Professional Documents
Culture Documents
Sarwono Waspadji
Pusat Diabetes dan Lipid, Divisi Metabolik-Endokrin, Departemen Ilmu Penyakit Dalam, FKUI / RSUPN Cipto Mangunkusumo, Jakarta
Diabetic Complications
Acute
Chronic :
Microangiopathy
Macroangiopathy
Hypoglycemia
Retinopathy Nephropathy Neuropathy CAD PVD Stroke
Metabolic Decompensation
Ketoasidosis Diabetik Hiperosmolar non Ketotik Asidosis Laktat Hipoglikemia Sebab Lain - Trauma - Obat - Penyakit Lain : Stroke Koma hepatik Uremik
Keton
+s/d4+ 0 s/d+
Hipervent. Dehid.
++ 0 ++ +++
TD
N/ N/
Kulit
hngt N
Hipoglik
Asidosis Laktat Non Metab
< 50
lmb
20-200 N/
+++ 0 s/d +
Rnd
hngt
0 s/d + Variasi N
Hipoglikemia
Simtom:
Efek adrenergik alfa: sekresi insulin menurun, cerebral blood flow meningkat peripheral vasoconstriction Efek adrenergik beta: glycogenolisis otot dan hati stimulasi release glukagon lipolisis uptake glukosa otot menurun increase c.o.p, cerebral flow Efek adrenomedullary discharge of Catecholamine augmentasi efek adrenergik alfa dan beta
a h
Waktu
Perlu pemantauan yang lama jika pasien memakai obat long acting Jika hipoglikemia berkelanjutan dapat menyebabkan kerusakan otak permanen, demensia
Penatalaksanaan Hipoglikemia
Ringan: Berikan gula murni (bukan pemanis) yang cukup sampai keluhan hilang Pastikan pemberian makanan / kalori cukup untuk selanjutnya, terutama jika OAD long acting
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: 281303.
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
A1C (%)*
<6.5
6.5-7
7-8
8-10
>10
Continue
Monotherapy* : Metformin AGI TZD Specific Condition: SU Meglitinides Short/Rapid-acting Insulin analog
Target Achieved
Oral Combination Oral# : SU Metformin AGI TZD Meglitinides Specific condition: Short/Rapid-acting Insulin analog Pre-mixed Insulin analog
Combination Oral+Insulin : Metformin TZD SU Long-acting Insulin Short/Rapid-acting Insulin analog Pre-mixed Insulin analog NPH Other Combination
Insulin Therapy: Short/Rapid-acting Insulin analog NPH or Long-acting Insulin Pre-mixed Insulin analog In selected Patients with A1C> 10% OHO Combination might be effective
Continue Treatment
Intensification Therapy OR
Target Achieved
Target Achieved
Target Achieved
Continue Treatment
Intensification Therapy OR
Continue Treatment
In critically ill patients, more over in metabolic decompensation, the blood glucose target should be more aggressive and achieved quicker
Hyperglycemia states
DM HHNC IGT Stress
Hyperglycemia
Acidosis
DKA
Ketotic states
Ketotic hypoglycemia Alkaholic ketosis Starvation ketosis
Ketosis
DKA Episode and Mortality Rate at Dr. Cipto Mangunkusumo Hospital, Jakarta
Year
1983-84 (9 months) 1984-88 (48 months) 1995 (12 months) 1997 (6 months) 1998-99 (12 months) 2002 (5 months)
HHNC DKA
DKA
HHNC
HHNC
HHNC
A
0
B
guyur guyur guyur
D
50 mEq per six hour
E
If pH <7 7-7.1 >7.1
dst
dst
Suhendro 2008
Pengukuran asam laktat perlu pada pengelolaan KAD Serum laktat > 4 mmol/L petanda prognostik buruk Jika disertai kesadaran menurun prognostik buruk Perlu pengelolaan yang ketat sejak awal Pasang CVP segera Hidrasi dicapai dengan lebih cepat
Prevention (1)
Better access to medical care
Intensive patients education Effective communication acute illness
Prevention
(2)
Increase BG monitoring during acute illness Check ketone bodies (either urine or blood) when BG > 300 mg/dL
Hatur Nuhun
Hibiscus rosasinensis