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Penatalaksanaan Terkini

Kegawatdaruratan pada Diabetes

Sarwono Waspadji

Pusat Diabetes dan Lipid,


Divisi Metabolik-Endokrin, Departemen Ilmu Penyakit Dalam,
FKUI / RSUPN Cipto Mangunkusumo,
Jakarta
Diabetic Complications

Acute Chronic :

Microangiopathy Macroangiopathy
• Hypoglycemia
• Diabetic Ketoacidosis = DKA
Retinopathy CAD
• Hyperosmolar Hyperglycemia Nephropathy PVD
Neuropathy Stroke
Nonketoric Coma = HHNC

• Metabolic Decompensation
Sebab
Sebab Kesadaran
Kesadaran Menurun
Menurun pada
pada Diabetes
Diabetes Melitus
Melitus

Ketoasidosis
Ketoasidosis Diabetik
Diabetik
Hiperosmolar
Hiperosmolar non
non Ketotik
Ketotik
Asidosis
Asidosis Laktat
Laktat
Hipoglikemia
Hipoglikemia
Sebab
Sebab Lain
Lain -- Trauma
Trauma
-- Obat
Obat
-- Penyakit
Penyakit Lain
Lain ::
Stroke
Stroke
Koma
Koma hepatik
hepatik
Uremik
Uremik
Diagnosis Banding Koma
Glukosa Keton Hipervent. Dehid. TD Kulit
mg/d L
DKA >300 +s/d4+ ++ ++ N/ hngt

HONK >500 0 s/d+ 0 +++ N/ N

Hipoglik < 50 0 0 0 N lmb

Asidosis
Laktat 20-200 trc s/d + +++ 0 Rnd hngt

Non N/ 0 s/d trc 0 s/d + 0 s/d + Variasi N


Metab
Hipoglikemia
Simtom:
Efek adrenergik alfa: sekresi insulin menurun,
cerebral blood flow meningkat
peripheral vasoconstriction
Efek adrenergik beta: glycogenolisis otot dan hati
stimulasi release glukagon
lipolisis
uptake glukosa otot menurun
increase c.o.p, cerebral flow
Efek adrenomedullary discharge of Catecholamine
augmentasi efek adrenergik
alfa dan beta

Gejala neuroglikopenik, gejala adrenergik


Hipoglikemia kronik berkepanjangan - demensia
Kadar Glukosa Darah dan Gejala Hipoglikemik Akut

g 72
l
u ................................................................. Neuroglikopenia
k 54 Disfungsi Kognitif ringan
o
................................................................ Aktivasi gejala
s
Keringat autonomik
a 36 Gemetar
.....................................Berdebar ...... Neuroglikopenia
d berat
a 18 Kejang
r ............................................................... Koma
a
h Waktu
Respons Perubahan Hormonal pada Hipoglikemia:
Penurunan sekresi insulin
Peningkatan katekolamin dan epinefrin
Peningkatan sekresi glukagon
Peningkatan sekresi kortisol
Peningkatan hormon pertumbuhan

Diagnosis Relatif mudah: pemeriksaan GD


Trias Whipple:
Keluhan dan gejala hipoglikemia s/d kesadaran menurun,
Kadar Glukosa < 45 mg/dL (pada wanita dapat < 30 mg/dL),
Bangun kembali setelah diberikan glukosa

Perlu pemantauan yang lama jika pasien memakai obat long


acting
Jika hipoglikemia berkelanjutan dapat menyebabkan
kerusakan otak permanen, demensia
Penatalaksanaan Hipoglikemia
Ringan: Berikan gula murni (bukan pemanis) yang
cukup sampai keluhan hilang
Pastikan pemberian makanan / kalori cukup
untuk selanjutnya, terutama jika OAD long acting
Berat: Berikan glukosa 40 % IV sampai pasien sadar
Berikan infus rumatan D10 6-8 jam perkolf
cek glukosa darah setiap jam
jika < 100 mg/dL berikan kembali bolus D40
Jika sudah 2 kali berturut-turut >100 mg/dL, setiap 2 jam
Jika sudah 2 kali berturut-turut > 100 md/dL, setiap 4 jam,
dst sampai yakin bahwa kadar glukosa darah stabil aman

Perhatikan obat hipoglikemik yang dipakai:


Obat kerja panjang, pemantauan dapat lama, berhari
Perhatikan pula fungsi ginjal dan hati dan usia pasien
Oral Antidiabetic Agents: side
effects

