P O4- (mmo l / k g ) M g2+ (mEq / k g ) Ca 2+ (mEq / k g ) Ni l a i 6 10 0 7 10 35 35 57 12 12

2 .Te r a p i In s u l i n T e r a p ii n s u l i nh a r u ss e g e r ad i mu l a is e s a a t 1 s e t e l a hd i a g n o s i s KAD d a nr e h i d r a s i y a n gme ma d a i . S u mb e r l a i n me n y e b u t k a n p e mb e r i a n i n s u l i n d i mu l a is e t e l a hd i a g n o s i s KAD d i t e g a k k a nd a n 12 p e mb e r i a nc a i r a nt e l a hd i mu l a i . P e ma k a i a ni n s u l i n a k a nme n u r u n k a nk a d a r h o r mo ng l u k a g o n , s e h i n g g a me n e k a np r o d u k s ib e n d ak e t o nd ih a t i ,p e l e p a s a n a s a ml e ma kb e b a sd a r ij a r i n g a nl e ma k ,p e l e p a s a n a s a m a mi n od a r ij a r i n g a no t o td a n me n i n g k a t k a n 1, 6 u t i l i s a s ig l u k o s ao l e hj a r i n g a n . S a mp a it a h u n 1970 -a np e n g g u n a a ni n s u l i nu mu mn y as e c a r ab o l u s i n t r a v e n a , i n t r a mu s k u l a r , a t a u p u ns u b k u t a n . S e j a kp e r t e n g a h a nt a h u n 1970 -a np r o t o k o l p e n g e l o l a a n KAD d e n g a nd r i pi n s u l i ni n t r a v e n a d o s i sr e n d a hmu l a i d i g u n a k a nd a nme n j a d i p o p u l a r . Ca r ai n i d i a n j u r k a nk a r e n al e b i hmu d a hme n g o n t r o l d o s i si n s u l i n , me n u r u n k a nk a d a rg l u k o s ad a r a h l e b i h l a mb a t ,e f e k i n s u l i n c e p a t me n g h i l a n g , ma s u k n y a k a l i u m k e i n t r a s e l l e b i h l a mb a t , k o mp l i k a s ih i p o g l i k e mi ad a nh i p o k a l e mi al e b i h 1 s e d i k i t . P e mb e r i a ni n s u l i nd e n g a ni n f u si n t r a v e n a d o s i sr e n d a ha d a l a ht e r a p ip i l i h a np a d aKAD y a n g 131

d i s e b u t k a no l e hb e b e r a p al i t e r a t u r , s e d a n g k a nADA me n g a n j u r k a ni n s u l i ni n t r a v e n at i d a kd i b e r i k a n p a d aKAD d e r a j a t r i n g a n . J i k at i d a kt e r d a p a th i p o k a l e mi a (K < 3, 3 mEq / l ) ,d a p a td i b e r i k a ni n s u l i nr e g u l a r0 , 15 u / k g BB,d i i k u t id e n g a ni n f u sk o n t i n u0 , 1u / k g BB/ j a m (5 7 u / j a m) . J i k ak a d a rk a l i u m < 3, 3 mEq / l , ma k a h a r u sd i k o r e k s i d a h u l uu n t u kme n c e g a hp e r b u r u k a n h i p o k a l e mi a y a n g a k a n d a p a t me n g a k i b a t k a n 6, 12 a r i t mi aj a n t u n g . I n s u l i nd o s i sr e n d a hb i a s a n y a me n u r u n k a ng u l ad a r a hd e n g a nk e c e p a t a n 50 75 mg / d l / j a m,s a ma s e p e r t ip e mb e r i a ni n s u l i nd o s i s l e b i ht i n g g i . J i k ag u l ad a r a ht i d a kme n u r u ns e b e s a r 50mg / d l d a r i n i l a i a wa l p a d aj a mp e r t a ma , p e r i k s a s t a t u sh i d r a s i p a s i e n . J i k as t a t u sh i d r a s i me n c u k u p i , i n f u si n s u l i nd a p a td i n a i k k a n2 k a l il i p a ts e t i a p j a ms a mp a it e r c a p a ip e n u r u n a ng u l ad a r a hk o n s t a n a n t a r a50 75 mg / d l / j a m. Ke t i k ak a d a rg u l ad a r a h me n c a p a i 250mg / d l , t u r u n k a ni n f u si n s u l i nme n j a d i 0 , 0 50 , 1u / k g BB/ j a m (3 6 u / j a m) , d a nt a mb a h k a n 6, 7 i n f u sd e x t r o s e5 10 %. S e t e l a h i t u k e c e p a t a n p e mb e r i a n i n s u l i n a t a uk o n s e n t r a s id e x t r o s eh a r u sd i s e s u a i k a nu n t u k me me l i h a r an i l a ig l u k o s as a mp a ik e a d a a na s i d o s i s me mb a i k .P a d ak o n d i s ik l i n i kp e mb e r i a ni n s u l i n i n t r a v e n a t i d a k d a p a td i b e r i k a n , ma k a i n s u l i n d i b e r i k a nd e n g a nd o s i s0 , 3 i u (0 , 4 0 , 6 i u ) / k g BB y a n gt e r b a g ime n j a d is e t e n g a hd o s i ss e c a r a i n t r a v e n ad a ns e t e n g a h n y al a g is e c a r as u b k u t a n a t a ui n t r a mu s k u l a r ,s e l a n j u t n y ad i b e r i k a ni n s u l i n s e c a r ai n t r a mu s k u l a ra t a us u b k u t a n0 , 1 i u / k g BB/ j a m, s e l a n j u t n y ap r o t o k o l p e n a t a l a k s a n a a n n y as a ma 12 s e p e r t i p e mb e r i a nd r i pi n t r a v e n a . P e r b a i k a n k e t o n e mi a me me r l u k a n wa k t u l e b i hl a ma d a r i p a d ah i p e r g l i k e mi a .P e n g u k u r a n l a n g s u n g -OHB (b e t a h i d r o k s ib u t i r a t )p a d a d a r a h me r u p a k a n me t o d ay a n gl e b i hd i s u k a iu n t u k p e ma n t a u a n KAD. S e l a mat e r a p i-OHB b e r u b a h me n j a d i a s a ma s e t o a s e t a t , y a n gme n a n d a k a nb a h wa k e t o s i s me mb u r u k .S e l a ma t e r a p i KAD h a r u s d i p e r i k s ak a d a re l e k t r o l i t ,g l u k o s a ,BUN,s e r u m 132

