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KETOASIDOSIS

DIABETIKUM
dr. Rima Rizqi Meltahayati

Program Internsip Dokter Indonesia


RSUD Kota Bogor
2017
IDENTITAS PASIEN
Nama : Nn. N
Usia : 21 tahun
Jenis kelamin : Perempuan
Agama : Islam
Alamat : Kp. Babakan RT 3/2, Sukaharja
kec. Ciomas, Kab Bogor
Tanggal masuk RS : 22 Maret 2017
Tanggal perawatan : 22 30 Maret 2017
No. RM : 42-27-16
DPJP : dr. Erwindo, SpPD.
ANAMNESIS
KU : Tubuh terasa lemas dan demam
RPS : Pasien berusia 22 tahun datang ke IGD RSUD kota Bogor
dengan keluhan badan terasa lemas sejak 2 hari SMRS.
Sebelumnya pasien demam selama 4 hari SMRS naik - turun,
disertai tidak nafsu makan, mual + muntah batuk +.
Selama perawatan awal di RS terdapat penurunan
kesadaran dan sesak nafas. Keluhan ini sebelumnya disangkal
keluarga, BAB normal, BAK normal, kejang disangkal, bicara
meracau disangkal, penurunan BB dalam 3 bulan terakhir.
RPD :
Riwayat Diabetes melitus (-)
Riwayat Hipertensi (-)
Riwayat penyakit jantung (-)
Riwayat hiperlipidemia (-)

RPK :
Riwayat Diabetes melitus (-)
Riwayat Hipertensi (-)
Riwayat penyakit jantung (-)
Riwayat hiperlipidemia (-)
PEMERIKSAAN FISIK
Keadaan umum : Tampak sakit sedang, kesadaran Somnolen
Tanda vital : TD 90/60 mmHg RR 35 x/menit
N 110 x/menit S 37C
Status Generalis
Kepala : Mata conjunctiva anemis -/-, sklera ikterik -/-,
pupil bulat isokor, reflex cahaya +/+
Leher : KGB tidak teraba membesar
Jantung : BJ murni S1=S2, regular, murmur (-), gallop (-)
Paru : B/P simetris, VBS +/+ kanan=kiri, Rh -/-, Wh -/-
Abdomen : Datar, supel, BU (+) normal
Ekstremitas : Akral dingin, edema -/-
PEMERIKSAAN PENUNJANG
Tanggal Pemeriksaan Hasil Nilai Rujukan
23 Mar 2017 (00.27) Hb 15,5 gr/dl (L) 11,7-15,5
Ht 49,3 % (L) 36-47
Leukosit 16050/L 4000-11000
Trombosit 299000/L 154000-386000
Hitung Jenis
-Basofil 0,1 % 0,0-1,0
-Eosinofil 0,0 % 2,0-4,0
-Netrofil segmen 78,7 % 50,0-70,0
- Limfosit 11,5 % 25,0-40,0
- Monosit 9,7 % 2,0-8,0

GDS 428 mg/Dl <200

SGOT 25 0 31
SGPT 25 0 32
PEMERIKSAAN PENUNJANG
Pemeriksaan Hasil Hasil
23 Mar 2017 (02.42) 23 Mar 2017 (22.24)

Ur 17
Cr 0,7

Ph 6,83 7,14
P Co2 12 21
P o2 128 215
BE -31,2 -20,0
HCO3 2,0 7,1
sO2 99 99
Laktat 1,4 1,1

Na 132
K 4,5
CL 104
Ca2++ 1,24
Pemeriksaan Urinalisa Hasil
26 Mar 2017 (12.44)

Makroskopis
Warna Kuning
Kejernihan Keruh
Rutin Urin
Glukosa +4
Bilirubin -
Keton Trace
Berat jenis 1,010
pH 6,5
Protein +1
Urobilinogen 0,1
Nitrit -
Blood +2
Leukosit +2
Sedimen
Sel epitel +1
Leukosit 9-10
Eritrosit 24-26
Silinder -
Kristal -
Jamur -
Bakteria -
Rontgen Thorax

