DIABETICUM KETOACIDOSIS

Ach. Najich RF, dr.

 TERMINOLOGI

• Ketoasidosis Diabetikum (KAD)

 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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 EPIDEMOLOGI

• Despite advancements in self-care of patients with diabetes, DKA

accounts for 14% of all hospital admissions of patients with diabetes
and 16% of all diabetes-related fatalities. Almost 50% of diabetes-
related admissions in young persons are related to DKA. DKA
frequently is observed during the diagnosis of type 1 diabetes and
often indicates this diagnosis. While the exact incidence is not
known, it is estimated to be 1 out of 2000.
• DKA occurs primarily in patients with type 1 diabetes. The incidence
is roughly 2 episodes per 100 patient years of diabetes, with about
3% of patients with type 1 diabetes initially presenting with DKA. It
can occur in patients with type 2 diabetes as well; this is less
common, however.
• The incidence of diabetic ketoacidosis in developing countries is not
known, but it may be higher than in industrialized nations.[
 Hospital Discharges for Diabetic
Ketoacidosis (DKA) in the US
• In 2005, diagnosis of DKA was present on
– 120,000 discharges
– 7.4 discharges per 1000 DM patient population
• There was a higher rate of DKA for persons
<age 45
– 55.4 discharges/1000 DM patient population (1987)
– 31.6 discharges/1000 DM patient population (2005)

CDCP. Diabetes Data and Trends. Hospitalization. Available from:

http://www.cdc.gov/diabetes/statistics/hospitalization_national.htm#5 5
 ETIOLOGI

• The most common scenarios for diabetic ketoacidosis (DKA) are underlying or concomitant
infection (40%), missed or disrupted insulin treatments (25%), and newly diagnosed, previously
unknown diabetes (15%). Other associated causes make up roughly 20% in the various
scenarios.
• Causes of DKA in type 1 diabetes mellitus include the following:[5]
• In 25% of patients, DKA is present at diagnosis of type 1 diabetes due to acute insulin deficiency
(occurs in 25% of patients)
• Poor compliance with insulin through the omission of insulin injections, due to lack of
patient/guardian education or as a result of psychological stress, particularly in adolescents
• Missed, omitted or forgotten insulin doses due to illness, vomiting or excess alcohol intake
• Bacterial infection and intercurrent illness (eg, urinary tract infection [UTI])
• Klebsiella pneumoniae (the leading cause of bacterial infections precipitating DKA)
• Medical, surgical, or emotional stress
• Brittle diabetes
• Idiopathic (no identifiable cause)
• Insulin infusion catheter blockage
• Mechanical failure of the insulin infusion pump
• Causes of DKA in type 2 diabetes mellitus include the following:[6]
• Intercurrent illness (eg, myocardial infarction, pneumonia, prostatitis, UTI)
• Medication (eg, corticosteroids, pentamidine, clozapine)
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

• Often a precipitating event is identified (infection, lack of insulin

administration)

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 Insulin Deficiency

Hyperglycemia

Hyper-
osmolality
Glycosuria

Δ MS
Dehydration

Electrolyte
Renal Failure Losses

Shock CV
Collapse 8
Insulin Deficiency

Lipolysis

FFAs

Ketones

Acidosis

CV
Collapse 9
 Insulin Deficiency

Hyperglycemia Lipolysis

Hyper-
osmolality
Glycosuria FFAs

Δ MS Ketones
Dehydration
Acidosis
Electrolyte
Renal Failure Losses

Shock CV
Collapse 10
 Clinical Presentation of
Diabetic Ketoacidosis

History Physical Exam

• Thirst • Kussmaul respirations
• Polyuria • Fruity breath
• Abdominal pain • Relative hypothermia
• Nausea and/or vomiting • Tachycardia
• Profound weakness • Supine hypotension,
orthostatic drop of blood
pressure
• Dry mucous membranes
• Poor skin turgor

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 Lab Findings in DKA

• Severe hyperglycemia
• Increased blood and urine ketones
• Low bicarbonate
• High anion gap
• Low arterial pH
• Low PCO2 (respiratory compensation)

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 Treatment

Fase I 1. Rehidrasi: Nacl

0,9% / RL 2 liter/
2 jam, 80 tts/mt
4 jam, 30 tts/mt
18 jam, 20
tts/mt 24 jam.
2. IDRIV: minus satu
3. K: 25 meq (3-35) dst
4. Bikarbonat:
pH≤7,2-7,3 50-100 meq
drip dlm 2 j BIK <12 20
tts/mt
pH < 7 25 meq bolus
sisanya 20 ttsx/mt
5. Antibiotik
Glukosa +/- 250 mg/dl atau reduksi ±
Fase II 1. Maintenance: Nacl
0,9% Potacol R ( RI 4U -
8U ) , Maltosa 10% (RI6-
12U) bergantian 20
tts/mt (start slow, go
slow, stop slow)
2. K < 4 parenteral, per
os dg air tomat/ kaldu
3. RI: rumus kali dua
4. Makanan lunak:KH
kom pleks per-os
 DKA and HHS Are Life-Threatening
Emergencies

Diabetic Ketoacidosis (DKA) Hyperglycemic Hyperosmolar State (HHS)

Plasma glucose >250 mg/dL Plasma glucose >600 mg/dL

Arterial pH <7.3 Arterial pH >7.3

Bicarbonate <15 mEq/L Bicarbonate >15 mEq/L

Moderate ketonuria or ketonemia Minimal ketonuria and ketonemia

Anion gap >12 mEq/L Serum osmolality >320 mosm/L

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 Characteristics of DKA and HHS
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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 Diabetic Hyperglycemic Crises

Diabetic Ketoacidosis Hyperglycemic Hyperosmolar State

(DKA) (HHS)

Younger, type 1 diabetes Older, type 2 diabetes

No hyperosmolality Hyperosmolality

Volume depletion Volume depletion

Electrolyte disturbances Electrolyte disturbances

Acidosis No acidosis

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