k r e a t i n i n ,o s mo l a l i t a s ,d a nd e r a j a tk e a s a ma nv e n a s e t i a p2 4 j a m, s u mb e rl a i n me n y e b u t k a nb a h wa 6 k a d a rg l u k o s ak a p i l e rd i p e r i k s at i a p1 2 j a m. P a d a KAD r i n g a n ,i n s u l i nr e g u l a rd a p a td i b e r i k a n s e c a r as u b k u t a n a t a u i n t r a mu s k u l a rs e t i a p j a m d e n g a ne f e k t i t a sy a n gs a ma d e n g a np e mb e r i a n i n t r a v e n ap a d ak a d a rg u l ad a r a hy a n gr e n d a hd a n k eton b od ies y a n gr e n d a h .Ef e k t i t a sp e mb e r i a n i n s u l i nd e n g a ni n t r a mu s k u l a rd a ns u b k u t a na d a l a h s a ma ,n a mu ni n j e k s is u b k u t a nl e b i h mu d a hd a n k u r a n g me n y a k i t k a np a s i e n .P a s i e nd e n g a n KAD r i n g a nh a r u sme n d a p a t k a n priming d ose i n s u l i n r e g u l a r0 , 4 0 , 6 u / k g BB,s e t e n g a hd o s i ss e b a g a i b o l u sd a ns e t e n g a hd o s i sd e n g a ns u b k u t a na t a u i n j e k s i i n t r a mu s k u l a r . S e l a n j u t n y ad i b e r i k a ni n s u l i n s u b k u t a na t a ui n t r a mu s k u l a r0 , 1u / k g BB/ j a m. Kr i t e r i ar e s o l u s i KAD d i a n t a r a n y aa d a l a h k a d a rg u l ad a r a h < 20 0 mg / d l , s e r u mb i k a r b o n a t 18 mEq / l , p Hv e n a>7, 3, d a na n i o ng a p 12 mEq / l . S a a t i n i , j i k ap a s i e nNP O, l a n j u t k a ni n s u l i ni n t r a v e n a d a np e mb e r i a nc a i r a nd a nd i t a mb a hd e n g a ni n s u l i n r e g u l a rs u b k u t a ns e s u a ik e p e r l u a ns e t i a p4 j a m. P a d ap a s i e nd e wa s ad a p a td i b e r i k a n5 i ui n s u l i n t a mb a h a ns e t i a pk e n a i k a ng u l ad a r a h50mg / d lp a d a g u l ad a r a hd i a t a s150mg / d l d a nd a p a t d i t i n g k a t k a n 20i uu n t u kg u l ad a r a h 30 0mg / d l . Ke t i k ap a s i e n d a p a tma k a n ,j a d wa ld o s i smu l t i p e lh a r u sd i mu l a i d e n g a n me ma k a ik o mb i n a s id o s i ssh ort a t a u rapid acting insulin d a n intermed iate a t a u long acting insulin s e s u a i k e b u t u h a nu n t u kme n g o n t r o l g l u k o s a d a r a h . Le b i h mu d a hu n t u k me l a k u k a nt r a n s i s ii n i d e n g a np e mb e r i a ni n s u l i ns a a t p a g i s e b e l u m ma k a n a t a us a a t ma k a nma l a m. T e r u s k a ni n s u l i ni n t r a v e n a s e l a ma 1 2 j a m s e t e l a hp e r g a n t i a nr e g i me n d i mu l a iu n t u k me ma s t i k a nk a d a ri n s u l i np l a s ma y a n ga d e k u a t . P e n g h e n t i a ni n s u l i nt i b a -t i b ad i s e r t a i d e n g a np e mb e r i a ni n s u l i ns u b k u t a ny a n gt e r l a mb a t d a p a t me n g a k i b a t k a nk o n t r o l y a n gb u r u k , s e h i n g g a d i p e r l u k a ns e d i k i tov erlapping p e mb e r i a ni n s u l i n i n t r a v e n ad a ns u b k u t a n .P a s i e ny a n gd i k e t a h u i
J Peny Dalam, Volume 11 Nomor 2 Mei 2010

