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TATA LAKSANA KASUS

DIABETES KETO ASIDOSIS
RS ST. CAROLUS
1. Pengertian
Diabetic ketoacidosis (DKA) is a complex disordered metabolic state
characterised by hyperglycaemia, acidosis, and ketonaemia.
2. Anamnesis
The clinical presentation of DKA includes symptoms of hyperglycemia,
Kussmaul respiration, acetone-odoured breath, ECFV contraction, nausea,
vomiting and abdominal pain. There also may be a decreased level of
consciousness.
3. Pemeriksaan Fisik
These include osmotic diuresis due to hyperglycaemia, vomiting
commonly associated with DKA, and eventually, inability to take in fluid
due to a diminished level of consciousness.
4. Kriteria Diagnosis
Diagnostic criteria: all three of the following must be present
capillary blood glucose above 11 mmol/L
capillary ketones above 3 mmol/L or urine ketones ++ or more
venous pH less than 7.3 and/or bicarbonate less than 15 mmol/L
5. Diagnosis Kerja
Diabetic Ketoacidosis
6. Diagnosis Banding
Hyperosmolar Hyperglycemic State (HHS)
7. Pemeriksaan Penunjang

Blood ketones over 6 mmol/L

Bicarbonate level below 5 mmol/L

Venous/arterial pH below 7.1

Hypokalaemia on admission (under 3.5 mmol/L)

GCS less than 12 or abnormal AVPU scale

Oxygen saturation below 92% on air (assuming normal baseline

respiratory function)

Systolic BP below 90 mmHg

Pulse over 100 or below 60 bpm

Anion gap above16 [Anion Gap = (Na+ + K+) (Cl- + HCO3-) ]I

Initial investigations should include:

o Blood ketones
o Capillary blood glucose o Venous plasma glucose o Urea and
electrolytes
o Venous blood gases
o Full blood count
o Blood cultures
o ECG
o Chest radiograph
o Urinalysis and culture
8. Tatalaksana
Objectives of management include restoration of normal ECFV and
tissue perfusion; resolution of ketoacidosis; correction of electrolyte
imbalances and hyperglycemia; and the diagnosis and treatment of
coexistent illness.

Start intravenous fluids before insulin therapy.

Potassium level should be >3.3 mEq/L before the initiation of insulin
therapy (supplement potassium intravenously if needed).
Administer priming insulin bolus at 0.1 U/kg and initiate continuous insulin
infusion at 0.1 U/kg/h. Measure bedside glucose every 1 hour to adjust the
insulin infusion rate.
Avoid hypoglycemia during the insulin infusion by initiating dextrosecontaining fluids and/or reduction of insulin infusion rate until DKA is
resolved.
Transition to subcutaneous insulin only when DKA resolution is
established.
9. Edukasi
Discharge planning should include diabetes education, selection of an
appropriate insulin regimen that is understood by and affordable for the
patient, and preparation of supplies for the initial insulin administration at
home. Many cases of DKA can be prevented by better access to medical
care, proper education, and effective communication with a health care
provider during an intercurrent illness. Sick-day management should be
reviewed with all patients and include specific information on 1) when to
contact the health care provider, 2) blood glucose goals and the use of
supplemental short-acting insulin during illness, 3) insulin use during
fever and infection, and 4) initiation of an easily digestible liquid diet
containing carbohydrates and electrolytes. Most importantly, the patient
should be advised to never discontinue insulin and to seek professional
advice early in the course of the illness.

10. Prognosis
Mortality rates have fallen significantly in the last 20 years from 7.96% to
0.67% (Lin 2005). The mortality rate is still high in developing countries
and among non hospitalised patients (Otieno 2005).

11. Tingkat Evidens

Population- based studies range from 4.6 to 8 episodes per 1,000 patients
with diabetes (Johnson 1980, Faich 1983).