Kesan :
-Tidak tampak kelainan radiologis
pada jantung dan paru
- Skoliosis thorakalis ke kanan
DIAGNOSIS KERJA
Ketoasidosis Metabolik
DM Tipe I
TATALAKSANA
- O2 NRM 10 lpm Konsul dr. Erwindo Sp.PD :
- IVFD Nacl 0,9% 250cc - Loading NaCl 4 Kolf
- OMZ 1 amp - Novorapid bolus 10 unit IV
- Ondancentron 4 mg - Metronidazol 3 x 500 mg
- PCT tab 3 x 500 mg - Aspar-K 2 x 1
- Ceftriaxone 2 x 1 gr - Ondancentron 2 x 4 mg
- DC & NGT - Ceftriaxone 2 x 1 gr
- Sliding scale kelipatan 5/ 4
jam
- Pro HCU
FOLLOW UP
23/4/17 24/3/17 25/3/17 26/3/17

S:- S : lemas + S : pusing + mual + S : Mual +

O: O: O: O:
Kes : Somnolen Kes : CM Kes : CM Kes : CM
TD : 90/70 N: 150 RR : 30 TD : 110/70 N: 98 RR : 26 TD : 110/80 N: 79 RR : 20 TD : 100/70 N: 76 RR : 24
S : 37 S : 37,8 S : 37 S : 36,7
GDS : 358, 273, 375 GDS : 442, 165 GDS : 206, 294, 314 GDS : 208
A: A: A: A:
KAD KAD DM tipe I DM tipe I
DM tipe I DM tipe I

P: P: P : cek urin P : terapi lanjut


-Syring pump Novorapid - Asering 30 tpm
50 U dalam 50 cc Nacl -Novorapid (SP) 1,5
1,5 cc/jam cc/jam
- pindah HCU -Novorapid 3 x 18 U (SC)
-Cek GDS/12 jam sebelum makan
- aff NGT
- gds / 12 jam
-Diit lunak
FOLLOW UP
27/4/17 28/3/17 29/3/17 30/3/17

S : Lemas + pusing + S : lemas + S : lemas berkurang S : lemas berkurang, sesak


-
O: O: O: O:
Kes : CM Kes : CM Kes : CM Kes : CM
TD : 110/80 N : 80 RR : 20 TD : 110/80 N : 80 RR : 20 TD : 110/80 N : 83 RR : 22 TD: 120/70 N: 80 RR: 20 S:
S : 36,7 S : 36,7 S : 36,2 36,7
GDS : 298, >600 GDS : 191, 126, 106 GDS : 84, 370 GDS : 117, 234
A : DM tipe I A : DM tipe I A : DM tipe I A : DM tipe I

P: P: P: P : Boleh pulang
-Asering loading 300cc - cek GD/12 jam -Infus pump stop
30 tpm - Novorapid 3 x 20 U - Novorapid 3 x 20 U
-Syring pump 2cc/jam - Lavemir lantus 0 0 - Cek gds/12 jam
-Novorapid 3 x 20 U 14
- lavemir 0 0 14
-GDS/12 jam
PROGNOSIS

Quo ad vitam : Dubia


Quo ad functionam : Dubia
Quo ad sanationam : Dubia
KETOASIDOSIS
DIABETIKUM
DKA and HHS Are Life-
Threatening Emergencies
Diabetic Ketoacidosis (DKA) Hyperglycemic Hyperosmolar State (HHS)

Plasma glucose >250 mg/dL Plasma glucose >600 mg/dL

Arterial pH <7.3 Arterial pH >7.3

Bicarbonate <15 mEq/L Bicarbonate >15 mEq/L

Moderate ketonuria or ketonemia Minimal ketonuria and ketonemia

Anion gap >12 mEq/L Serum osmolality >320 mosm/L

16
Ketoasidosis Diabetikum
Type
Type 11Diabetes
Diabetes Accounts
Accounts for thefor the of
Majority
Primary DKA
Majority ofEpisodes
Primay DKA Episodes
Primary DKA Episodes
134,633 (2006 34% of episodes are Type 2
~46,000 cases
T1D - Children 18%
Longer Hospital Stays
66%
T1D - Adults 48% 4.2 vs average of 3.5
Very few have CV issues or serious
T2D 34% 34% infections => Less than 15%