d i a b e t e ss e b e l u mn y ad a p a t d i b e r i k a ni n s u l i nd e n g a n d o s i sy a n gd i b e r i k a ns e b e l u mt i mb u l n y aKAD d a n s e l a n j u t n y ad i s e s u a i k a ns e p e r l u n y a .P a d ap a s i e n DM y a n gb a r u , i n s u l i na wa l h e n d a k n y a0 , 5 1, 0u / k g BB/ h a r i ,d i b e r i k a nt e r b a g ime n j a d is e k u r a n g n y a 2 d o s i sd a l a m r e g i me ny a n gt e r ma s u k sh ort d a n long acting insulin s a mp a id o s i so p t i ma lt e r c a p a i , d u a p e r t i g ad o s i sh a r i a ni n id i b e r i k a np a g ih a r id a n s e p e r t i g a n y ad i b e r i k a ns o r eh a r i s e b a g a i splitmix ed 6, 7 d ose. Ak h i r n y ap a s i e n DM t i p e2 d a p a tk e l u a r r u ma hs a k i td e n g a na n t i d i a b e t i ko r a ld a nt e r a p i 7 d i e t . 3 .Na t r i u m P e n d e r i t a d e n g a n KAD k a d a n g -k a d a n g me mp u n y a i k a d a rn a t r i u ms e r u my a n gr e n d a h , o l e h k a r e n al e v e lg u l ad a r a hy a n gt i n g g i .Un t u kt i a p p e n i n g k a t a ng u l ad a r a h10 0mg / d l d i a t a s10 0mg / d l ma k ak a d a rn a t r i u md i a s u ms i k a nl e b i ht i n g g i 1, 6 mEq / ld a r i p a d ak a d a ry a n gd i u k u r .Hi p o n a t r e mi a me me r l u k a n k o r e k s ij i k a l e v e ln a t r i u m ma s i h r e n d a hs e t e l a hp e n y e s u a i a ne f e ki n i .Co n t o h ,p a d a o r a n gd e n g a nk a d a rg u l ad a r a h 60 0 mg / d ld a n l e v e l n a t r i u my a n gd i u k u r130 , ma k al e v e l n a t r i u m y a n gs e b e n a r n y as e b e s a r130 + (1, 6 x 5)= 138, s e h i n g g at i d a k me me r l u k a nk o r e k s id a nh a n y a me me r l u k a np e mb e r i a nc a i r a nn o r ma l s a l i n e(Na Cl 0 , 9%) .S e b a l i k n y ak a d a rn a t r i u md a p a tme n i n g k a t s e t e l a hd i l a k u k a nr e s u s i t a s ic a i r a nd e n g a nn o r ma l s a l i n eo l e hk a r e n an o r ma ls a l i n e me mi l i k ik a d a r n a t r i u ml e b i ht i n g g i d a r i k a d a r n a t r i u me k s t r a s e l u l a r s a a ti t ud i s a mp i n go l e hk a r e n aa i rt a n p an a t r i u m a k a n b e r p i n d a h k e i n t r a s e l u l a rs e h i n g g a a k a n me n i n g k a t k a nk a d a rn a t r i u m8. S e r u mn a t r i u my a n g l e b i ht i n g g i d a r i p a d a150mEq / l me me r l u k a nk o r e k s i 7 d e n g a nNa Cl 0 , 45%. 4 .Ka l i u m Me s k i p u nt e r d a p a t k e k u r a n g a nk a l i u ms e c a r a t o t a ld a l a m t u b u h (s a mp a i 3 5 mEq / k g BB) , h i p e r k a l e mi a r i n g a n s a mp a is e d a n g s e r i n g k a l i
P e n a t a l a k s a n a a n Ke t o a s i d o s i sDi a b e t i k(KAD) Wira Gotera, Dewa Gd e Agung Bud iyasa

t e r j a d i . Ha li n it e r j a d ik a r e n as h i f tk a l i u m d a r i i n t r a s e l k e e k s t r a s e l o l e hk a r e n a a s i d o s i s , k e k u r a n g a n i n s u l i n ,d a nh i p e r t o n i s i t a s ,s e h i n g g at e r a p ii n s u l i n , k o r e k s ia s i d o s i s ,d a np e n a mb a h a nv o l u me c a i r a n a k a nme n u r u n k a nk o n s e n t r a s i k a l i u ms e r u m. Un t u k me n c e g a hh i p o k a l e mi a , p e n g g a n t i a nk a l i u md i mu l a i s e t e l a hk a d a r k a l i u ms e r u mk u r a n gd a r i 5, 0 , s u mb e r l a i nme n y e b u t k a nn i l a i 5, 5 mEq / l . Umu mn y a , 20 30 mEqk a l i u m (2/ 3 KCl d a n1/ 3 KP O4) p a d at i a pl i t e r c a i r a ni n f u sc u k u pu n t u kme me l i h a r ak a d a rk a l i u m s e r u md a l a m range n o r ma l4 5 mEq / l .Ka d a n g k a d a n gp a s i e n KAD me n g a l a mih i p o k a l e mi ay a n g s i g n i k a n . P a d ak a s u st e r s e b u t , p e n g g a n t i a nk a l i u m h a r u sd i mu l a id e n g a nt e r a p iKCl40 mEq / l ,d a n t e r a p ii n s u l i nh a r u sd i t u n d ah i n g g ak a d a rk a l i u m > 3, 3 mEq / lu n t u k me n g h i n d a r ia r i t mi aa t a ug a g a l 6, 7 j a n t u n gd a nk e l e ma h a no t o tp e r n a p a s a n . T e r a p i k a l i u m d i mu l a is a a tt e r a p ic a i r a ns u d a hd i mu l a i , d a nt i d a kd i l a k u k a nj i k at i d a ka d ap r o d u k s iu r i n e , t e r d a p a tk e l a i n a ng i n j a l ,a t a uk a d a rk a l i u m >6 16 mEq / l . 5 .Bi k a r b o n a t P e ma k a i a n b i k a r b o n a tp a d a KAD ma s i h k o n t r o v e r s i a l .P a d a p H > 7, 0 ,p e n g e mb a l i a n a k t i t a si n s u l i nme mb l o kl i p o l i s i sd a nme mp e r b a i k i k e t o a s i d o s i st a n p ap e mb e r i a nb i k a r b o n a t .S t u d i r a n d o m p r o s p e k t i f t e l a h g a g a l me n u n j u k k a n b a i kk e u n t u n g a na t a uk e r u g i a np a d ap e r u b a h a n mo r b i d i t a sa t a umo r t a l i t a sd e n g a nt e r a p i b i k a r b o n a t p a d ap a s i e n KAD d e n g a np H a n t a r a 6, 9 7, 1. T i d a kd i d a p a t k a ns t u d ir a n d o m p r o s p e k t i fy a n g me mp e l a j a r ip e ma k a i a n b i k a r b o n a tp a d a KAD d e n g a nn i l a ip H < 6, 9. Me n g e t a h u ib a h waa s i d o s i s b e r a t me n y e b a b k a nb a n y a ke f e kv a s k u l a r y a n gt i d a k d i i n g i n k a n , t a mp a k n y ac u k u pb i j a k s a n ame n e n t u k a n b a h wa p a d ap a s i e nd e wa s ad e n g a np H < 6, 9,10 0 mmo l n a t r i u mb i k a r b o n a t d i t a mb a h k a nk ed a l a m 40 0 ml c a i r a ns i o l o g i sd a nd i b e r i k a nd e n g a nk e c e p a t a n 20 0 ml / j a m.P a d ap a s i e nd e n g a np H 6, 9 7, 0 ,50 mmo ln a t r i u mb i k a r b o n a td i c a mp u rd a l a m 20 0 ml 133

