KETOASIDOSIS

CRITERIA of DKA
DKA is diagnosed when patients with diabetes mellitus
exhibit BOTH hyperglycemia (blood glucose of >200
mg/dL [11 mmol/L]) and metabolic acidosis (venous
pH <7.3 and/or plasma bicarbonate <15 mEq/L [15
mmol/L]), caused by severe hyperketonemia
(concentration of total ketone bodies >5 mmol/L)
 CLASSIFICATION
Mild Moderate Severe
Defining features
Venous pH 7.2-7.3 7.1-7.2 <7.1
Serum
bicarbonat 10-15 5-10 <5
e (mEq/L)
 SIGN & SYMPTOM
The earliest symptoms are related to hyperglycemia.
Older children and adolescents typically present with :
polyuria (due to the glucose-induced osmotic diuresis)
polydipsia (due to the increased urinary losses),
Fatigue
Other findings include weight loss, nocturia (with or
without secondary enuresis), and daytime enuresis.
Hypovolemia may be severe if the urinary losses are
not replaced.
 SIGN & SYMPTOM
In infants, the diagnosis is more difficult because the
patients are not toilet trained and they cannot express
thirst.
As a result, polyuria may not be detected and
polydipsia is not apparent.
However, decreased energy and activity, irritability,
weight loss, and physical signs of dehydration are
common findings.
In addition, severe Candida diaper rash or otherwise
unexplained metabolic acidosis or hypovolemia
should heighten the suspicion for diabetes.
 SIGN & SYMPTOM
Polyphagia usually occurs early in the course of
the illness. However, once insulin deficiency
becomes more severe and ketoacidosis develops,
appetite is suppressed.
Hyperventilation & deep (Kussmaul) respirations
represent the respiratory compensation for
metabolic acidosis. respiratory rate should be
carefully observed. In infants, the hyperpnea may
be manifested only by tachypnea. Patients may
also have a fruity breath secondary to exhaled
acetone.
 Although children with DKA are volume
depleted, they are less likely to show the
classic signs of hypovolemia such as dry oral
mucous membranes and decreased skin
turgor than patients with the same degree of
weight loss from vomiting or diarrhea due to
gastroenteritis.
 SIGN OF DEHYDRATION
Ringan Sedang Berat
Turgor Kelopak Renjatan,
menurun mata Nadi tidak
Mukosa cekung, teraba atau
mulut Ubun-ubun lemah
kering cekung Hipotensi
takikardia Turgor oliguria
Takipnea menurun
lebih berat
 Neurologic findings, ranging from drowsiness,
lethargy, and obtundation to coma, are
related to the severity of hyperosmolality
and/or to the degree of acidosis . Cerebral
edema occurs in 0.5 to 1 percent of cases of
DKA in children, and is the leading cause of
mortality.
 FLUID & ELECTROLYTE
Average losses in severe DKA:
Water 70 (range 30 to 100) mL/kg
Sodium 5 to 13 mEq/kg
Potassium 6 to 7 mEq/kg
 LABORATORY FINDING
Initial laboratory testing should include
Glucose
Electrolytes= increase or decrease (Sodium, Potassium, and
Phosphate)
creatinine
blood urea nitrogen (increase in hypovolemic)
blood gases, and hematocrit.
Direct measurement of beta-hydroxybutyrate in the blood
should also be performed if possible.
The diagnosis of DKA is confirmed by the findings of
hyperglycemia, a high anion gap acidosis, ketonuria, and
ketonemia.
 MANAGEMENT
Fluid replacement
If shock = isotonic (NS or RL) 10-20 ml/ kg
bolus, may repeat if shock still present
Generally 10 ml/ kg/hour in one hour; can be
repeated if cardiovascular still compromised.
Only use crystaloid, not coloid
 To minimize risks for cerebral edema and
electrolyte imbalances, hypovolemia should
be corrected gradually. The maximal volume
of isotonic solution used for initial treatment
is 10 mL/kg, unless the patient is objectively
hypotensive.
PENGHITUNGAN KEBUTUHAN CAIRAN
A = Derajat dehidrasi (ringan, sedang)
B = A x kgBB x 1000 = B ml
C = Kebutuhan rumatan untuk 48 jam (Holiday
dan Segarr)
B + C = Kebutuhan total dalam 48 jam ml
Tetesan (ml) / jam = (B+C) / 48 jam
 FORMULA HOLIDAY dan SEGARR
KEBUTUHAN CAIRAN RUMATAN
kebutuhan Cairan per Hari
3 10 kg = 100 mL/kg
10 20 kg = 1000 mL + 50 ml/kg setiap kg
BB di atas 10 kg
20 kg = 1500 mL + 20 ml/kg setiap kg
BB di atas 20 kg
 TWO BAG SYSTEM
Contoh:
Kecepatan infus total = 200 mL/jam
Jenis cairan Kec infus A Kec infus B

