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

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

*
Ketosis
Hyperglycemia
Adapted from Kitabchi AE, Fisher JN. Diabetes Mellitus. In: Glew RA, Peters SP, ed. Clinical
Studies in Medical Biochemistry. New York, NY: Oxford University Press; 1987:105.
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PATHOGENESIS AND
PATHOPHYSIOLOGY

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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, kurangnya

pemberian insulin)

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 Insulin Deficiency

Hyperglycemia

Hyper-
osmolality
Glycosuria

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

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)

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Krisis Hiperglikem Diabetes

Diabetic Ketoacidosis Hyperglycemic Hyperosmolar State

(DKA) (HHS)

Usia muda, diabetes tipe 1 Usia tua, diabetes tipe 2

Hiperosmolalitas - Hiperosmolalitas +

Penipisan volume Penipisan volume

Gangguan elektrolit Gangguan elektrolit

Asidosis + Asidosis -

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

Monitoring Koreksi
pasien yg ketat hiperglikemia

TERAPI

Koreksi
Identifikasi
gangguan
faktor
keseimbangan
presipitasi
elektrolit
Terapi Cairan
Rata-rata kekurangan cairan pd KAD 3-5L, 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)