c a i r a n s i o l o g i sd a nd i b e r i k a nd e n g a nk e c e p a t a n 20 0 ml / j a m.Na t r i u m b i k a r b o n a tt i d a kd i p e r l u k a n 7, 15 j i k ap H > 7, 0 . S e b a g a i ma n an a t r i u mb i k a r b o n a t , i n s u l i n me n u r u n k a n k a d a rk a l i u m s e r u m, o l e h k a r e n ai t up e mb e r i a nk a l i u mh a r u st e r u sd i b e r i k a n s e c a r ai n t r a v e n ad a nd i mo n i t o rs e c a r ab e r k a l a . S e t e l a hi t up Hd a r a hv e n ad i p e r i k s as e t i a p2 j a m s a mp a ip H me n j a d i7, 0 ,d a nt e r a p ih a r u sd i u l a n g i 7 s e t i a p2 j a mj i k ap e r l u . 6 .Fo s f a t Me s k i p u n k a d a r f o s f a t t u b u h s e c a r a k e s e l u r u h a n me n g a l a mi p e n u r u n a n h i n g g a 1, 0 mmo l / k g BB,k a d a rf o s f a ts e r u ms e r i n g k a l in o r ma l a t a u me n i n g k a t . Ka d a rf o s f a t me n u r u nd e n g a n t e r a p ii n s u l i n .S t u d ia c a kp r o s p e k t i fg a g a lu n t u k me n u n j u k k a ne f e k me n g u n t u n g k a nd a r ip e mb e r i a n f o s f a t p a d ah a s i l a k h i r p a s i e nKAD, d a nt e r a p i f o s f a t b e r l e b i h a nd a p a tme n y e b a b k a nh i p o k a l e mi ab e r a t t a n p ab u k t ia d a n y at e t a n u s .Ba g a i ma n a p u nu n t u k me n g h i n d a r i l e ma h n y ao t o t r a n g k ad a nj a n t u n gs e r t a d e p r e sp e r n a p a s a ny a n gd i s e b a b k a nh i p o f o s f a t e mi a , p e mb e r i a nf o s f a ts e c a r ah a t i -h a t imu n g k i nk a d a n g k a d a n gd i i n d i k a s i k a np a d ap a s i e nd e n g a nk e l a i n a n j a n t u n g , a n e mi a , a t a ud e p r e s ip e r n a p a s a nd a np a d a me r e k ad e n g a nk a d a rs e r u m p o s f a t< 1, 0 mg / d l . Ke t i k ad i p e r l u k a n , 20 30mEq / l k a l i u mf o s f a t d a p a t d i t a mb a h k a np a d at e r a p i c a i r a ny a n gt e l a hd i b e r i k a n . 7 Un t u ki t ud i p e r l u k a np e ma n t a u a ns e c a r ak o n t i n u . Be b e r a p ap e n e l i t i me n g a n j u r k a np e ma k a i a nk a l i u m f o s f a tr u t i nk a r e n a me r e k ap e r c a y aa k a nd a p a t me n u r u n k a nh i p e r k l o r e mi as e t e l a ht e r a p id e n g a n me mb a t a s ip e mb e r i a na n i o n Cl .P e mb e r i a nf o s f a t j u g a me n c e t u s k a nh i p o k a l s e mi as i mt o ma t i sp a d a 9 b e b e r a p ap a s i e n . 7 .M a g n e s i u m Bi a s a n y at e r d a p a t d e s i t ma g n e s i u ms e b e s a r 1 2 mEq / lp a d ap a s i e n KAD.Ka d a rma g n e s i u m i n ij u g ad i p e n g a r u h io l e hp e ma k a i a no b a ts e p e r t i

