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Sarwono Waspadji
Acute Chronic :
Microangiopathy Macroangiopathy
• Hypoglycemia
• Diabetic Ketoacidosis = DKA
Retinopathy CAD
• Hyperosmolar Hyperglycemia Nephropathy PVD
Neuropathy Stroke
Nonketoric Coma = HHNC
• Metabolic Decompensation
Sebab
Sebab Kesadaran
Kesadaran Menurun
Menurun pada
pada Diabetes
Diabetes Melitus
Melitus
Ketoasidosis
Ketoasidosis Diabetik
Diabetik
Hiperosmolar
Hiperosmolar non
non Ketotik
Ketotik
Asidosis
Asidosis Laktat
Laktat
Hipoglikemia
Hipoglikemia
Sebab
Sebab Lain
Lain -- Trauma
Trauma
-- Obat
Obat
-- Penyakit
Penyakit Lain
Lain ::
Stroke
Stroke
Koma
Koma hepatik
hepatik
Uremik
Uremik
Diagnosis Banding Koma
Glukosa Keton Hipervent. Dehid. TD Kulit
mg/d L
DKA >300 +s/d4+ ++ ++ N/ hngt
Asidosis
Laktat 20-200 trc s/d + +++ 0 Rnd hngt
g 72
l
u ................................................................. Neuroglikopenia
k 54 Disfungsi Kognitif ringan
o
................................................................ Aktivasi gejala
s
Keringat autonomik
a 36 Gemetar
.....................................Berdebar ...... Neuroglikopenia
d berat
a 18 Kejang
r ............................................................... Koma
a
h Waktu
Respons Perubahan Hormonal pada Hipoglikemia:
Penurunan sekresi insulin
Peningkatan katekolamin dan epinefrin
Peningkatan sekresi glukagon
Peningkatan sekresi kortisol
Peningkatan hormon pertumbuhan
TZ s ase
to id
s
ue
bi os
in
og
hi c
r
rm
in glu
cr lin
s
ag
D
fo
se s u
-
et
et
In
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Risk of hypoglycaemia – – –
Weight gain – –
Gastrointestinal – –
side-effects
Lactic acidosis – * – –
Oedema – – –
Anaemia – –
*Observed in patients with renal impairment Adapted from DeFronzo RA. Ann Int Med. 1999; 131: 281–303.
Principles in Selecting
Antihyperglycemic Interventions
• Effectiveness in lowering blood glucose
• Extraglycemic effect that may reduce
longterm complications
• Safety profile
• Tolerability
• Ease of use
• Cost
Nathan DM et al. Clinical Diabetes. 2009; 27 (1): 4-16
Algorithm for Management of Type 2 DM without Metabolic Decompensation
Indonesian Society of Endocrinology 2007
Diagnosis Type 2 DM
Lifestyle changes
Target Target
Continue Target
Achieved not Target
Treatment Intensification Target Target not
Achieved Achieved
Therapy OR Achieved not Achieved
Achieeved
Continue
Treatment Continue
Intensification
Continue Treatment
Therapy OR
Treatment Intensification
*surrogate average blood glucose Therapy OR Intensification of
Insulin Treatment
might be used Basal+bolus
Management of Hyperglycemia
In Patients
General Principles:
Maximal blood glucose control, avoiding
hypoglycemia
Meticulous, Prudent, Individualized
Management of T2DM synchronized with other
disease management
In critically ill patients, more over in
metabolic decompensation, the blood
glucose target should be more
aggressive and achieved quicker
Sasaran Glukosa darah yang dianjurkan
DKA
Ketosis
Ketotic states
•Ketotic hypoglycemia
•Alkaholic ketosis
•Starvation ketosis
Kitabchi and Wall
DKA Episode and Mortality Rate at Dr.
Cipto Mangunkusumo Hospital, Jakarta
HHNC
DKA
Precipitating Factors of DKA & HHNC
Infection
Cerebro vascular accident
Pancreatitis
Myocardial infarction
Trauma
Medication
Newly diagnosed type 1 diabetes
Discontinuation of or inadequate insulin
Substance abuse
Not found
Clinical Features of DKA
• Polyuria and nocturia • Abdominal pain
• Weight loss • Leg cramps
• Weakness • Nausea and vomiting
• Blurred vision • Confusion and
• Kussmaul respiration drowsiness
• Coma
DKA HHNC
HHNC
HHNC
Principal Management of DKA and HHNC
Management
Management of
of DKA
DKA
at
at Cipto
Cipto Mangunkusumo
Mangunkusumo Hospital,
Hospital, Jakarta
Jakarta
Hour
Hour Hydration
Hydration Insulin
Insulin K
K++Correction
Correction HCO3--correction
HCO3 correction
A
A B
B C
C D
D E
E
00 guyur
guyur 50
50 mEq
mEq per
per IfIf pH
pH
•• guyur
guyur six
six hour
hour <7
<7 7-7.17-7.1 >7.1
>7.1
•• guyur
guyur Start
Start hour
hour 22
iv
iv bolus
bolus iv,
iv,
Cont
Cont by by infusion
infusion
dst
dst dst
dst dst
dst
Penatalaksanaan Ketoasidosis Diabetik
1. Rehidrasi Cepat
* 1 jam 2 kolf, 1 jam 1 kolf, dst
* Na Cl Fisiologis
* 1/2 N, 2A - Kalau Na > 150 mek/l
2. Insulin
Bolus 10 U IV. G.D setiap jam
Drip 5 U/jam sampai g.d. < 200 mg/dl - D5 %
Drip 2,5 U/jam sampai g.d. stabil 200 - 300 mg/dl
Drip 1 U/jam + sliding scale g.d. tiap 4 jam
Dosis terbagi 3-4 kali sehari
***Dosis Kecil 5 U IM *** Pemantauan dengan Urin
3.Kalium < 3,5 mek/L -- 50 mek/L 4. Na HCO3
3,5 - 5 mek/L -- 25 mek/L pH < 7 - 7,1
>5 mek/L -- 0 5. Faktor Presipitasi
Suhendro 2008
Pengukuran asam laktat perlu pada pengelolaan KAD
Serum laktat > 4 mmol/L petanda prognostik buruk
Jika disertai kesadaran menurun prognostik buruk
Hibiscus rosasinensis