Acute Complication of Diabetes – dr. Fitria
Benda keton
Komplikasi akut pada diabetes adalah komplikasi yang
terjadi dalam waktu singkat, meliputi diabetes
ketoasidosis (DKA), hiperglikemia dan kondisi
hiperosmolar/nonketotik (HHNK), dan hipoglikemia.
Hipoglikemia terjadi karena penggunaan insulin yang
berlebih, efek samping insulin, overdosis insulin
(berhubungan dengan terapi nanti). Hipoglikemi
berbahaya, karena jika 5 menit saja otak tidak dapat
asupan gula, maka akan terjadi penurunan kesadaran,
bahkan berujung kematian.
A. Diabetic Ketoacidosis
Terjadi ketika sel otot menjadi sangat kelaparan
(sangat butuh energi) dan menyebabkan tubuh
menggunakan “energi emergensi” dengan memecah
lemak yang terdapat benda keton. Glukoneogenesis
membongkar lemak dan membongkar protein sebagai
cadangan akhir benda keton.
Biasanya terjadi pada pasien DM tipe 1, terdapat
gangguan produksi sel. Keadaan di mana tidak
cukupnya insulin untuk menyeimbangkan kenaikan
gula darah
(1) bisa karena extreme stress or illness that leads to
infection and body will produce adrenaline.
When stressed, the body prepares itself by ensuring
that enough sugar or energy is readily available.
Insulin levels fall, glucagon and epinephrine
(adrenaline) levels rise and more glucose is released
from the liver. At the same time, growth hormone and
cortisol levels rise, which causes body tissues (muscle
and fat) to be less sensitive to insulin. As a result,
more glucose is available in the blood stream.
(2) atau karena lupa mengonsumsi insulin
1. Patofisiologi
Na berhubungan dengan osmolalitas.
bersifat asam, tubuh kita punya range normal pH yaitu
7.35-7.45, kalau keton dalam darah terlalu asam
jadinya asidosis. Kalau ada keton di darah, akan
akibatkan ketonuria (untuk mendeteksi); standar DAK
ya keton di dalam darah. Kalau ini berlanjut maka bisa
berujung passed out.
Our bodies live and die at the cellular level. The
billions of cells in our bodies must maintain alkalinity,
in order to function and stay alive. The first line of
defense against disease is a proper pH balance.
Disease can only grow in an acidic body, which makes
a condition favorable for the growth of bacteria,
yeast, fungus, mold, viruses, and any other unwanted
organisms. Cancer always strikes those with an over-
acidic body. 
An acidic state causes a lack of oxygenation at the
cellular level. When the pH level falls below 7.4, there
is less than the maximum oxygen in the blood. Blood
carries the maximum oxygen at pH 7.4 (alkaline).
Without proper oxygenation, unfriendly bacteria,
mold, and viruses will prosper.
When the human body is in an acidic state, it will try
to shield itself from the damaging acid by storing the
acid in fat cells. The body tries to prevent the acid
from eating holes in tissues. When the acid level is
high in the body, calcium is also depleted. Your body
may make fat cells in order to store unwanted acid for
its own protection. This process may save your vital
organs from severe damage. By returning to a
balanced pH level, you may lose unwanted fat cells.
Osteoporosis is an acidic problem. As the body
becomes more acidic, calcium is depleted. The body
will then leach calcium from bones, teeth, and tissue
to make up for this loss. One of the first warning signs
is calcium deposits in the body, which come from the
calcium in our teeth and bones and not from Infeksi 40%, infeksi saluran kemih, missed insulin
nutritional calcium.  treatment 25%, previously unknown diabetes 15%,
lainnya 20%.

Associated causes: myocardial infarction, trauma

Untuk diagnosis DKA ada 3, yaitu acidemia (dalam (kepala), stress, surgery, complicated pregnancy,
darah), ketonimia (ph <7), hiperglikemia. cerebrovascular accident. Produksi urin normal

2. Sign and Symptom

Terjadi polyuria dan polydipsia (enuresis/ngompol),

dehidrasi (dicirikan dengan takikardi dan
orthostasis/posisi yag kalo duduk trs langsung bangun
jadi berkunang kunang), abdominal pain (adanya
nausea and vommiting), fruity breath (bau acetone),
kussmaul breathing (napas cepat dan dalam), change
in mental status (coma, combative/agressive).

3. Precipitationg Factor

25% terjadi pada penderita DM tipe 1 (ga tau

awalnya), 40% karena infeksi, bisa juga karena obat
(steroids/hormon antiperadangan antiinflamasi,
thiazides/obat hipertensi, bobutamine/obat perkuat
kontraksi jantung, dan turbutaline/obat asma), insulin
tidak teratur karena takut hipoglikemi dan takut berat
badan naik, stress karena chronic disease.

