Ketoasidosis

Diabetikum
Disusun oleh: Clarissa Tania (00000002743)
Pembimbing: dr. Anggun Mekar Kusuma, Sp.PD
 “
Komplikasi akut & emergensi pada DM

Asidosis

Ketosis Hiperglikemia
 Definisi dan Klasifikasi
KAD SHH
Ringan Sedang Berat
Glukosa plasma (mg/dL) >250 >250 >250 >600
pH arterial 7.25- 7.00-7.24 <7.00 >7.30
7.30
Bikarbonat serum (mEq/L) 15-18 10 - <15 <10 >18
Keton urin* + + + Kecil
Keton serum* + + + Kecil
Osmolalitas serum efektif Beragam Beragam Beragam >320
(mOsm/kg)
Anion gap >10 >12 >12 Beragam
Perubahan sensoria / Sadar Sadar/drowsy Stupor/koma Stupor/koma
obtundasi mental
 Epidemiologi

1996 +35% 2006

Presentase KAD berdasarkan tipe DM Presentase KAD berdasarkan
jenis kelamin

DMT 2
34% Peremp Laki-
uan laki
50% 50%
DMT 1
66%

Presentase KAD berdasarkan usia

<20
tahun
20%

20-44
45-65 tahun
tahun 56%
24%
 Etiologi dan Faktor Risiko

Terapi insulin Penyakit akut

Infeksi (30-40%)
inadekuat dan Stroke
nonkomplians Infark miokardium
Pankreatitis akut

STRESS

Diabetes onset baru Obat

Clozapine Olanzapine
Kokain
Lithium
Terbutaline
 Patogenesis

Hormon
kontraregulator

Net effect insulin

 Gangguan utilisasi
glukosa
jaringan perifer

Peningkatan Peningkatan
Glukoneogenesis Glikogenolisis
Gambar 2. Patogenesis KAD dan KHH
Gambar 3. Mekanisme produksi badan keton
Tabel 3. Defisit air dan elektrolit pada presentasi KAD dan SHH5

Parameter DKA SHH

Air, mL/kg 100 100
Natrium, mmol/kg 7-10 5-13
Kalium, mmol/kg 3-5 5-15
Klorida, mmol/kg 3-5 3-7
Fosfat, mmol/kg 1-1.5 1-2
Magnesium, mmol/kg 1-2 1-2
Kalsium, mmol/kg 1-2 1-2
 Presentasi Klinis

Evaluasi Awal Gejala asidosis Gejala hiperosmolar

◉ Status ABC (airway, ◉ Mual ◉ Clouding of

breathing, ◉ Muntah sensoria
circulation) ◉ Koma
◉ Nyeri perut
◉ Status mental
◉ Pencetus
◉ Status volume
 Evaluasi Awal

◉ Status ABC (airway, breathing, circulation)

◉ Status mental
◉ Pencetus
◉ Status volume

Gejala DM Gejala asidosis Gejala hiperosmolar

◉ Polidipsia ◉ Mual ◉ Penurunan

◉ Polifagia ◉ Muntah kesadaran
◉ Poliuria ◉ Nyeri perut
Perubahan Bau keton
kesadaran

Kussmaul
breathing Takikardia

Nyeri perut

Tanda dehidrasi
 Evaluasi Laboratorium

◉ Glukosa serum ◉ Plasma osmolalitas

◉ Elektrolit serum (dengan
perhitungan anion gap)
◉ Urinalisis, keton urin dipstick
◉ Keton serum (keton urin +)
◉ BUN, dan kreatinin serum
◉ Hitung darah lengkap
dengan hitung jenis
◉ Gas darah arteri
◉ Elektrokardiogram
◉ Kultur
◉ Lipase dan amilase,
◉ Rontgen dada
Positif palsu
• Sulfihidril
• Penisilamin

Negatif palsu
• Tidak mendeteksi Beta-hidroksibutirat
Anion gap = Na serum - (Cl + HCO3 serum)
 Kalium

