DIABETIC

KETOACIDOSIS
HYPERGLYCEMIC
HYPEROSMOLAR
STATE
DKA DAN HHS

DKA dan HHS

Hyperglycemic Hyperosmolar State
Diabetic Ketoacidosis (DKA)
(HHS)

Kadar gula darah >250 mg/dL Kadar gula darah >600 mg/dL

PH Arteri <7.3 PH Arteri >7.3

Kadar Bicarbonat <15 mEq/L Kadar Bicarbonate >15 mEq/L

Ketonuria atau ketonemia Ketonuria dan ketonemia minimal

Anion gap >12 mEq/L Osmolalitas serum >320 mosm/L

2

but Typically presents in type 2 or previously increasingly seen in type 2 diabetes unrecognized diabetes Higher mortality rate 3 .Karakteristik Hyperglycemic Hyperosmolar State Diabetic Ketoacidosis (DKA) (HHS) Absolute (or near-absolute) insulin Severe relative insulin deficiency. resulting in resulting in • Severe hyperglycemia • Profound hyperglycemia and • Ketone body production hyperosmolality (from urinary free • Systemic acidosis water losses) • No significant ketone production or acidosis Develops over hours to 1-2 days Develops over days to weeks Most common in type 1 diabetes. deficiency.

Clinical Studies in Medical Biochemistry. Fisher JN. New York. 4 . NY: Oxford University Press. Definition of Diabetic Ketoacidosis* Acidosis * Ketosis Hyperglycemia Adapted from Kitabchi AE. 1987:105. ed. In: Glew RA. Diabetes Mellitus. Peters SP.

PATHOGENESIS AND PATHOPHYSIOLOGY 5 .

kurangnya pemberian insulin) 6 .Diabetic Ketoacidosis: Pathophysiology Unchecked gluconeogenesis  Hyperglycemia Osmotic diuresis  Dehydration Unchecked ketogenesis  Ketosis Dissociation of ketone bodies into Anion-gap metabolic  hydrogen ion and anions acidosis • Seringkali peristiwa pencetus diidentifikasi (infeksi.

Insulin Deficiency Hyperglycemia Hyper- osmolality Glycosuria Δ MS Dehydration Electrolyte Renal Failure Losses Shock CV Collapse 7 .

Insulin Deficiency Lipolysis FFAs Ketones Acidosis CV Collapse 8 .

Insulin Deficiency Hyperglycemia Lipolysis Hyper- osmolality Glycosuria FFAs Δ MS Ketones Dehydration Acidosis Electrolyte Renal Failure Losses Shock CV Collapse 9 .

Hyperosmolar Hyperglycemic State: Pathophysiology Unchecked gluconeogenesis  Hyperglycemia Osmotic diuresis  Dehydration • Menyajikan umum dengan gagal ginjal • insulin tidak mencukupi untuk pencegahan hiperglikemia tetapi cukup untuk menekan lipolisis dan ketogenesis • Tidak adanya asidosis signifikan • Sering diidentifikasi acara pencetus (infeksi. MI) 10 .

diabetes tipe 1 Usia tua. Hiperosmolalitas + Penipisan volume Penipisan volume Gangguan elektrolit Gangguan elektrolit Asidosis + Asidosis - 11 .Krisis Hiperglikem Diabetes Diabetic Ketoacidosis Hyperglycemic Hyperosmolar State (DKA) (HHS) Usia muda. diabetes tipe 2 Hiperosmolalitas .

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Gambaran klinis DKA Anamnesis Pemeriksaan fisik • Haus • Pemeriksaan fisik • Poliuria • Respirasi kussmaul • Nyeri perut • Napas fruity • Mual atau muntah • Hipotermia relatif • Kelemahan yang mendalam • Takikardia • Hipotensi terlentang. penurunan ortostatik tekanan darah • Membran mukosa kering • Turgor kulit buruk .

Lab pada DKA • Hiperglikemia • Ketonuria dan kenonemia • bikarbonat rendah • gap anion tinggi • pH arteri rendah • PCO2 rendah (kompensasi pernapasan) .

Gambaran klinis HHS • Dehidrasi • hiperglikemia • hipernatremia • Hiperosmolalitas • Ketonuria dan ketonemia minimal / tidak ada .

which • Greater osmolality and mental may have been unrecognized status changes than DKA • Dehydration presenting with a shock-like state 16 .Clinical Presentation of Hyperglycemic Hyperosmolar State Patient Profile Disease Characteristics • Older • More insidious development than • More comorbidities DKA (weeks vs hours/days) • History of type 2 diabetes.

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Koreksi dehidrasi Monitoring Koreksi pasien yg ketat hiperglikemia TERAPI Koreksi Identifikasi gangguan faktor keseimbangan presipitasi elektrolit .

HHS  10L/lebih • Tujuan : • Memperbaiki volume intravaskular dan ekstravaskular • Mempertahankan perfusi ginjal • Menurunkan kadar glukosa darah tanpa bergantung pada insulin • Menurunkan hormon kontra insulin (perbaikan sensitivitas thd insulin) .Terapi Cairan • Rata-rata kekurangan cairan pd KAD  3-5L.