KETOASIDOSIS DIABETIK

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Pendahuluan

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

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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

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patofisiologi KAD

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Kriteria
Diagnosis

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

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Klasifikasi
KAD

Berdasarkan
derajat
Asidosis
• 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

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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

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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

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 Tatalaksana KAD
pada sarana lengkap
Shock (reduced peripheral pulses)
Reduced conscious level/coma
Resuscitation
Airway +/- NG tube
Breathing (100% Oxygen)
Circulation (0.9%
Saline 20ml/kg as quickly as
possible; additional 10 mL/kg
boluses until circulation is
stable)
Clinical Signs Biochemical features &
Assess dehydration investigations
Deep sighing respiration (Kussmaul) Ketones in urine
Small of ketones Elevated blood glucose
Lathargy/drowsiness ± vomiting Acidemia
Bloood gases, urea, electrolytes
Other investigations as indicated
Diagnosis confirmed
Diabetic Ketoacidosis
Contact Senior Staff
Dehydration ≥ 5%
Minimal dehydraion,
Not in shock
tolerating oral fluid
Acidotic (hyperventilation)
+/- vomiting
0.9% saline 10m/s per kg IV over 1 hour
Therapy
IV Therapy Start with SC insulin
Calculate fluid requirements Continue oral hydration
Correct over 48 hours
Saline 0.9%
ECG for
abnormal T-waves
Add KCl 40 No improvement
mmol per lirte fluid infusion 0.1 U/kg/hr
Continuous insulin
started 1-2 hours after fluid treatment
has been initiated
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 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 headache, slowing heart
mg/dl/h) 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 increase
Insulin delivery system & dose 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

Start SC Insulin then stop IV insulin after Give mannitol 0.5-1g/kg
an appropriate interval Restrict IV fluids by one-third
Call senior staff
* Bolus added when dehydration ≥5% as Move to ICU
presentation are often late in less-resourced settings Consider cranial imaging
only after patient stabilised

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 Tatalaksana KAD pada sarana terbatas
Clinical History Clinical Signs Biochemical features &
Polyuria Assess dehydration investigations
Polydipsia Deep sighing respiration (Kussmaul) Elevated blood glucose
Weight less (weigh) Smell of ketones Ketones in urine
Abdominal pain
Tiredness
Diagnosis confirmed
Diabetic Ketoacidosis
Contact Senior Staff

IV fluids available?

YES NO Urgent transport to another facility

Assess peripheral circulation Oral rehydration with ORS 5 ml/kg/h
Decreased? in small sips or via nasogastic tube.
Give ½ as fruit juice or coconut water
YES if ORS is not available
NO
Shock?
NO
YES
Rehydrate slowly over 48
0.9% NaCl hours . 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

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 No transport available or possible,
or transport ≥ 6-8 hours
IV insulin available? Begin with insulin
1-2 hours after fluid treatment has
been initiated Insulin available?

YE S
IV dose 0.1 U/kg/h
(0.05 U/kg if < 5 years)
YES NO
NO Oral rehydration with ORS 5 ml/kg/h
in small sips or via nasogastic tube.
SC or IM dose 0.1 U/kg/ Give ½ as fruit juice or coconut
every 1-2 hours water it ORS is not available.
(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
YES resolving of acidosis.

Monitor potassium and sodium

Give potassium Give 5% glucose when blood glucose YES NO
40 mmol/l in approaches 17 mmol/l (300 mg/dl) When acidosis
rehydration fluids Add sodium, according to tab tests, has resolved
Transport MUST
80 mmol/l initially SC Insulin
be arranged

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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

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 Perkiraan derajat dehidrasi penderita

5% (turgor menurun, mukosa mulut kering,

takikardia, takipnea)

10% ( mata cowong,ubun-ubun cekung, turgor

menurun lebih berat)

> 10% (renjatan, nadi tak teraba atau sangat

lemah, hipotensi, oliguria)

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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

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Penutu
p
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)

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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

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Untuk mencegah terjadinya hiperglikemia rebound maka insulin
subkutan 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

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