d i u r e t i ky a n gd a p a tme n u r u n k a nk a d a rma g n e s i u m d a r a h .Ge j a l ak e k u r a n g a n ma g n e s i u ms a n g a ts u l i t d i n i l a id a ns e r i n gt u mp a n gt i n d i hd e n g a ng e j a l a a k i b a tk e k u r a n g a nk a l s i u m,k a l i u m a t a un a t r i u m. Ge j a l ay a n gs e r i n gd i l a p o r k a na d a l a hp a r e s t e s i a , t r e mo r ,s p a me k a r p o p e d a l ,a g i t a s i ,k e j a n g ,d a n a r i t mi a j a n t u n g .P a s i e n b i a s a n y a me n u n j u k k a n g e j a l ap a d ak a d a r 1, 2 mg / d l .J i k ak a d a r n y ad i b a wa hn o r ma ld i s e r t a ig e j a l a , ma k ap e mb e r i a n 7 ma g n e s i u md a p a t d i p e r t i mb a n g k a n . 8 .Hi p e r k l o r e mi ka s i d o s i ss e l a mat e r a p i Ol e hk a r e n ap e r t i mb a n g a np e n g e l u a r a nk e t o a c i dd a l a mu r i n es e l a maf a s ea wa lt e r a p i ,s u b s t r a t a t a u b a h a n t u r u n a n b i k a r b o n a ta k a n me n u r u n . S e b a g i a nd e s i tb i k a r b o n a ta k a nd i g a n t id e n g a n i n f u si o nk l o r i d ap a d as e j u ml a hb e s a rs a l i nu n t u k me n g k o r e k s id e h i d r a s i .P a d ak e b a n y a k a np a s i e n a k a n me n g a l a mi s e b u a hk e a d a a nh i p e r k l o r e mi k d e n g a nb i k a r b o n a ty a n gr e n d a hd e n g a na n i o ng a p y a n gn o r ma l . Ke a d a a ni n i me r u p a k a nk e l a i n a n y a n gr i n g a nd a nt i d a ka k a nb e r b a h a y ad a l a m wa k t u 12 24 j a mj i k ap e mb e r i a nc a i r a ni n t r a v e n at i d a k 3 d i b e r i k a nt e r l a l ul a ma . 9 .Pe n a t a l a k s a a nt e r h a d a pIn f e k s i y a n gM e n y e r t a i An t i b i o t i k ad i b e r i k a ns e s u a i d e n g a ni n d i k a s i , 3 t e r u t a mat e r h a d a pf a k t o r p e n c e t u st e r j a d i n y aKAD. J i k af a k t o r p e n c e t u si n f e k s i b e l u md a p a t d i t e mu k a n , ma k aa n t i b i o t i k ay a n gd i p i l i ha d a l a ha n t i b i o t i k a 5 s p e k t r u ml u a s . 1 0 . Te r a p i Pe n c e g a h a n t e r h a d a p Deep Vein Thrombosis (DVT) T e r a p ip e n c e g a h a n DVT d i b e r i k a nt e r h a d a p p e n d e r i t ad e n g a nr i s i k ot i n g g i ,t e r u t a ma t e r h a d a p p e n d e r i t ay a n gt i d a ks a d a r , i mmo b i l i s a s i , o r a n gt u a , d a nh i p e r o s mo l a r b e r a t . Do s i sy a n gd i a n j u r k a n50 0 0 16 i ut i a p8 j a ms e c a r as u b k u t a n .

134

J Peny Dalam, Volume 11 Nomor 2 Mei 2010

Ga mb a r2. Ba g a nP e n a t a l a k s a n a a nKAD 7

Ga mb a r2. Ba g a np e n a t a l a k s a n a a nKAD 7

Mo n i t o r i n gTe r a p i S e mu ap a s i e nKAD h a r u sme n d a p a t k a ne v a l u a s i l a b o r a t o r i u my a n gk o mp r e h e n s i f t e r ma s u kp e me r i k s a a n d a r a h l e n g k a p d e n g a n p r o l k i mi a t e r ma s u k p e me r i k s a a n e l e k t r o l i t d a na n a l i s i sg a sd a r a h . P e mb e r i a nc a i r a nd a n p e n g e l u a r a nu r i n eh a r u sd i mo n i t o rs e c a r ah a t i -h a t i d a n d i c a t a tt i a pj a m.P e me r i k s a a n EKG h a r u sd i k e r j a k a n k e p a d as e t i a pp a s i e n , k h u s u s n y ame r e k ad e n g a nr i s i k o 9 k a r d i o v a s k u l a r . T e r d a p a tb e r ma c a mp e n d a p a tt e n t a n g f r e k u e n s ip e me r i k s a a np a d ab e b e r a p ap a r a me t e ry a n g a d a .ADA me r e k o me n d a s i k a np e me r i k s a a ng l u k o s a ,

