KETOASIDOSIS DIABETIK:

TATALAKSANA DI SARANA TERBATAS

dr. Aris Sunardi, Msi,Med, Sp.A

RSUD Hj. Anna Lasmanah Banjarnegara
Pendahuluan

• Kontrol metabolik
Diabetes Ketoasidosis buruk
Diabetik • Riwayat KAD
Melitus (KAD)
sebelumnya,
• Tidak menggunakan
insulin,
• Gadis remaja
dengan gangguan
makan (eating
disorders),
- 1-10% / tahun  • Status sosial
KAD ekonomi rendah.
542.000 <15
tahun  DMT1
Defenisi KAD

Ketonemia,
Glukosuria dan
Glukosa serum Ketonuria
>200 mg/dL
Darah vena  (11 mmol/L)
pH <7,3 atau
bikarbonat
serum <15
mmol/L
Patofisiologi KAD Insulin deficiency

Lipolysis ↓Glucose utilization

Hepatic Starvation of insulin dependent

ketogenesis tissue (liver, fat, muscle)

Base loss Vomiting

Glucagon
Catecholamins
Growth Proinflammatory
cortisol cytokines

KETOACIDOSIS
Proteolysis & hepatic gluconeogenesis

Osmotic diuresis HYPERGLYCEMIA

Hyperventilation Dehydration Tissue hypoperfusion

Lactic acidosis
Kriteria Diagnosis

Hiperglikemia 
glukosa darah >200 Asidosis  pH <7,3
Ketonemia dan
mg/dL (>11 dan/atau HCO3- <
ketonuria.
mmol/L) 15 mEq/L
Klasifikasi KAD

arkan
Berdasarkan ajat
derajat
idosis
dehidrasi

• KAD ringan : pH < 7,3 atau

HCO3 < 15 mEq/L
• KAD sedang : pH < 7,2 atau
HCO3 < 10 mEq/L
• KAD berat : pH < 7,1 atau
HCO3 < 5 mEq/L
Manifestasi Klinis

Gejala klasik DM : poliuria, polidipsi, serta penurunan berat badan

Dehidrasi, dengan derajat yang bervariasi

Mual, muntah, nyeri perut, takikardi, hipotensi, turgor kulit menurun,

dan syok
Perubahan kesadaran dengan derajat yang bervariasi, mulai dari
bingung sampai koma

Pola napas Kussmaul

Tatalaksana KAD

• Penilaian awal • Koreksi perlahan

• ABC (airway, breathing,
circulation)
• Koreksi defisit garam dan
air  48 jam
• pemberian potassium.
• Reduksi perlahan
hiperglikemia
asidosis/ketoasidosis
metabolik
• Penanganan berbagai
infeksi
• Pemantauan, pengenalan
dan penanganan komplikasi
• Pemantauan lanjut dan
transisi ke terapi insulin
 Tatalaksana KAD
pada sarana lengkap Clinical Signs
Assess dehydration
Deep sighing respiration
(Kussmaul) Small of ketones
Lathargy/drowsiness ±
vomiting
Diagnosis confirmed Diabetic
Ketoacidosis Contact Senior Staff
Biochemical features &
investigations Ketones in urine
Elevated blood glucose
Acidemia
Bloood gases, urea, electrolytes
Other investigations as
indicated

Dehydration ≥ 5%
Shock (reduced peripheral pulses) Minimal dehydraion, tolerating
Not in shock
Reduced conscious level/coma oral fluid
Acidotic (hyperventilation)
+/- vomiting

0.9% saline 10m/s per kg IV over 1 hour

Resuscitation
Airway +/- NG tube
Breathing (100%
Oxygen)
Circulation (0.9% Saline
20ml/kg as quickly as possible;
additional10 mL/kg boluses until
circulation is stable)
Therapy Start with SC insulin
IV Therapy Continue oral hydration
Calculatefluid requirements
Correct over48hoursSaline 0.9
ECG for abnormalT-waves Add KCl 40
mmol per lirte fluid
No improvement
Continuous insulin infusion 0.1 U/kg/hr
started 1-2 hours after fluid treatment has
been initiated
 Critical Observations
Hourty blood glucose
Hourty fluid input & output
Neurological status after start of IV therapy
Monitor EGG for T-wave changes

Blood glucose 17 mmol/L (300 mg/dl) Neurological deterioration

Acidosis not improving or WARNING SIGNS:
blood glucose falls ≥ 5 mmol/L/hour (≥ 90 mg/dl/h) headache, slowing heart rate,
irritability,
decreased conscious level,
IV Therapy incontinence, specific
Re-evaluate Change to 0.45% saline + 5% glucose neurological signs
IV fluid calculations Adjust sodium infusion to promote an
Insulin delivery system & dose increase in measured serum sodium
Need for additional resuscitation
Consider sepsis Exclued hypoglycaemia
Improvement Is it cerebral edema?
Clinically well, tolerating oral fluids

Transition to SC Insulin Management Give mannitol

Start SC Insulin then stop IV insulin 0.5-1g/kg Restrict IV fluids by
after an appropriate interval one-third Call senior staff
Move to ICUConsider cranial
* Bolus added when dehydration ≥5% as imaging only after patient
presentation are often late in less-resourced settings stabilised
 Tatalaksana KAD pada sarana terbatas
Clinical History Clinical Signs Biochemical features &
Polyuria Assess dehydration investigations Elevated blood
Polydipsia Deep sighing respiration glucose Ketones in urine
Weight less (weigh) (Kussmaul) Small of ketones
Abdominal pain
Tiredness
Diagnosis confirmed Diabetic
Ketoacidosis Contact Senior Staff

IV fluids available?

