KETOASIDOSIS DIABETIKUM

&
HIPERGLIKEMIA HIPEROSMOLAR STATE
 KETOASIDOSIS DIABETIK

Ketoasidosis diabetik (KAD) adalah keadaan

dekompensasi metabolik yang ditandai oleh
hiperglikemia, asidosis dan ketosis.
Faktor Pencetus KAD
PATOGENESIS KAD DAN HHS
Gejala Klinis

 Mual dan muntah

 Polidipsi dan poliuri
 Sakit kepala
 Nyeri abdomen
 Sesak – nyeri dada
 Bibir kering
Pemeriksaan Fisik

 Takikardi dengan nadi yang lemah

 Dehidrasi – hipotensi
 Takipnea/ nafas Kussmaul/ sukar bernafas
 Nyeri abdomen
 Letargi sampai koma
Laboratorium

125-135
Kategori

Kategorisasi KAD oleh American Diabetes Association

 Ringan : pH darah berkurang antara 7.25 dan 7.30 (normal 7.35–7.45);
serum bikarbonat berkurang jadi 15–18 mmol/l (normal > 20); pasien masih
sadar
 Sedang : pH 7.00–7.25, bikarbonat 10–15, pasien merasa pusing dan
mengantuk
 Berat : pH < 7.00, bikarbonat < 10, keadaan pasien dapat stupor atau koma
Tatalaksana

 Medikamentosa
 Rehidrasi
 Insulin
 Kalium (kalau diperlukan)
 Bikarbonat
 Non-medikamentosa
 Edukasi
 Management of Adult Patients with DKA *

Complete initial evaluation. Start IV fluid: 1.0 L of 0.9% NaCl per hour initially

IV Fluids Insulin Potassium Asses Need for Bicnat

Determine hydration status IV Route SC/IM If serum K+ pH pH pH

Route <3.3 mEq/L <6.9 6.9-7.0 >7.0
Hold insulin
Hypovol Mild Cardio Insulin Insulin and give 40
mEq K+/h Dilute Dilute No
shock Hypo genic Regular Regular NaHCO3
(2/3 KCL and NaHCO3 HCO3
tension shock 0.15 U/kg 0.4 U/kg (100 (50
IV bolus ½ IV bolus 1/3 KPO4) until mmol) in mmol) in
½ IM or SC K > 3.3 mEq/L 400 ml 200 ml
0.9% H20 H20
NaCl Hemo infuse at infuse at
(1.0 L/h) Dynamic 0.1 U/kg/h 200 ml/h 200 ml/h
If serum K+
And/or monitoring RI IV 0.1 U/kg/h
5.0 mEq/L
Plasma infusion RI SC or IM
Do not give
expander K+ but check
If serum glucose does not fall K+ every 2 h Repeat HCO3 every 2 h
by 50 – 70 mg/dl in first hour Until pH>7.0. Monitor
serum K+
Evaluate corrected serum Na+
* ADA.Hyperglycemic Crises in Patients with Diabetes Mellitus.
Continued Diabetes Care 2002;25(S1):102
 If serum K+
 3.3
If serum glucose does not fall mEq/L but
Evaluate corrected serum Na+
by 50 – 70 mg/dl in first hour < 5.0 mEq/l,
give
20-30 mEq
Serum Serum Serum K in
Double insulin Give hourly IV insulin
Na+ high Na+ Na+ low Each liter of
Infusion hourly bolus (10 U) until
normal IV fluid
until glucose falls Glucose falls by
To keep
by 50-70 mg/dl 50-70 mg/dl
serum K at
4 – 5 mEq/l

0.45% NaCl 0. 9% NaCl

(4-14 ml/kg/h (4-14 ml/kg/h
Depending on Depending on
Hydration state Hydration state

Check electrolytes, BUN, creatinine and

When serum glucose reaches 250 mg/ml
Change to 5% Dextrose with 0.45% NaCl at
150-250 ml/h with adequate insulin (0.05- 0.1
U/kg/h IV infusion or 5-10 U SC every 2 h) to
keep the serum glucose between 150 and 200
mg/dl until metabolic control is achieved
glucose every 2-4 h until stable. After
resolution of DKA, if the patient is NPO,
continue IV insulin and supplement with SC RI
as needed. When the patient can eat, initiate a
multidose insulin regimen and adjust as
needed. Continue IV insulin infusion for 1-2 h
after SC insulin is begun to ensure adequate
plasma insulin levels. Continue to look for
precipitating cause (s).
HIPERGLIKEMIA HIPEROSMOLAR STATE

Suatu sindrom yang ditandai dengan

hiperglikemia berat, hiperosmolar,
dehidrasi berat tanpa ketoasidosis,
disertai penurunan kesadaran
FAKTOR PENCETUS HHS
GEJALA KLINIS

 Tidak ada riwayat DM

 Usia lanjut
 Poliuria
 Penurunan kesadaran
 Takikardia atau bradikardia
 Biasanya mual, muntah, nyeri abdomen
 Biasa terjadi pada orang tua yang mempunyai
penyakit penyerta seperti sepsis, infark miokard
Kriteria Diagnosis
- Hiperglikemia > 600 mg/dL
- Tidak ada riwayat DM
-Tidak ada Ketonemia
- Perubahan status mental

Diagnosis pasti ditegakan apabila terdapat diagnosis

klinis dan osmolaritas darah > 325 – 350 mOSM/L
Defisit Air dan Elektrolit
 Management of Adult Patients with HHS *

Complete initial evaluation. Start IV fluid: 1.0 L of 0.9% NaCl per hour initially

IV Fluids Insulin Potassium

Determine hydration status Insulin If serum K+

Regular <3.3 mEq/L
0.15 U/kg Hold insulin
Hypovol Mild Cardio IV bolus and give 40
shock Hypo genic mEq K+/h
tension shock (2/3 KCL and
1/3 KPO4) until
0.1 U/kg/h
K > 3.3 mEq/L
RI IV
0.9%
Hemo infusion
NaCl
(1.0 L/h) Dynamic
If serum K+
And/or monitoring
5.0 mEq/L
Plasma If serum glucose does not fall Do not give
expander by 50 – 70 mg/dl in first hour K+ but check
K+ every 2 h

Evaluate corrected serum Na+

* ADA.Hyperglycemic Crises in Patients with Diabetes Mellitus.
Continued Diabetes Care 2002;25(S1):102
 If serum K+
If serum glucose does not fall  3.3 mEq/L but
Evaluate corrected serum Na+ < 5.0 mEq/l, give
by 50 – 70 mg/dl in first hour
20-30 mEq K in
Each liter of IV fluid
Serum Serum To keep serum K at
Serum Double insulin 4 – 5 mEq/l
Na+ high Na+ Na+ low
normal Dose hourly
until glucose falls
by 50-70 mg/dl

0.45% NaCl 0. 9% NaCl

(4-14 ml/kg/h (4-14 ml/kg/h
Depending on Depending on
Hydration state Hydration state

Check electrolytes, BUN, creatinine and

When serum glucose reaches 300 mg/ml
Change to 5% Dextrose with 0.45% NaCl and
decrease insulin to 0.05- 0.1 U/kg/h IV infusion
to maintain serum glucose between 250 - 300
mg/dl until plasma osmolality is  315
mOsm/kg and patient is mentally alert
glucose every 2-4 h until stable. After
resolution of DKA, if the patient is NPO,
continue IV insulin and supplement with SC RI
as needed. When the patient can eat, initiate
SC insulin aor previous treatment regimen and
assess metabolic control . Continue to look for
precipitating cause (s).