Defisiensi insulin Asidemia Hipertonisitas

Diuresis Osmotik Ekskresi anion ketoasid GI loss

Diagnosis diferensial
Tatalaksana
 Bikarbonat

pH >7.0 pH <6.9-7.0 pH >7.0

50 mmol HCO + 100 mmol HCO

Tidak diberi 200 ml saline + 400 ml saline
HCO3
(200ml/jam) (200ml/jam)
 Kalium

<3 mEq/L 3-5 mEq/L >3 mEq/L

Stop insulin Beri 20-30 mEq/jam Jangan beri K+ tapi

Beri 20-30 mEq/jam untuk menjaga K+ 4- cek serum K+ per 2
sampai K+>3 mEq/L 5 mEq/L jam
 Pemantauan

◉ TTV
◉ per 30 menit (jam pertama),
◉ per jam (4 jam berikutnya)
◉ per 2 – 4 jam (berikutnya)
◉ Urine output per jam
◉ Glukosa darah kapiler per jam
◉ Elektrolit setiap
◉ per 1 jam (2 jam pertama)
◉ per 4 jam
◉ pH vena/arteri per 4 jam
 Komplikasi

◉ Hipoglikemia dan hipokalemia

◉ Edema serebral
◉ ARDS
 Daftar Pustaka

◉ Kitabchi, A., Umpierrez, G., Miles, J. and Fisher, J. (2009). Hyperglycemic Crises in
Adult Patients With Diabetes. Diabetes Care, 32(7), pp.1335-1343.
◉ Hirsch, IB. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults:
Epidemiology and pathogenesis. In: UpToDate, Post, TW (Ed), UpToDate, Waltham,
MA, 2018.
◉ Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic
Ketoacidosis (DKA), And Hyperglycemic Hyperosmolar State (HHS) [Updated 2015
May 19]. In: De Groot LJ, Chrousos G, Dungan K, et al., editors. Endotext [Internet].
South Dartmouth (MA): MDText.com, Inc.; 2000-.
◉ Gropper, S., Smith, J. and Carr, T. (n.d.). Advanced nutrition and human metabolism.
◉ Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar
state. Chiasson, JL, et al. 7, April 1, 2003, Canadian Medical Association Journal, Vol.
168, pp. 859-866
◉ Hirsch, IB. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults:
Clinical features, evaluation, and diagnosis. In: UpToDate, Post, TW (Ed), UpToDate,
Waltham, MA, 2018.
◉ Van Zyl, D. (2008). Diagnosis and treatment of diabetic ketoacidosis. South African
Family Practice, 50(1), pp.35-39.
◉ Diabetic ketoacidosis in type 1 and type 2 diabetes mellitus: Clinical and biochemical
differences. Newton, Christopher A and Raskin, Phillip. September 27, 2004, Archive
of Internal Medicine, Vol. 164, pp. 1925-1931.
◉ Brewster, S., Curtis, L. and Poole, R. (2017). Urine versus blood ketones. Practical
Diabetes, 34(1), pp.13-15.
◉ Casteels, K. & Mathieu, C. Rev Endocr Metab Disord (2003) 4: 159.
◉ Hirsch, IB. DDiabetic ketoacidosis and hyperosmolar hyperglycemic state in adults:
Treatment. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2018.
◉ Bohn, D. and Daneman, D. (2002). Diabetic ketoacidosis and cerebral edema. Current
Opinion in Pediatrics, 14(3), pp.287-291.
◉ Vavilala, M. S. (2014). In Response to: “Hypertonic saline therapy for cerebral edema
in diabetic ketoacidosis: no change yet, please.” Pediatric Critical Care Medicine : A
Journal of the Society of Critical Care Medicine and the World Federation of Pediatric
Intensive and Critical Care Societies, 15(3), 286.
◉ Sudhanshu, S., Jevalikar, G., Das, P., Singh, P., Bhatia, E. and Bhatia, V. (2015).
Acute Respiratory Distress Syndrome: A Rare Complication in Pediatric Diabetic
Ketoacidosis. The Indian Journal of Pediatrics, 83(5), pp.463-465.
THANKS!
Any questions?