YES NO Urgent transport to another facility Oral

Assess peripheral circulation rehydration with ORS 5 ml/kg/h in small
Decreased? sips or via nasogastic tube. Give ½ as fruit
juice or coconut water if ORS is not
YES available
NO
Shock?
NO
YES
Rehydrate slowly over 48 hours .
0.9% NaCl Begin with 0.9% NaCl
20 ml/kg bolus 0.9% NaCl 10 ml/kg /h 4-9 kg: 6 ml/kg/h
Repeat it necessary over 1-2 hours 10-19 kg: 5 ml/kg/h
20-39 kg: 4 ml/kg/h
40-59 kg: 3.5 ml/kg/h
60-80 kg: 3 ml/kg/h
 No transport available or possible,
or transport ≥ 6-8 hours
IV insulin available? Begin with insulin
1-2 hours after fluid treatment has
Insulin available?
been initiated
YES
NO
YES NO Oral rehydration with ORS 5 ml/kg/h in small
sips or via nasogastic tube. Give ½ as fruit
SC or IM dose 0.1 U/kg/ juice or coconut
IV dose 0.1 U/kg/h
water it ORS is not available.
(0.05 U/kg if < 5 years) every 1-2 hours
(0.05 U/kg if < 5 years
Give SC or IM insulin 0.1 U/kg every
1-2 hours (0.05 U/kg if < 5 years)

IV potassium available? NO Transport if possible,

Begin potassium replacement at same otherwise oral Improved condition?
time as insulin treatment potassium
Decreasing blood glucose AND decreasing
ketones in urine indicate resolving of acidosis.
YES
Monitor potassium and sodium YES NO
Give potassium Give 5% glucose when blood glucose
40 mmol/l in When acidosis
approaches 17 mmol/l (300 mg/dl) Add
rehydration fluids sodium, according to tab tests, has resolved
Transport MUST
80 mmol/l initially SC Insulin
be arranged
Cara penghitungan kebutuhan cairan
pada DKA
1. Tentukan derajat dehidrasi .... % (A)

2. Tentukan defisit cairan A x Berat Badan (kg) x 1000

= B ml
3. Tentukan kebutuhan rumatan C ml
untuk 48 jam (tabel 2)
4. Tentukan kebutuhan total (B+C) ml
dalam 48 jam
5. Tentukan dalam tetesan per (B+C)/48 = …. ml/jam
jam
Court J. The Management of Diabetes Mellitus in Brook CGD ed.
Clinical paediatric Endocrinology. 3rd ed. Oxford, Blackwell
Science: 1995, p. 655

14
 Penentuan derajat dehidrasi
Bayi Anak

Ringan 5% = 50ml/kg 3% = 30ml/kg

Sedang 10% = 100ml/kg 6% = 60ml/kg

Berat 15% = 150ml/kg 9% = 90ml/kg

 Pada umumnya kehilangan cairan ekstraseluler antara 5 – 10 %

 Jarang melebihi 10%
Kebutuhan cairan rumatan
Berat Badan Kebutuhan Cairan per Hari
3 – 10 kg 100 mL/kg

10 – 20 kg 1000 mL + 50 ml/kg setiap kg BB

di atas 10 kg
≥ 20 kg 1500 mL + 20 ml/kg setiap kg BB
di atas 20 kg
Court J. The Management of Diabetes Mellitus in Brook CGD ed.
Clinical paediatric Endocrinology. 3rd ed. Oxford, Blackwell
Science: 1995, p. 655

15
Penutup
• Pasien KAD harus dirawat di tempat yang memiliki
tenaga terlatih dalam menangani KAD, panduan
tatalaksana KAD, lab yang memungkinkan evaluasi
pasien secara ketat
• Rehidrasi awal dengan NaCl 0,9% atau ringer
asetat, dilakukan dalam waktu 48 jam
• Pemberian insulin dalam waktu 1 sampai 2 jam set
resusitasi
• Untuk mencegah penurunan glukosa darah yang
terlalu cepat maka tambahkan cairan Dektrosa 5%
dalam cairan intravena jika kadar glukosa plasma
turun menjadi 250-300 mg/dL (14-17 mmol/L)
• Jika insulin intravena kontinu tidak
memungkinkan pada pasien dengan KAD
tanpa gangguan sirkulasi perifer  insulin
subkutan atau intramuskuler tiap jam atau
tiap dua jam
• Insulin yang digunakan adalah insulin kerja
cepat atau kerja pendek
• Semua pasien KAD perlu koreksi kalium,
kecuali jika terdapat gagal ginjal
• Bikarbonat dapat digunakan pada kondisi
hiperkalemia berat atau jika pH darah < 6,8
• Untuk mencegah terjadinya hiperglikemia
rebound maka insulinsubkutan pertama harus
diberikan 15-30 menit (insulin kerja cepat) atau
1-2 jam (insulin kerja pendek) sebelum insulin IV
dihentikan
• Pencegahan KAD dapat dilakukan dengan edukasi
dan monitoring secara konsisten dan kontinu
Terima Kasih