TZ s ase
to id
s
ue

bi os
in
og

hi c
r
rm

in glu
cr lin

s
ag

D
fo
se s u

-
et

et
In

M
Risk of hypoglycaemia  – – –
Weight gain  – – 
Gastrointestinal –   –
side-effects
Lactic acidosis – * – –
Oedema – – – 
Anaemia –  – 

*Observed in patients with renal impairment Adapted from DeFronzo RA. Ann Int Med. 1999; 131: 281–303.
Principles in Selecting
Antihyperglycemic Interventions
• Effectiveness in lowering blood glucose
• Extraglycemic effect that may reduce
longterm complications
• Safety profile
• Tolerability
• Ease of use
• Cost
Nathan DM et al. Clinical Diabetes. 2009; 27 (1): 4-16
Algorithm for Management of Type 2 DM without Metabolic Decompensation
Indonesian Society of Endocrinology 2007
Diagnosis Type 2 DM

Lifestyle changes

Blood Glucose Monitoring


A1C (%)* (FPG, PPG, Bed time)

<6.5 6.5-7 7-8 8-10 >10

Monotherapy* : Oral Combination Combination Insulin Therapy:


•Metformin Oral## : Oral+Insulin : •Short/Rapid-acting
Continue •AGI •SU •Metformin Insulin analog
•TZD •Metformin •TZD •NPH or
Specific Condition: •AGI •SU Long-acting
•SU •TZD •Long-acting Insulin
•Meglitinides •Meglitinides Insulin •Pre-mixed
•Short/Rapid-acting Specific condition: •Short/Rapid-acting Insulin analog
Insulin analog •Short/Rapid-acting Insulin analog In selected Patients
Insulin analog •Pre-mixed with A1C> 10%
•Pre-mixed Insulin analog OHO Combination
Target Target Insulin analog •NPH might be effective
Achieved not •Other Combination
Achieved

Target Target
Continue Target
Achieved not Target
Treatment Intensification Target Target not
Achieved Achieved
Therapy OR Achieved not Achieved
Achieeved
Continue
Treatment Continue
Intensification
Continue Treatment
Therapy OR
Treatment Intensification
*surrogate average blood glucose Therapy OR Intensification of
Insulin Treatment
might be used Basal+bolus
Management of Hyperglycemia
In Patients
General Principles:
Maximal blood glucose control, avoiding
hypoglycemia
Meticulous, Prudent, Individualized
Management of T2DM synchronized with other
disease management
In critically ill patients, more over in
metabolic decompensation, the blood
glucose target should be more
aggressive and achieved quicker
Sasaran Glukosa darah yang dianjurkan

Pasien Tidak Kritis : Senormal mungkin


(110 – 180 mg/dL)
Insulin mungkin diperlukan
Sedekat mungkin dengan 130 mg/dL
Pasien Kritis: Senormal mungkin
(110 – 180 mg/dL)
Umumnya memerlukan insulin
Sedekat mungkin dengan 110 mg/dL
* Beberapa Institusi mungkin menganggap nilai ini
terlalu over agresif karena kepedulian akan risiko hipoglikemia

A D A Clinical Practice Recommendation


Diabetes Care. 2007;3(suppl 1): S 32-33
The Nice-Sugar Study
ICU setting 3 or more consecutive days
Intensive (81-108 mg/dL)
Conventional (<180 mg/dL)
Outcome mortality at 90 days
3054 intensive control vs. 3050 conventional
Similar characteristic baseline
Primary outcome available for 3010 and 3012 respectively

829 (27.5 %) mortality in intensive control, OR 1.14


751 (24.9%) mortality in conventional group

Severe hypoglycemia (< 40 mg/dL)


206 (6.8%) in intensive control
15 (0.5 %) in conventional group
The NICE Sugar study investigators.
Intensive vs. conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-97
Blood Glucose Target
Critically ill surgical patients: as normal as possible
(110 – 140 mg/dL)*
Insulin is needed, IV protocol
Close to 110 mg/dL (A)
Critically ill non surgical pts: as normal as possible
(110 – 140 mg/dL)*
Insulin is needed, IV protocol
Keep BG < 140 mg/dL (C)
Non critically ill: as normal as possible, no specific goals
Insulin is preferred
FBG <126 mg/dL, Random BG<180-200 mg/dL (E)

* Some institutions might considered this blood glucose target as


over aggressive due to their cautious attitude toward hypoglycemia
Pemantauan kadar glukosa darah harus cermat
A D A Clinical Practice Recommendation
Diabetes Care. 2009;32(suppl 1): S 32-33
Hyperglycemia states Metabolic Acidosis states
•DM •Lactic acidosis
•HHNC •Hyperchloremic acidosis
•IGT •Salicylism
•Stress •Uremic acidosis
•Drug-induced
acidosis
Hyper-
glycemia Acidosis