P e n a t a l a k s a n a a n Ke t o a s i d o s i sDi a b e t i k(KAD) Wira Gotera, Dewa Gd e Agung Bud iyasa

e l e k t r o l i t , BUN, k r e a t i n i n ,o s mo l a l i t a sd a nd e r a j a t k e a s a ma nv e n at i a p2 4 j a ms a mp a ik e a d a a ns t a b i l t e r c a p a i .S u mb e rl a i n me n y e b u t k a np e me r i k s a a ng u l a 6 d a r a ht i a p1 2 j a m. P e me r i k s a a nk a d a r g u l ad a r a hy a n g s e r i n ga d a l a hp e n t i n gu n t u kme n i l a i e k a s i p e mb e r i a n i n s u l i nd a n me n g u b a hd o s i si n s u l i nk e t i k ah a s i l n y a t i d a k me mu a s k a n .Ke t i k ak a d a rg u l ad a r a h 250 mg / d l , mo n i t o rk a d a rg u l ad a r a hd a p a t l e b i hj a r a n g(t i a p4 j a m) . Ka d a r e l e k t r o l i t s e r u md i p e r i k s ad a l a mi n t e r v a l 2 j a ms a mp a i 68j a mt e r a p i . J u ml a hp e mb e r i a nk a l i u m s e s u a i k a d a rk a l i u m, t e r a p i f o s f a t s e s u a i i n d i k a s i . T i t i k 135

t e r e n d a hk a d a r k a l i u md a nf o s f a t p a d as a a t t e r a p i t e r j a d i 7 4-6 j a ms e t e l a hmu l a i n y at e r a p i . Ko mp l i k a s i Te r a p i Ko mp l i k a s i y a n gp a l i n gs e r i n gd a r i KAD a d a l a h h i p o g l i k e mi ao l e hk a r e n ap e n a n g a n a ny a n gb e r l e b i h a n d e n g a ni n s u l i n ,h i p o k a l e mi ay a n gd i s e b a b k a no l e h p e mb e r i a ni n s u l i nd a nt e r a p i a s i d o s i s d e n g a nb i k a r b o n a t , d a nh i p e r g l i k e mi as e k u n d e ra k i b a tp e mb e r i a ni n s u l i n y a n gt i d a kk o n t i n us e t e l a hp e r b a i k a nt a n p ad i b e r i k a n i n s u l i ns u b k u t a n .Umu mn y ap a s i e n KAD y a n gt e l a h me mb a i k me n g a l a mih i p e r k l o r e mi ay a n gd i s e b a b k a n o l e hp e n g g u n a a nc a i r a ns a l i n ey a n gb e r l e b i h a nu n t u k p e n g g a n t i a nc a i r a nd a ne l e k t r o l i td a n nonanion gap metab olic acid osis s e p e r t ik l o rd a r ic a i r a ni n t r a v e n a me n g g a n t ih i l a n g n y ak e t o a n i o ns e p e r t ig a r a mn a t r i u m d a n k a l i u m s e l a ma d i u r e s i so s mo t i k . Ke l a i n a n b i o k e mi k a li n it e r j a d is e me n t a r ad a n t i d a ka d ae f e k k l i n i ks i g n i k a nk e c u a l ip a d ak a s u sg a g a lg i n j a la k u t 7 a t a uo l i g u r i ae k s t r e m. Ed e mas e r e b r i u mu mn y at e r j a d i p a d aa n a k -a n a k , j a r a n gp a d ad e wa s a . T i d a kd i d a p a t k a nd a t ay a n gp a s t i
T a b e l 3. Ko mp l i k a s i Ak i b a t P e n a t a l a k s a n a a nKAD5
Co mp l i c a t i o n Hy p o g l y c e mi a Hy p e r g l y c e mi a Hy p o k a l e mi a Hy p e r c h l o r e mi c a c i d o s i s Th r o mb o e mb o l i s m F l u i do v e r l o a d Ce r e b r a l e d e ma Hy p o x i a / a c u t e r e s p i r a t o r i d i s t r e s s s y n d r o me Ca u s e I n s u l i na d mi n i s t r a t i o n I n t e r r u p t i o no fi n s u l i n c o v e r a g e I n s u l i na d mi n i s t r a t i o n Bi c a r b o n a t e s u p p l e me n t a t i o n I n t r a v e n o u sNa Cl u i d s Ur i n a r yk e t o a c i dl o s s Hy p e r c o a g u l a b l es t a t e S e v e r ed e h y d r a t i o n I n t r a v e n o u su i d s Un k n o wn , p o s s i b l yd u e t or a p i dc o r r e c t i o no f h y p e r o s mo l a l i t y

mo r b i d i t a s p a s i e nKAD o l e hk a r e n ae d e mas e r e b r i p a d a o r a n gd e wa s a .Ge j a l ay a n gt a mp a kb e r u p ap e n u r u n a n k e s a d a r a n ,l e t a r g i ,p e n u r u n a n arousal, d a n s a k i t k e p a l a . Ke l a i n a nn e u r o l o g i sd a p a t t e r j a d i c e p a t , d e n g a n k e j a n g ,i n k o n t i n e n s i a ,p e r u b a h a np u p i l ,b r a d i k a r d i a , d a nk e g a g a l a nr e s p i r a s i . Me s k i p u n me k a n i s mee d e ma s e r e b r i b e l u md i k e t a h u i , t a mp a k n y ah a l i n i me r u p a k a n a k i b a td a r ima s u k n y ac a i r a nk es u s u n a ns a r a fp u s a t l e wa tme k a n i s me o s mo s i s ,k e t i k ao s mo l a r i t a sp l a s ma me n u r u ns e c a r ac e p a ts a a tt e r a p iKAD. Ol e hk a r e n a t e r b a t a s n y ai n f o r ma s i t e n t a n ge d e ma s e r e b r ip a d a o r a n gd e wa s a ,b e b e r a p ar e k o me n d a s id i b e r i k a np a d a p e n a n g a n a n n y a ,a n t a r al a i n p e n i l a i a n k l i n i sy a n g t e p a td i b a n d i n g k a nd e n g a nb u k t ik l i n i s .P e n c e g a h a n y a n gt e p a td a p a t me n u r u n k a nr i s i k oe d e ma s e r e b r i p a d ap a s i e nr i s i k ot i n g g i ,d i a n t a r a n y ap e n g g a n t i a n c a i r a nd a nn a t r i u ms e c a r ab e r t a h a pp a d ap a s i e ny a n g h i p e r o s mo l a r(p e n u r u n a nma k s i ma l p a d ao s mo l a l i t a s2 mOs m/ k g H2O/ j a m) ,d a np e n a mb a h a nd e x t r o s eu n t u k 7 h i d r a s i k e t i k ak a d a rg u l ad a r a hme n c a p a i 250mg / d l . Hi p o k s e mi ad a nk e l a i n a ny a n gj a r a n gs e p e r t i e d e ma p a r un o n k a r d i a k d a p a ts e b a g a ik o mp l i k a s i

