DIABETES MELITUS TIPE I

POST KETOASIDOSIS DIABETIKUM

Fachrezi Khatami dan Rizki Fadillah
Ilmu Kesehatan Anak
Pembimbing: dr. Yulisnawati, SpA(K)

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ANAMNESIS
 IDENTIFIKASI
Nama : An. ANQ
Usia : 12 tahun 5 bulan
Jenis Kelamin : Perempuan
Agama : Islam
Alamat : Ogan Komering Ilir
Suku : Palembang
MRS : 23 Juni 2019
No. Rekam medik: 0001117648
 ANAMNESIS
(Alloanamnesis, tanggal 2 Juli 2019)

Keluhan Utama: Sesak Nafas Riwayat Perjalanan Penyakit

• Penderita mengeluh sering haus, pasien

±2 minggu minum 2 liter per hari, sering terbangun
tengah malam untuk buang air kecil, nafsu
SMRS makan bertambah, sesak (-) demam (-)
penurunan berat badan (+). GDS 370 mg/dL

• Pasien berobat ke dokter umum untuk

±6 hari memeriksakan gula darah. GDS 500 mg/dL,
SMRS pasien diberikan obat penurun gula darah
(glukos).
4
 ANAMNESIS
(Alloanamnesis, tanggal 2 Juli 2019)

Keluhan Utama: Sesak Nafas Riwayat Perjalanan Penyakit

• ± 1 hari SMRS pasien mengeluhkan

±1 hari muntah ± 10 kali, satu kali muntah
SMRS sebanyak seperempat gelas belimbing, isi
muntah makanan yang dimakan.

±6 jam • Pasien mengeluh mual (+),

SMRS pandangan kabur (+).

5
 ANAMNESIS
(Alloanamnesis, tanggal 2 Juli 2019)

Keluhan Utama: Sesak Nafas Riwayat Perjalanan Penyakit

• keadaan pasien telah membaik sesak (-),

mual (-), polidipsi (+), poliuria (-),
±9 hari MRS polifagia (+), rasa lemah pada tubuh (-)
penglihatan kabur (-), keram otot (-).

6
Riwayat Penyakit
Riwayat Penyakit Dahulu
•Riwayat diare-dehidrasi pada maret 2019
•Riwayat SN = edema pada maret 2019
•Riwayat ISK + anemia pada april 2019

Riwayat Penyakit Keluarga

•Riwayat kakek menderita DM
•Riwayat paman menderita DM
Riwayat Penyakit
Riwayat Kehamilan dan Persalinan
Masa Kehamilan: Cukup bulan
Partus : Spontan, per vaginam
Tempat : Rumah Sakit
Ditolong oleh : Dokter
Tanggal :
BB : 3,300 g
TB : 49 cm
Lingkar kepala : 33 cm
Riwayat Makanan
ASI : 0-6 bulan
MPASI (bubur saring) : 6 bulan
Makanan keluarga : 12 bulan
PEMERIKSAAN
FISIK
 KHUSUS

KEPALA
Normocephali (lingkar kepala 33 cm), rambut hitam

• MATA : Mata tidak cekung, konjungtiva tidak anemis, sklera tidak ikterik, pupil isokor
3mm/3mm, injeksi konjungtiva (-), facial flush (-)

• HIDUNG : kavum nasi lapang, septum tidak deviasi, epistaksis (-)

• MULUT: Mukosa bibir kering, faring tidak hiperemis, Tonsil T1-T1 tenang, sianosis tidak ada,
gusi berdarah (-)

LEHER
• Simetris, tidak ada deviasi trakhea, tidak teraba pembesaran KGB
 KHUSUS ABDOMEN
Abdomen
THORAX
Paru-paru Jantung I: Datar
P: nyeri tekan (+), lemas, tur
I: Statis dan dinamis I: Tidak tampak ictus gor kulit baik, hepar dan lien
simetris, retraksi (-) cordis belum dapat dinilai.
P: Strem fremitus ka P: Thrill tidak teraba P: Timpani, asites (-)
nan=kiri P: Redup, dalam bat A: Bising usus (+) normal
P: Sonor di kedua la as normal
pang paru A: BJ I dan II reguler, EKSTREMITAS
A: Vesikuler (+) nor Gallop (-), Murmur (-) Edema (-), sianosis (-), capill
mal, ronkhi (-/-), whe
ary refill < 2 detik detik, akral
ezing (-/-)
hangat (+), ptekie (-).
STATUS NEUROLOGIKUS
Fungsi motorik Lengan Kanan Lengan Kiri Kaki kanan Kaki kiri
Gerakan Aktif Aktif Aktif Aktif
Kekuatan 5 5 5 5
Tonus Eutoni Eutoni Eutoni Eutoni
Klonus - - - -
Refleks fisiologis tidak dilakukan pemeriksaan
Refleks patologis tidak dilakukan pemeriksaan

GRM Tidak dilakukan pemeriksaan

Fungsi motorik Dalam batas normal

Nervi craniales Dalam batas normal
PEMERIKSAAN
PENUNJANG
PEMERIKSAAN PENUNJANG (1/7/19)
RBC : 3.87 x WBC : 5.49 x HT: 32%
Hb : 11.3 g/dl
106/mm3 103/mm3

