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KOMPLIKASI DM

Hemi Sinorita
SubBag Endokrinologi Bagian/SMF Penyakit Dalam FK UGM/RS Dr Sardjito Yogyakarta

Komplikasi Diabetes
hipoglikemi
Komplikasi akut

hiperglikemi

Keto-asidosis diabetik Koma hiperglikemi hiperosmoler non-ketotik

mikroangiopathy

Komplikasi kronis
makroangiopathy

Microangiopathy

Macroangiopathy

Diabetic Retinopathy
Leading cause of blindness in adults1,2

Stroke
2- to 4-fold increase in cardiovascular mortality and stroke5

Diabetic Nephropathy
Leading cause of end-stage renal disease3,4

Cardiovascular Disease
8/10 individuals with diabetes die from CV events6

Diabetic Neuropathy

Peripheral Arterial Disease

Prospective Diabetes Study Group. Diabetes Res 1990; 13:111. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99S102. 3The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94S98. 5Kannel WB, et al. Am Heart J 1990; 120:672676. 6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7Kings Fund. Counting the cost. The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78S79.
1UK

The unifying mechanism of hyperglycemia-induced cellular damage

Retinopathy
Its recommended to perform a routine-retinal check up each year Diabetic retinopathy haemorhage ablasio blindness Methods:

Direct opthalmoscope Indirect opthalmoscope Retinal photography

Early referral

Nephropathy
Start : microalbuminuria macroalbuminuria - renal filtration rate renal failure Early detection of microalbuminuria is required, referring experienced physician If GFR<30 consult to the nephrologists

Coronary Heart Disease


More cautious especially to those who have historical CHD, family history. Stress test and rest ECG Consult to cardiologist

Targets for treatment of Type 2 diabetes

HbA1c

Blood pressure <130/80 mmHg LDL cholesterol <100 mg/dL HDL cholesterol >50 mg/dL F >40mg/dL M Triglycerides <150 mg/dL STOP smoking! 30 minutes daily exercise Diet advise

<6.0%? < 7%

Peripheral Vascular Disease


Need for patients counseling Need to examine:
1. 2. 3.

Deformation of foot and leg Neuropathy Decrease of foots blood flow

Tekanan atau beban kaki berlebih

Pemeriksaan kelainan syaraf


Mono filamen Semmes Weinstein 10 gram Deteksi adanya neuropati

Deteksi dini Kelainan pembuluh darah kaki

1. Meraba denyut pembuluh darah pada punggung kaki 2. Pemeriksaan dengan alat doppler

Chronic complications treatment and management


Glycemic control Blood pressure control Lipid control Others: healthy lifestyle and diet scheduling Some distinctive methods:

Retinopathy with photo coagulation Nephropathy with dialysis: hemodialysis or peritonial CHD with stent installment Peripheral vascular disease with metabolic and infection control, foot rest Neuropathy symptomatis

Metabolic Ketoacidosis (Ketoasidosis metabolik) Hyperglycemic Hyperosmoler State (Kondisi hiperglikemik hiperosmoler)

Asam laktat

KRITERIA DIAGNOSIS

1 jam I
jam II

NaCl 0,45%

dextran L

icu, CVP

NaCl 0,9% 500 cc + RI 50 U, 20 tts

pH<7,2 + shock pCO2 ?

konsentrasi maksimal 25 mEq KCl dlam 500 cc

HYPOGLYCEMIA
Hypoglycemia : blood glucose < 50 mg/dl Clinically, it is defined by Whipple triad : 1.Low plasma glucose level 2.Symptoms consistent with hypoglycemia 3.Resolution of symptoms with correction of plasma glucose

Symptoms
Adrenergic symptoms (catecholamine mediated) : diaphoresis palpitations pallor tachycardia apprehension anxiety sensation of hunger headache weakness restlessness Neuroglycopenic symptoms : reduced intellectual capacity confusion convulsion

irritability abnormal behavior coma

Management of hypoglycemia:
Mild hypoglycemia: Oral glucose 15-20 g : 10-15 min then check blood glucose. If glucose level does not increase 18 mg/dl, give oral glucose again Severe hypoglycemia: Solution 50 ml of dextrose 50% given intravenously, check blood glucose in 20 min. If it is still hypoglycemia administrate once again Glucagon 1.0 mg s.c/i.m/i.v. Adverse effects include nausea, vomiting and headache. Contraindicated to sulfonylureas-induced hypoglycemia. Ineffective in patient who is anorectic, or with protracted hypoglycemia

terima kasih

Algorithm I.v. Insulin Infusion Therapy


BG (mg/dL) Insulin infusion dose (u/hr) Algr1 Algr2 Algr3 Algr4

< 60 = Hypoglycemia (need dextrose Tx) 60-70 0 0 0 0 70-109 0,2 0,5 1 1,5 110-119 0,5 1 2 3 120-149 1 1,5 3 5 150-179 1,5 2 4 7 180-209 2 3 5 9 210-239 2 4 6 12 240-269 3 5 8 16 270-299 3 6 10 20 300-329 4 7 12 24 330-359 4 8 14 28 >360 6 12 16 28