P r e v e n t i o n / Co mme n t s Ch e c kb l o o dg l u c o s ee v e r yh r Lo w-d o s ei n s u l i np r o t o c o l Ov e r l a pi n s u l i ni n f u s i o na n ds u b c u t a n e o u s i n s u l i no n c ed i a b e t i ck e t o a s i d o s i sr e s o l v e Ch e c kp o t a s s i u me v e r y2 4 h r

S u p p l e me n t i fp o t a s s i u mi s< 5, 3 mEq / L
Re s o l v e sq u i c k l y F r e q u e n t l yc l i n i c a l l yi n s i g n i c a n t Nod a t at os u p p o r t p r o p h y l a c t i ca n t i c o l a g u l a t i o n Mo n i t o rt o t a l b o d yi n p u t a n do u t p u t Ch e c ks e r u ms o d i u me v e r y2 4 h r

Ch e c ks e r u mo s mo d i a l i t ye v e r y2 4 h r Re p l a c eu i d sg r a d u a l l y dd e x t r o s ei fg l u c o s ei s< 250mg / d l De c r e a s e do s mo t i cp r e s s u r e Ad Av o i dc h a r g i n gs o d i u ma t ar a t e> 1 mmo l / h r l e a d st oi n c r e a s e dl u n g Av o i dc h a n g i n go s mo l i a l i t ya t ar a t e> 3 mmo l / h r wa t e rc o n t e n t

J Peny Dalam, Volume 11 Nomor 2 Mei 2010

136

KAD. Hi p o k s e mi at e r j a d i me n g i k u t i p e n u r u n a nt e k a n a n k o l o i do s mo t i ky a n g me r u p a k a na k i b a tp e n i n g k a t a n k a d a r c a i r a np a d ap a r ud a np e n u r u n a ncompliance p a r u . P a s i e nd e n g a nKAD y a n gme mp u n y a i g r a d i e n t o k s i g e n a l v e o l o -a r t e r i o l a ry a n gl e b a ry a n gd i u k u rp a d aa wa l p e n e r i k s a a na n a l i s ag a sd a r a ha t a ud e n g a nr o n k ip a d a p a r up a d ap e me r i k s a a n s i kt a mp a k n y a me mp u n y a i 7 r i s i k ot i n g g i u n t u kme n j a d i e d e map a r u . RI NGKAS AN KAD a d a l a hk e a d a a nd e k o mp e n s a s ik e k a c a u a n me t a b o l i k y a n g d i t a n d a io l e h t r i a sh i p e r g l i k e mi a , a s i d o s i s ,d a n k e t o s i sy a n g me r u p a k a n s a l a h s a t u k o mp l i k a s ia k u t me t a b o l i kd i a b e t e s me l l i t u sy a n g p a l i n g s e r i u sd a n me n g a n c a m n y a wa . Wa l a u p u n a n g k ai n s i d e n n y ad iI n d o n e s i at i d a kb e g i t ut i n g g i d i b a n d i n g k a nn e g a r ab a r a t , k e ma t i a na k i b a t KAD ma s i h s e r i n gd i j u mp a i ,d i ma n ak e ma t i a np a d ap a s i e n KAD u s i amu d au mu mn y ad a p a t d i h i n d a r i d e n g a nd i a g n o s i s c e p a t , p e n g o b a t a ny a n gt e p a t d a nr a s i o n a l s e s u a i d e n g a n p a t o s i o l o g i n y a . Ke b e r h a s i l a np e n a t a l a k s a n a a n KAD me mb u t u h k a nk o r e k s i d e h i d r a s i , h i p e r g l i k e mi a , a s i d o s i s d a nk e l a i n a ne l e k t r o l i t ,i d e n t i k a s if a k t o rp r e s i p i t a s i k o mo r b i d ,d a ny a n gt e r p e n t i n ga d a l a hp e ma n t a u a n p a s i e nt e r u sme n e r u s .P e n a t a l a k s a n a a n KAD me l i p u t i t e r a p ic a i r a ny a n ga d e k u a t ,p e mb e r i a ni n s u l i ny a n g me ma d a i , t e r a p i k a l i u m, b i k a r b o n a t , f o s f a t , ma g n e s i u m, t e r a p i t e r h a d a pk e a d a a nh i p e r k l o r e mi ks e r t ap e mb e r i a n a n t i b i o t i k as e s u a i d e n g a ni n d i k a s i . F a k t o ry a n gs a n g a t p e n t i n gp u l au n t u kd i p e r h a t i k a na d a l a hp e n g e n a l a n t e r h a d a pk o mp l i k a s i a k i b a t t e r a p i s e h i n g g at e r a p i y a n g d i b e r i k a nt i d a kj u s t r ume mp e r b u r u kk o n d i s i p a s i e n . DAF T AR RUJ UKAN 1. S o e wo n d oP . Ke t o a s i d o s i sDi a b e t i k . I n : S u d o y o AW, S e t i y o h a d i B, Al wi I , S i ma d i b r a t aM , S e t i a t i h S ,e d i t o r s .Bu k ua j a rI l mu P e n y a k i tDa l a m.4t e d .J a k a r t a :P u s a tP e n e r b i t a n De p a r t e me nI l mu P e n y a k i t Da l a mF KUI ; 20 0 6. p . 1896-9.