Akhir (%) ml/jam ml/jam

D0 200 0

D5 100 100

D 7.5 50 150

D 10 0 200
 TERAPI INSULIN
Mulai infus insulin 1-2 jam setelah pemberian
cairan
0.1 unit/kgBB per jam
50 unit insulin reguler ditambahkan ke 50 mL
isotonic saline membentuk 1 unit per mL dari
infus.
 TERAPI INSULIN
Target kecepatan penurunan gula darah: 75 -
100 mg/dL/jam.
Gula darah mencapai 250-300 mg/dL, infus
diganti dengan D5% in S atau D5% in S
Laju kecepatan insulin dan pemberian
dekstrosa diatur sehingga kadar gula darah
berkisar antara 90 - 180 mg/dL.
Jika perlu koreksi Natrium.
 Konsentrasi awal sebaiknya tidak melebihi 40
mmol/ L,
Bila bersamaan dengan resusitasi cairan awal:
20 mmol/ L.
Selanjutnya tergantung kadar K selama
pemantauan.
Pegangan praktis: KCl 7,46 % => 1 mmol = 1 ml
Kalium plasma (mmol/L) KCL (Mmol/Kg/jam)
<3 0,5
3-4 0,4
4-5 0,3
5-6 0,2
>6 0
 PENGGANTIAN NATRIUM
Perkiraan corrected Na dapat diperhitungkan
dengan rumus:
Corrected Na = Na + [1,6(glukosa-100)/100]
glukosa dalam mg/dL
Na: 1 mmol/L = 1 mEq/dL.
Jadi tambahkan 1,6 mmol/L atau 1,6 mEq/dL
Na untuk setiap 100 mg/dL penurunan
glukosa untuk glukosa diatas 100 mg/dL.
 BIKARBONAT
Indikasi :
Asidosis berat (pH arteri < 6,9)
Hiperkalemia berat
Dosis:
1-2 mmol/ kg selama 1 jam
 Pantau tiap jam
Tanda vital : Sp02, bradikardi relatif.
Status neurologis: GCS; Kesadaran, gejala
peningkatan TIK(Bradikardi relatif, nyeri kepala,
kesadaran); gangguan neurologis seperti paralisis
nervus kranialis.
Jumlah insulin yang diberikan
Balans cairan
GD kapiler
 Pantau tiap 2 jam
Lab: elektrolit, GD, BUN, kalsium, Mg, P,
Hematokrit, AGD
Keton urin atau darah.
 EDEMA OTAK
Herniasi karena edema otak merupakan
komplikasi terapi pada DKA
akut dan tidak dapat diprediksi.
24 jam pertama pengobatan.
 FAKTOR RISIKO EDEMA OTAK
Hipokapnia
BUN yang meningkat
Asidosis berat
Pemberian bikarbonat sebagai koreksi asidosis
Kegagalan peningkatan natrium sewaktu diterapi
Pemberian cairan yang masif dalam 4 jam
pertama
Pemberian insulin pada awal terapi cairan
 MANAJEMEN EDEMA OTAK
Waktu penanganan yang efektif sangatlah
pendek.
Posisikan kepala lebih tinggi
Bila ragu-ragu segera berikan Mannitol 0,5-1
g/kgBB IV drip (20 menit), diulang bila tidak
respons dalam 30 menit-2 jam
Kecepatan cairan iv dikurangi 1/3 nya
Alternatif : NaCl 3% -- 5-10mL/kg dalam 30
menit
 TANDA-TANDA EDEMA OTAL
Peningkatan TD
Penurunan saturasi O2
Tanda neurologis spesifik
Perubahan status neurologis (gelisah, irritabel
pusing)
Nyeri kepala dan laju jantung/ nadi menurun