GDS: 565 mg/dL

(23/6/19)
Trombosit (PLT) Kalium: 4.8 mEq/L
GDS: 161 mg/dL
253 x 103/uL (2/7/19 pukul 06.00)

PEMERIKSAAN
IMUNOSEROLO Dengue
DengueIgM
IgG
(+)(-) Dengue NS I Ag :
Hb-A1c : 10%
GI Reaktif
DAFTAR MASALAH

•
01
Haus
02
• Nyeri Perut
03 • Sering Kencing
04 • Sesak
DIAGNOSIS BANDING
01

02 1. Diabetes Melitus tipe 1

2. Diabetes Melitus tipe 2
03 3. Asidosis Metabolik
04
DIAGNOSIS KERJA
01
Diabetes Melitus tipe I
02
Post Ketoasidosis
03
Diabetikum
04
 TATALAKSANA
01
Insulin rapid
02 Cek BSS

03
Diet (45-40% karbohidrat, 15-20% protein,
04 30% lemak dan 10% snack diselingi)
Monitoring tanda hipoglikemia
 Diabetes melitus tipe I / IDD
Epidemiologi  98% DM pada anak dan remaja
Dulu dikenal  Juvenile M
onset diabetes atau Ketosis
prone diabetes.
Gejala klinis  tidak sama persis dengan tipe II. Pada
umumnya gejala klinis bersifat akut, dengan riwayat
klasik adanya poliuria, polidipsia, dan polifagia. Kehi
langan berat badan merupakan tanda yang khas.
 Patofisiologi
Pada DM tipe I, dikenal 2 bentuk dengan patofisiologi
– Tipe IA  genetik dan lingkungan mempengaruhi terjadinya kerusakan pankre
as. HLA-DR4 ditemukan mempunyai hubungan yang sangat erat

– Tipe IB  keadaan autoimun primer pada penderita yang juga sering menunju
kkan manifestasi autoimun lainnya, seperti Hashimoto disease, Graves diseas
e, pernicious anemia, dan myasthenia gravis. Keadaan ini berhubungan denga
n antigen HLA-DR3 dan muncul pada usia sekitar 30 - 50 tahun.

Pada DM tipe I cenderung terjadi ketoasidosis diabetik

Klasifikasi & Karakteristik D
iabetes Melitus
Diabetes melitus tipe I:
Destruksi sel beta, umumnya me
njurus ke defisiensi insulin absolu
t baik melalui proses imunologik
maupun idiopatik.
Pasien mewarisi kerentanan gene
tik yang merupakan predisposisi
untuk kerusakan autoimun sel be
ta pankreas. Respon autoimun di
pacu oleh aktivitas limfosit, antib
odi terhadap sel pulau langerhan
s dan terhadap insulin itu sendiri.
 Manifestasi klinis diabetes mellit
Manifestasi us tipe1
Patofisiologi

Polidipsia Karena peningkatan gula darah , air akan tertarik

keluar dari sel, menyebabkan dehidrasi intraselul
er dan stimulasi rasa haus di hipotalamus

Poliuria Hiperglikemia – glukosuria menyebabkan diuresis

osmotik
Polifagia Sel mengalami starvasi karena cadangan KH, lemak
dan protein berkurang (tidak ada pengisian depot
yang biasa dilakukan oleh insulin

Berat badan turun Cairan tubuh berkurang karena diuresis osmotik,

protein dan lemak berkurang karena dipecah
sebagai sumber energi
 GEJALA KLINIS
Polidipsi, poliuria, polifagia, berat badan turun
Hiperglikemia (≥ 200 mg/dl), ketonemia, glukosuri
a
Anak dengan DM tipe-1 cepat sekali menjurus ke-
dalam ketoasidosis diabetik yang disertai atau t
anpa koma dengan prognosis yang kurang baik
bila tidak diterapi dengan baik. Oleh karena itu,
pada dugaan DM tipe-1, penderita harus seger
a dirawat inap
 DIAGNOSIS
Anamnesis
Gejala klinis
Laboratorium :
– Kadar glukosa darah puasa >125 mg/dl dan 2 jam set
elah makan > 200 mg/dl.
– Ketonemia, ketonuria.
– Glukosuria.
– Bila hasil meragukan atau asimtomatis, perlu dilakuka
n uji toleransi glukosa oral (oral glucosa tolerance test
).
 PENATALAKSANAAN
Pada dugaan DM tipe-1 penderita harus segera rawat inap
.

