9.Keto Asidosis Diabetik
-
Upload
caerulus-fuad-abdul-baqi -
Category
Documents
-
view
223 -
download
0
Transcript of 9.Keto Asidosis Diabetik
-
7/29/2019 9.Keto Asidosis Diabetik
1/30
Keto-Asidosis Diabetik
Pradana Soewondo
Division of Endocrinology and Metabolism,Department of Medicine, School of Medicine
University of Indonesia
-
7/29/2019 9.Keto Asidosis Diabetik
2/30
Diabetic Complications
Diabetic Ketoacidosis = DKA
Hyperosmolar Hyperglycemia
Nonketoric Coma = HHNC
RetinopathyNephropathy
Neuropathy
Macroangiopathy
Chronic :Acute :
Microangiopathy
CADPVD
Stroke
Hypoglycemia
Metabolic Decompensation
-
7/29/2019 9.Keto Asidosis Diabetik
3/30
Hyper-
glycemia Acidosis
Ketosis
DKA
Kitabchi and Wall
Hyperglycemia statesDM
HHNC
IGT
Stress
Metabolic Acidosis statesLactic acidosis
Hyperchloremic acidosis
Salicylism
Uremic acidosis
Drug-inducedacidosis
Ketotic statesKetotic hypoglycemia
Alkaholic ketotis
Starvation ketosis
-
7/29/2019 9.Keto Asidosis Diabetik
4/30
DKA Episode and Mortality Rate at Dr. CiptoMangunkusumo Hospital, Jakarta
Year Number of Cases Mortality rate %
1983-84 (9 months) 14 31,4
1984-88 (48 months) 55 40
1995 (12 months) 17 -
1997 (6 months) 23 18,7
1998-99 (12 months) 37 51
2002 (5 months) 39 15
-
7/29/2019 9.Keto Asidosis Diabetik
5/30
DKA HHNC
DKA HHNC
-
7/29/2019 9.Keto Asidosis Diabetik
6/30
PATOGENESISKAD
-
7/29/2019 9.Keto Asidosis Diabetik
7/30
LIPOLYSIS
A C E T O A C E T A T E
FATTY ACYL CoA
A C E T O N E3- H Y D R O X YB U T Y R A T E
MITOCHONDRION
K E T O N B O D I E S
HEPATOCYTE
CYTOSOL
FFA
Catecholamine
Growth Hormone
Insulin
SHUTTL
E
Insulin
FATTY ACYL CoA
Glucagon
FATTY ACYL CoA
CoA
KETOGEN
ESIS
-
7/29/2019 9.Keto Asidosis Diabetik
8/30
Triglyceride
Malonyl CoA
CPT 1Carnitine
Acyl Co A
Glycerol-3-P
Glucagon
Acetyl CoA
Insulin
Acetyl CoA
Acyl carnitine
Acyl carnitine
3 Hydroxybuyrate
3-HMG CoA
Acetoacetyl CoAAcyl Co A
Acetoacetate
CarnitineCPT 2
Acetone
b oxidat ion
+
--outer
inner
mitochondrial
membrane
Krebs
cycle
CYTOSOL
MITOCHON-DRION
Fatty acid
-
7/29/2019 9.Keto Asidosis Diabetik
9/30
DKA HHNC
Kadar Hormon dan FFA pada KAD
-
7/29/2019 9.Keto Asidosis Diabetik
10/30
Clinical Features of DKA
Abdominal pain
Leg cramps
Nausea and vomiting
Confusion and
drowsiness
Coma
Polyuria and nocturia
Weight loss
Weakness
Blurred vision
Kussmaul respiration
-
7/29/2019 9.Keto Asidosis Diabetik
11/30
Precipitating Factors of DKA & HHNC
Infection
Cerebro vascular
accident
Pancreatitis
Myocardial infarction
Trauma
Medication
Newly type 1
diabetes
Discontinuation of or
inadequate insulin
Substance abuse
Not found
-
7/29/2019 9.Keto Asidosis Diabetik
12/30
-
7/29/2019 9.Keto Asidosis Diabetik
13/30
Average Water and Electrolyte Deficits in DKA
Water (liters) 5 - 7 liters
Sodium (mmol) 500
Chloride (mmol) 350
Potassium (mmol) 300 - 1000
Calcium (mmol) 50 - 100
Phosphate (mmol) 50 - 100
Magnesium (mmol) 25 - 50
-
7/29/2019 9.Keto Asidosis Diabetik
14/30
PrincipalManagement
of DKAand HHNC
-
7/29/2019 9.Keto Asidosis Diabetik
15/30
Hour Hydration Insulin K+Correction HCO3- correction
0 guyur 50 mEq per If pH
guyur six hour 7.1
guyur Start hour 2iv bolus iv,
Cont by infusion
dst dst dst
Management of DKAat Cipto Mangunkusumo Hospital, Jakarta
A B C D E
Lihat perincian pada slide berikut (per kolom)
-
7/29/2019 9.Keto Asidosis Diabetik
16/30
Jam 0 2 kolf 1/2 jam1 1 kolf 1/2 jam Guyur dengan NaCl 0,9%2 1 kolf 1 jam3 1 kolf 2 jam4 dst. bergantung kebutuhan
Sebaiknya dimonitor dengan CVP.