4. Diagnosis

- Dehydration
- Acidotic/Kussmaul breathing with fruity smell, tergantung berat badan, gender (0.5-1cc/kgBB/jam).
- abdominal pain/ditention, vomiting,
K+? Kalo K+ kurang dari 3.3 maka jangan diberikan
- altered mental status ranging from disorientation
insulin dulu. Na K, untuk transport ion, dan banyak
to coma
terdapat di tubuh, yg paling penting di otot jantung,
+ Hyperglycemia >300mg/dL and glucosuria berujung pada aritmia kalau terganggu (terlalu rendah
+ Ketonemia and ketonuria K). Hubungan K dengan insulin: tiap kali glukosa
+ Metabolic acidosis pH <7.25, serum bicarbonate insulin mengalami binding, ketika masuk ke dalam sel
<15mmol/L, anion gap >10 akan terdapat pengiring, yaitu K. Kalau K nya kurang
dan ttp ditambah insulin, maka akan semakin rendah
Anion gap: [Na]+[K]-[Cl]+[HCO3]  berbedaan
K nya. Makanya kalau hiperkalemi, dikasihnya gula
natrium dengan kalium
dan insulin juga.
5. Komorbiditas
B. Hyperglycmia Hyperosmolar State/Nonketotic
A high lever of blood glucose may interfere blood
circulation (level >600mg/dL) tinggiiiiiiii bgt gulanya,
darah mengental; glucose uptake by the cells
decreases, the glucose passed from blood to urine
causing dehydration by drawing tremendous amounts
of fluid from the body (hiperosmolar). It’s common in
DM type 2 patient. Trigger factor: high-dose steroid,
diuretics, infection, illness, stress or drinking excessive
alcohol.

1. Patophysiology

Pasien biasanya datang dengan keadaan tidak

sadar.

C. Hypoglycemia

Adalah situasi klinis dengan ditandai penurunan

konsentrasi gula darah yang dapat menyebabkan
munculnya gejala dan tanda (a level that may induce
symptms or signs); ditandai juga dengan penurunan
kesadaran dan mengubah stimuasi saraf simpatis,
mengubah sistem hormon adrenalin (cemas,
berdebar, berkeringat, tremor) yang biasanya
meningkat ketika dalam keadaan
stress/hipermetabolisme/jadi resmponsif dan aware.
Plasma glucose level less than 50mg/dL is generally
considered the threshold. Hypoglycemia typically
arises from abnormalities in the mechanism involved
in glucose homeostasis.

1. Whiple Triad

The documentation of low blood sugar; presence of

symptoms; reversal of these syptoms when the blood
sugar level is stored to normal. Dikasih permen, bukan
roti gandum or other source of carbs; krn beda
polisakaridanya, permen lebih sederhana, dan
harusnya membaik gejalanya.
 2. Physiology d. Autoimmune hypoglycemia: insulin antibodies
and insulin receptor antibodies
e. Hormonal deficiency: hypoadrenalism
(corlisol), hypopituitarism (growth hormone in
children), glucagon deficiency, epinephrine.
f. Critical illnesses: cardiac, hepatic, renal
disease, sepsis with multiorgan failure
g. Pregnancy, exercise, starvation
h. Renal glycosuria
i. Ketotic hypoglycemia of childhood
j. Adrenal insufficiency
k. Hypopituitarism

4. Treatment

Dexitrose: 25g IV bolus slowly

Glucagon: for unconcious patients at home or if IV

access is difficult, 0.5 to 1mg IM/subcutaneously,
Mekanisme glukoneogenesis may repeat in 20min

Penurunan pada subkutan/periferal, induce sinyal ke Oral Glucose: for concious, cooperative patients,
otak, resulting in rasa makan/lapar. Kalau lapar + chewable glucose tablets 25 to 100g
hipoglikemi, otomatis akan mendatangkan
Target gula >70mg/dL biar nyampe ke otak cui
mekanisme blocking insulin; maka kontrainsulin akan
keluar yaitu glukagon, ia yang akan merangsang 5. Complication
pelepasan glukosa dari liver/hati.
Acute sequelae could lead to coma, cardiac
3. Ethiology dysrithmia, and death; the risk of permanent
neurologic deficits increases with prolonged
a. Fasting Hypoglycemia hypoglycemia (memory impairment, diminished
language skills, ataxia); cardiovascular event.
- Nesidioblastosis is a rare cause of fasting
hypoglycemia in infants and are rare in adults
- Inherited liver enzyme deficiencies that restrict
hepatic glucose release (deficiency of glucose-6-
phosphatase, fructose-1,6-diphosphatase, pyruvate
carboxylase, phosphorylase, glycogen synthase)

b. Drugs

Ethanol (alkohol, efek ke liver), haloperidol, quinine,

sallcylates, sulfonamides; oral hypoglycemic,
phenylbutazone, p-aminobenzoic acid, methanol,
isoniazide, triciyclic antidepressant, fluoxatine,
sertraline, , thiazide diuretics, lithium.

c. Endogenous insulin or insulin-receptor-

mediated hypoglycemia

- Insulin-producing tumours of pancreas (islet cell

adenoma or carcinoma/insulinoma)
- Non-beta-cell tumor