Va nZy l DG. Di a g n o s i sa n dt r e a t me n t o f d i a b e t i c k e t o a c i d o s i s . S AF a mP r a c20 0 8; 50 : 39-49. 3. M a s h a r a n i U. Di a b e t i ck e t o a c i d o s i s . I n : Mc P h e e S J ,P a p a d a k i s M A, e d i t o r s . La n g ec u r r e n t h me d i c a ld i a g n o s i sa n dt r e a t me n t .49t e d .Ne w Yo r k : La n g e ; 20 10 . p . 1111-5. 4. Ch i a s s o nJ L. Di a g n o s i sa n dt r e a t me n t o f d i a b e t i c k e t o a c i d o s i s a n d t h e h y p e r g l y c e mi c h y p e r o s mo l a r s t a t e . Ca n a d i a n Me d i c a l As s o c i a t i o nJ o u r n a l 20 0 3; 168(7) : 859-66. 5. Ye h i aBR, Ep p sKC, Go l d e nS H. Di a g n o s i sa n d ma n a g e me n to fd i a b e t i ck e t o a c i d o s i si na d u l t s . Ho s p i t a l P h y s i c i a n20 0 8; 15: 21-35. 6. Ump i e r r e z GE, M u r p h y M B, Ki t a b a c h i AE. Di a b e t i c k e t o a c i d o s i s a n d h y p e r g l y c e mi c h y p e r o s mo l a rs y n d r o me . Di a b e t e sS p e c t r u m 20 0 2; 15(1) : 28-35. 7. Ame r i c a nDi a b e t e sAs s o c i a t i o n . Hy p e r g l y c e mi c c r i s i si nd i a b e t e s . Di a b e t e sCa r e20 0 4; 27(1) : 9410 2. 8. Al b e r t i KG. Di a b e t i ca c i d o s i s ,h y p e r o s mo l a r c o ma , a n dl a c t i cAc i d o s i s . I n : Be c k e r KL, e d i t o r . P r i n c i p l e sa n dp r a c t i c eo fe n d o c r i n o l o g ya n d d me t a b o l i s m. 3r e d .P h i l a d e l p h i a : Li p p i n c o t t Wi l l i a ms& W i l k i n s ; 20 0 4. p . 1438-49. 9. En n i sED, Kr e i s b e r g RA. Di a b e t i ck e t o a c i d o s i s a n dt h eh y p e r g l y c e mi ch y p e r o s mo l a rs y n d r o me . I n :Le Ro i t h D,T a y l o rS I ,Ol e f s k yJ M ,e d i t o r s . Di a b e t e s me l l i t u sa f u n d a me n t a la n dc l i n i c a l t e x t . 2nd e d . P h i l a d e l p h i a : Li p p i n c o t t Wi l l i a ms& Wi l k i n s ; 20 0 0 . p . 336-46. 10 . Wa l l a c e TM ,M a t t h e ws DR.Re c e n ta d v a n c e s i nt h e mo n i t o r i n ga n d ma n a g e me n to fd i a b e t i c k e t o a c i d o s i s . Q JM e d20 0 4; 97(12) : 773-80 . 11. T r a c h t e n b a r g DE. Di a b e t i c k e t o a c i d o s i s . Ame r i c a n F a mi l y P h y s i c i a n 20 0 5; 71(9) : 170 5-14. 12. Ki t a b a c h i AE, Wa l l BM . Ma n a g e me n t o f d i a b e t i c k e t o a c i d o s i s . Ame r i c a n F a mi l y P h y s i c i a n 1999; 60 : 455-64. 137

2.

P e n a t a l a k s a n a a n Ke t o a s i d o s i sDi a b e t i k(KAD) Wira Gotera, Dewa Gd e Agung Bud iyasa

13. Wo l f s d o r eJ W, Gl a s e rN, S p e r l i n gM A. Di a b e t i c k e t o a c i d o s i s i ni n f a n t s , c h i l d r e n , a n da d o l e s c e n t s . Di a b e t e sCa r e20 0 6; 29(5) : 1150 -6. 14. P o we r sAC.Di a b e t e sme l l i t u s .I n :J a me s o nJ L, e d i t o r . Ha r r i s o n se n d o c r i n o l o g y . Ne w Yo r k : Mc Gr a w-Hi l l ; 20 0 6. p . 283-332.

15. Gu n e y s e l O, Gu r a l pI , On u r O. Bi c a r b o n a t e t h e r a p yi nd i a b e t i ck e t o a c i d o s i s . Br a t i s l Le k Li s t y20 0 9; 10 9(10 ) : 453-4. 16. NN. Di a b e t i ck e t o a c i d o s i s ,e p i s t a x i s ,s e p s i s , d y s p n e u . Th eme d i c a ls t u d e n tf o r u m. Av a i l a b l e f r o m: h t t p / / . www. me d k a a u . c o m. Ac c e s s e d t h o n : 10 J u l y20 0 9.

138

J Peny Dalam, Volume 11 Nomor 2 Mei 2010