Jumlah cairan per 15 jam sekitar 5 liter.
Bila kadar Na+ > 155 mEq/L (osmolarity >350 mosm/L) gunakan1/2 n NaCl.
Bila kadar glukose darah < 200 mg/dl NaCl diganti dextrose 5%.
Rehidrasi B
-
7/29/2019 9.Keto Asidosis Diabetik
17/30
Pemberian Insulin C
Mulai jam ke 2 dengan bolus 180 mU/kg BB (7-10 U/jam) I.V
dilanjutkan dengan drip 90mU/kgBB/jam dalam NaCl 0,9%(3 4 U/jam)
Bila kadar gd < 200mg/dl kecepatan drip insulin dikurangisetengahnya menjadi 45mU/kg/jam (1,5 2 U/jam)
Bila kadar gd stabil 200-300mg/dl, drip 1 U/jam + slidingscale tiap 6 jam:
gd 350 mg/dl 20 unit
Bila pasien sudah bisa makan dan gd stabil dengan sliding
scale rutin 3 kali sehari dengan dosis tetap
-
7/29/2019 9.Keto Asidosis Diabetik
18/30
Koreksi K+ D
Pada jam 0 diberikan KCl 50 mEq per 6 jam dengan drip dalaminfusSetelah 6 jam di cek lagi kadar K+ Bila kadar K+ (mEq/L):
< 3 3-4,5 4,5-6 >6
75 50 25 0
mEq/ mEq/ mEq/6 jam 6 jam 6 jam
Bila sudah sadar, beri K+ per oral selama seminggu
-
7/29/2019 9.Keto Asidosis Diabetik
19/30
-
7/29/2019 9.Keto Asidosis Diabetik
20/30
-
7/29/2019 9.Keto Asidosis Diabetik
21/30
The Benefit of 3HB Measurement within 24hours management of DKA at RSCM Jakarta
Ika P, Soewondo P et al. RSCM, Jakarta 2001.
OBJECTIVE To observe the benefit of 3HB in 24 hour management of
DKA.
To describe the changing of parameter metabolic variable
during the first 24 hours in the management of DKA
METHOD
Hospital based, observational study, enrolliring DKA patients
19 from 39 DKA patients participated in this study
January-May 2002
-
7/29/2019 9.Keto Asidosis Diabetik
22/30
Enrollement
39 DKA patients
20 excluded 19 included
4 patients died
within 24 hours
15 patients
completely of study
Serial measurement of
Blood glucose, BGA,
AcAc, 3HB, Electrolyte
every 6 hours
-
7/29/2019 9.Keto Asidosis Diabetik
23/30
Measurements at presentation of DKA
N 19
Age (years) 48.16 12.51
Sex (M/F) 8/11
Blood Glucose 383 80.30
Arterial pH 7.24 0.21
Blood pCO2 18.87 7.19
Blood
bicarbonate
10.17 6.37
BUN 43.24 40.18
Serum Creatinine 2.48
Serum AcAc (+/-) +++ (Median)
Blood 3HB (mmol/L) 3.31 2.41
K + (mmol/L) 4.52 0.92
Na + (mmol/L) 127.1 9.92
-
7/29/2019 9.Keto Asidosis Diabetik
24/30
Changes of 3HB and AcAc in 24 hours
Hours
241812620
3,5
3,0
2,5
2,0
1,5
1,0
,5
0,0
3,0
2,0
1,0
0,0
3HB
AcAc
-
7/29/2019 9.Keto Asidosis Diabetik
25/30
7.3
7.2 art. blood pH
241812620
25
20
15
10
5
0
Blood 3HB
Serum AcAc
pCO2
HCO3
Anion Gap
BG (mmol/l)
Observ
asi24jam
pH darah
glucose
pCO2
HCO3
3HB
-
7/29/2019 9.Keto Asidosis Diabetik
26/30
0
2
6
12
18
24
Hour
Correlation 3HB and Blood pH
0.00 2.00 4.00 6.00
3HB
6.80
7.00
7.20
7.40
pH
-
7/29/2019 9.Keto Asidosis Diabetik
27/30
0
2
6
12
18
24
Hour
Correlation 3HB and Blood Bicarbonate
0.00 2.00 4.00 6.00
3HB
5.00
10.00
15.00
20.00
25.00
HCO3
-
7/29/2019 9.Keto Asidosis Diabetik
28/30
0
2
6
12
18
24
Hour
Correlation 3HB and Anion Gap
0.00 2.00 4.00 6.00
3HB
0.00
10.00
20.00
30.00
Anion
Gap
-
7/29/2019 9.Keto Asidosis Diabetik
29/30
Kesimpulan
KAD dan HHNK komplikasi akut DM dengan angka
kesakitan dan kematian yang tinggi.
Patogenesis KAD dan HHNK defisiensi insulin dan
peningkatan kadar hormon kontraregulator insulin.
Faktor pencetus utama Infeksi
Pemeriksaan benda keton - 3HB secara bedsite dapat
mempercepat diagnosis KAD bahkan dapat mencegah
KAD pada pasien DM saat sakit/demam.
Evaluasi 3HB serial membantu dalam pengelolaan
KAD - peralihan terapi titerasi insulin ke dosis tetap.
-
7/29/2019 9.Keto Asidosis Diabetik
30/30