DKA

Ketosis
Ketotic states
•Ketotic hypoglycemia
•Alkaholic ketosis
•Starvation ketosis
Kitabchi and Wall
DKA Episode and Mortality Rate at Dr.
Cipto Mangunkusumo Hospital, Jakarta

Year Number of Cases Mortality rate %

1983-84 (9 months) 14 31,4


1984-88 (48 months) 55 40
1995 (12 months) 17 -
1997 (6 months) 23 18,7
1998-99 (12 months) 37 51
2002 (5 months) 39 15
Pathogenesis of DKA and HHNC

HHNC
DKA
Precipitating Factors of DKA & HHNC
 Infection
 Cerebro vascular accident
 Pancreatitis
 Myocardial infarction
 Trauma
 Medication
 Newly diagnosed type 1 diabetes
 Discontinuation of or inadequate insulin
 Substance abuse
 Not found
Clinical Features of DKA
• Polyuria and nocturia • Abdominal pain
• Weight loss • Leg cramps
• Weakness • Nausea and vomiting
• Blurred vision • Confusion and
• Kussmaul respiration drowsiness
• Coma
DKA HHNC

HHNC
HHNC
Principal Management of DKA and HHNC
Management
Management of
of DKA
DKA
at
at Cipto
Cipto Mangunkusumo
Mangunkusumo Hospital,
Hospital, Jakarta
Jakarta

Hour
Hour Hydration
Hydration Insulin
Insulin K
K++Correction
Correction HCO3--correction
HCO3 correction
A
A B
B C
C D
D E
E
00 guyur
guyur 50
50 mEq
mEq per
per IfIf pH
pH
•• guyur
guyur six
six hour
hour <7
<7 7-7.17-7.1 >7.1
>7.1
•• guyur
guyur Start
Start hour
hour 22
iv
iv bolus
bolus iv,
iv,
Cont
Cont by by infusion
infusion
dst
dst dst
dst dst
dst
Penatalaksanaan Ketoasidosis Diabetik
1. Rehidrasi Cepat
* 1 jam 2 kolf, 1 jam 1 kolf, dst
* Na Cl Fisiologis
* 1/2 N, 2A - Kalau Na > 150 mek/l
2. Insulin
Bolus 10 U IV. G.D setiap jam
Drip 5 U/jam sampai g.d. < 200 mg/dl - D5 %
Drip 2,5 U/jam sampai g.d. stabil 200 - 300 mg/dl
Drip 1 U/jam + sliding scale g.d. tiap 4 jam
Dosis terbagi 3-4 kali sehari
***Dosis Kecil 5 U IM *** Pemantauan dengan Urin
3.Kalium < 3,5 mek/L -- 50 mek/L 4. Na HCO3
3,5 - 5 mek/L -- 25 mek/L pH < 7 - 7,1
>5 mek/L -- 0 5. Faktor Presipitasi
Suhendro 2008
Pengukuran asam laktat perlu pada pengelolaan KAD
Serum laktat > 4 mmol/L petanda prognostik buruk
Jika disertai kesadaran menurun prognostik buruk

Perlu pengelolaan yang ketat sejak awal


Pasang CVP segera
Hidrasi dicapai dengan lebih cepat
Prevention (1)
• Better access to medical care
– Intensive patients education
– Effective communication  acute illness
• Review sick-day management
– Insulin treatment
– Blood glucose goal
– Treat fever and infection
– Start easy digestible liquid diet
• Do not stop insulin or oral anti diabetes
Prevention (2)
• Increase BG monitoring during acute
illness
• Check ketone bodies (either urine or
blood) when BG > 300 mg/dL
Peran Dokter Umum
Pencegahan terjadinya Hiperglikemia
dengan mengelola DM sebaik-baiknya
mencegah komplikasi kronik
mencegah komplikasi akut DKA
menghindari komplikasi hipoglikemia
Jika menjumpai pasien tersangka
komplikasi akut:
Pastikan bukan hipoglikemia, kalau ragu,
jangan takut memberikan D40
Jika bukan hipoglikemia, tetapi KAD:
Infus NaCl dan segera kirim ke RS
Jikalau ada (misal di RS primer)
dapat diberikan insulin, kemudian rujuk
Memerlukan perawatan yang cermat, segera
di RS dengan peralatan yang memadai
Hatur Nuhun

Hibiscus rosasinensis

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