Insulin
Dosis total insulin adalah 0,5 - 1 UI/kg BB/hari.
Selama pemberian perlu dilakukan pemantauan glukosa d
arah atau reduksi air kemih.
Gejala hipoglikemia dapat timbul karena kebutuhan insulin
berkurang. Pada keadaan ini, dosis insulin harus diturun
kan bahkan sampai kurang dari 0,5 UI/kg BB/hari, tetapi
sebaiknya tidak dihentikan sama sekali.
4 Pillars of good diabetes con
1. Diet
trol
2. Insulin

3. Exercise

4. Behavioural
 Diet
Jumlah kebutuhan kalori untuk anak usia 1 tahun sampai d
engan usia pubertas dapat juga ditentukan dengan rumu
s sebagai berikut :
1000 + (usia dalam tahun x 100) = ....... Kalori/hari
Komposisi sumber kalori per hari sebaiknya terdiri atas :
– 50-55% karbohidrat
– 10-15% protein (semakin menurun dengan bertambahnya umur)
– 30-35% lemak.
Pembagian kalori per 24 jam diberikan 3 kali makanan uta
ma dan 3 kali makanan kecil sebagai berikut :
• 20% berupa makan pagi.
• 10% berupa makanan kecil.
• 25% berupa makan siang.
• 10% berupa makanan kecil.
Technical issues:
2. Insulin
Storage
Expired
Injection sites (lipohypertrophy)

Non-adherence
skipping injections
wrong doses
 Terapi Insulin
Insulin replacement
Prandial (bolus) insulin
- to mimic response of e
ndogenous insulin to foo
d intake
Basal insulin
- small but constant release
of insulin that regulates li
polysis and output of hep
atic glucose
Konvesional insulins:
Insulin
Short acting (Actrapid, Humulin R)
digunaka 30 menit sebelum makan

Intermediate acting (Insulatard, Humulin N)

Newer Designer insulins:

Ultra-short acting (Novorapid, Lispro)

Basal analogues (Glargine, Detemir)

 Insulin regimens
Sehari 2 kali
Sehari 3 kali
Multiple dose regimen
 KOMPLIKASI
Komplikasi jangka pendek (akut) yang sering terjadi : hipoglikemi
a dan ketoasidosis
Komplikasi jangka panjang biasanya terjadi setelah tahun ke-5, b
erupa : nefropati, neuropati, dan retinopati. Nefropati diabetik
dijumpai pada 1 diantara 3 penderita DM tipe-1.
 PEMANTAUAN
Ditujukan untuk mengurangi morbiditas akibat komplikasi akut maupun kro
nis, baik dilakukan selama perawatan di rumah sakit maupun secara ma
ndiri di rumah, meliputi :
1. keadaan umum, tanda vital.
2. kemungkinan infeksi.
3. kadar gula darah (juga dapat dilakukan di rumah dengan menggunakan
glukometer) setiap sebelum makan utama dan menjelang tidur malam
hari.
4. kadar HbA1C (setiap 3 bulan).
5. pemeriksaan keton urine (terutama bila kadar gula > 250 mg/dl).
6. mikroalbuminuria (setiap 1 tahun).
7. fungsi ginjal.
8. funduskopi untuk memantau terjadinya retinopati (biasanya terjadi setel
ah 3-5 tahun menderita DM tipe-1, atau setelah pubertas).
9. tumbuh kembang.
 ANALISIS KASUS
• Anak ASQ, perempuan usia 12 tahun 5 bulan data
ng ke IGD RSMH pada tanggal 23 Juni 2019 deng
an keluhan sesak nafas sejak 6 jam sebelum masu
k rumah sakit. ± 2 minggu SMRS penderita meng
eluhkan sering haus, pasien minum 2 liter per hari,
sering terbangun tengah malam untuk buang air ke
cil, nafsu makan bertambah, sesak (-) demam (-) p
enurunan berat badan (+). Ibu pasien memeriksa
gula darah pasien dengan glucometer pribadi, dan
didapatkan hasil 370 mg/dL, pasien tidak berobat,
dan mencoba mengurangi makan makanan manis.
• ±6 hari sebelum masuk rumah sakit pasien berob
at ke dokter umum untuk memeriksakan gula dara
h, didapatkan hasil gula darah kisaran 500 mg/dL,
pasien diberikan obat penurun gula darah (glukos)
. ± 1 hari SMRS pasien mengeluhkan muntah ± 1
0 kali, satu kali muntah sebanyak seperempat gel
as belimbing, isi muntah makanan yang dimakan,
darah (-) muntah hitam (-), nyeri perut (+), mencre
t (-), sesak (-), pandangan kabur (-), keram otot (-)
rasa lemah pada tubuh (-). Lebih kurang 6 jam SM
RS pasien mengeluh mual (+), pandangan kabur (
+). Hari ke 9 Perawatan di RSMH, keadaan pasie
n telah membaik sesak (-), mual (-), polidipsi (+), p
oliuria (-), polifagia (+), rasa lemah pada tubuh (-)
penglihatan kabur (-), keram otot (-).
• Riwayat diare dan dehidrasi (+) bulan
maret 2019, Riwayat sindroma nefrotik
dan edema (+) bulan maret 2019, Riw
ayat ISK dan anemia (+) pada april 20
19. Riwayat penyakit yang sama pada
keluarga (+) pada kakek pasien dan p
aman pasien. Dari riwayat kebiasaan,
pasien jarang mengonsumsi makanan
manis dan berpengawet.
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