T2D accounts for 34% of primary DKA cases and


more than 50% of secondary causes
National Hospital
National Discharge
Hospital Survey.
Discharge 2006.
Survey (NHDS); 2006.
19
Perbedaan DM tipe 1 Dan DM tipe 2

Tipe 1 1. Mudah terjadi ketoasidosis


2. Pengobatan harus dg insulin
3. Onset akut
4. Biasanya kurus
5. Terjadi pada usia muda ( < 30 /40 tahun
6. Riwayat keluarga diabetes ( + ) 10%
7. 30 50 % kembar identik terkena
Tipe 2 1. Tidak mudah terjadi ketoasidosis
2. Pengobatan tidak harus dg insulin
3. Onset lambat
4. Gemuk atau bisa juga kurus
5. Umur > 45 tahun
6. Riwayat keluarga (+) 30 %
7. 100 % kembar siam identik terkena.
Possible Precipitating Causes or
Factors in DKA: Type 1 Diabetes

Nonadherence to insulin regimen or psychiatric issues


Insulin error or insulin pump malfunction
Poor sick-day management
Infection (intra-abdominal, pyelonephritis, flu)
Myocardial infarction
Pancreatitis
Other endocrinopathy (rare)
Steroid therapy, other drugs or substances
Possible Precipitating Causes or
Factors in DKA: Type 2 Diabetes

Nonadherence to medication regimen


Poor sick-day management
Dehydration
Renal insufficiency
Infection (intra-abdominal, pyelonephritis, flu)
Myocardial infarction, stroke
Other endocrinopathy (rare)
Steroid therapy, other drugs or substances
GEJALA DM ( tipe DM )
1. DM Tipe I :
BB turun ( kurus )
Lemah
Polyuria, polidipsi,polipagia
Banyak kehilangan air & elektrolit
Komplikasi kegawatan Ketoasidosis
2. DM Tipe 2 :
Obesitas
Sakit: diketahui stelah ada ggn penglihatan,
Lelah, Iritabilitas, nokturia, gatal pd pulva
Luka sukar sembuh, kram otot
Komplikasi: koma hiperosmolar (ketosis)
Clinical Presentation of Diabetic Ketoacidosis

History Physical Exam


Thirst Kussmaul respirations

Polyuria Fruity breath

Abdominal pain Relative hypothermia

Nausea and/or vomiting Tachycardia

Profound weakness Supine hypotension,


orthostatic drop of blood
Patients with any form of diabetes pressure
who present with abdominal pain, Dry mucous membranes
nausea, fatigue, and/or dyspnea
should be evaluated for DKA. Poor skin turgor

Handelsman Y, et al. Endocr Pract. 2016;22:753-762.


Pathogenesis of Hyperglycemic Crises

DKA HHS

Hyperglycemia Dehydration Lipolysis-


osmotic diuresis
Increased FFA

Increased
glucose
Increased
production
ketogenesis
Insulin Counterregulatory
Deficiency Hormones

Decreased
glucose Metabolic
uptake acidosis
Electrolyte Hypertonicity
abnormalities
Umpierrez G, Korytkowski M. Nat Rev Endocrinol. 2016;12:222-232.
Insulin Deficiency

Hyperglycemia Lipolysis

Hyper-
osmolality
Glycosuria FFAs

Ketones
Dehydration
Acidosis
Electrolyte
Renal Failure Losses

Shock CV
Collapse
DIAGNOSIS
Management of DKA and HHS

Replacement of fluids losses


Correction of hyperglycemia/metabolic acidosis
Replacement of electrolytes losses
Detection and treatment of precipitating causes
Conversion to a maintenance diabetes regimen (prevention of
recurrence)

Kitabchi AE, et al. Diabetes Care. 2009;32:1335-1343.


Fluid Therapy in DKA

Normal saline, 1-2 L over 1-2 h

Calculate corrected serum sodium

High or normal Low serum sodium


serum sodium

NS at 250-500 NS at
mL/h 250-500 mL/h

Glucose < 250 mg/dl

Change to D5% NS or 1/2NS

ADA. Diabetes Care. 2003;26:S109-S117.


KOMPLIKASI

HIPOGLIKEMIA
ASIDOSIS PERSISTEN
HIPOKALEMIA
EDEMA INTRASEREBRAL

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