emergency diabetes mellitus

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Penatalaksanaan Terkini egawatdaruratan pada Diabete Sarwono Waspadji Pusat Diabetes dan Lipid, Divisi Metabolik-Endokrin, Departemen Ilmu Penyakit Dalam, FKUI / RSUPN Cipto Mangunkusumo, Jakarta

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Page 1: Emergency Diabetes Mellitus

Penatalaksanaan Terkini Kegawatdaruratan pada Diabetes

Sarwono Waspadji

Pusat Diabetes dan Lipid,

Divisi Metabolik-Endokrin, Departemen Ilmu Penyakit Dalam,

FKUI / RSUPN Cipto Mangunkusumo,

Jakarta

Page 2: Emergency Diabetes Mellitus

Diabetic ComplicationsDiabetic Complications

• Diabetic Ketoacidosis = DKA• Hyperosmolar Hyperglycemia Nonketoric Coma = HHNC

• Diabetic Ketoacidosis = DKA• Hyperosmolar Hyperglycemia Nonketoric Coma = HHNC

Retinopathy Nephropathy

Neuropathy

Retinopathy Nephropathy

Neuropathy

MacroangiopathyMacroangiopathy

Chronic :Chronic :Acute Acute

MicroangiopathyMicroangiopathy

CADPVD

Stroke

CADPVD

Stroke

• Hypoglycemia

• Metabolic Decompensation

Page 3: Emergency Diabetes Mellitus

Sebab Kesadaran Menurun pada Diabetes MelitusSebab Kesadaran Menurun pada Diabetes Melitus

Ketoasidosis DiabetikHiperosmolar non KetotikAsidosis Laktat

HipoglikemiaSebab Lain - Trauma

- Obat - Penyakit Lain :

Stroke Koma hepatik Uremik

Ketoasidosis DiabetikHiperosmolar non KetotikAsidosis Laktat

HipoglikemiaSebab Lain - Trauma

- Obat - Penyakit Lain :

Stroke Koma hepatik Uremik

Page 4: Emergency Diabetes Mellitus

Diagnosis Banding Koma Glukosa Keton Hipervent. Dehid. TD Kulit mg/d L

DKA >300 +s/d4+ ++ ++ N/ hngt

HONK >500 0 s/d+ 0 +++ N/ N

Hipoglik < 50 0 0 0 N lmb

Asidosis Laktat 20-200 trc s/d + +++ 0 Rnd hngt

Non N/ 0 s/d trc 0 s/d + 0 s/d + Variasi NMetab

Page 5: Emergency Diabetes Mellitus

HipoglikemiaSimtom:

Efek adrenergik alfa: sekresi insulin menurun, cerebral blood flow meningkatperipheral vasoconstriction

Efek adrenergik beta: glycogenolisis otot dan hatistimulasi release glukagonlipolisisuptake glukosa otot menurunincrease c.o.p, cerebral flow

Efek adrenomedullary discharge of Catecholamineaugmentasi efek adrenergik alfa dan beta

Gejala neuroglikopenik, gejala adrenergikHipoglikemia kronik berkepanjangan - demensia

Page 6: Emergency Diabetes Mellitus

Kadar Glukosa Darah dan Gejala Hipoglikemik Akut

g 72luk 54o sa 36

d a 18rah

................................................................. Neuroglikopenia Disfungsi Kognitif ringan

................................................................ Aktivasi gejala Keringat autonomik Gemetar ..................................... Berdebar ...... Neuroglikopenia berat Kejang ............................................................... Koma Waktu

Page 7: Emergency Diabetes Mellitus

Diagnosis Relatif mudah: pemeriksaan GDTrias Whipple:

Keluhan dan gejala hipoglikemia s/d kesadaran menurun, Kadar Glukosa < 45 mg/dL (pada wanita dapat < 30 mg/dL), Bangun kembali setelah diberikan glukosa

Perlu pemantauan yang lama jika pasien memakai obat long acting

Jika hipoglikemia berkelanjutan dapat menyebabkan kerusakan otak permanen, demensia

Respons Perubahan Hormonal pada Hipoglikemia:Penurunan sekresi insulinPeningkatan katekolamin dan epinefrinPeningkatan sekresi glukagonPeningkatan sekresi kortisolPeningkatan hormon pertumbuhan

Page 8: Emergency Diabetes Mellitus

Penatalaksanaan HipoglikemiaRingan: Berikan gula murni (bukan pemanis) yang

cukup sampai keluhan hilang Pastikan pemberian makanan / kalori cukup

untuk selanjutnya, terutama jika OAD long acting

Berat: Berikan glukosa 40 % IV sampai pasien sadar Berikan infus rumatan D10 6-8 jam perkolf cek glukosa darah setiap jam

jika < 100 mg/dL berikan kembali bolus D40Jika sudah 2 kali berturut-turut >100 mg/dL, setiap 2 jamJika sudah 2 kali berturut-turut > 100 md/dL, setiap 4 jam,dst sampai yakin bahwa kadar glukosa darah stabil aman

Perhatikan obat hipoglikemik yang dipakai:Obat kerja panjang, pemantauan dapat lama, berhari

Perhatikan pula fungsi ginjal dan hati dan usia pasien

Page 9: Emergency Diabetes Mellitus

Oral Antidiabetic Agents: side effects

TZDs

Met

form

in

Insu

lin

secr

etag

ogues

Risk of hypoglycaemia

Weight gain

Gastrointestinal side-effects

Adapted from DeFronzo RA. Ann Int Med. 1999; 131: 281–303.

-glu

cosi

dase

inhib

itors

*Observed in patients with renal impairment

Oedema

Lactic acidosis –

*

Anaemia – –

Page 10: Emergency Diabetes Mellitus

Principles in Selecting Antihyperglycemic Interventions

• Effectiveness in lowering blood glucose• Extraglycemic effect that may reduce

longterm complications• Safety profile• Tolerability• Ease of use• Cost

Nathan DM et al. Clinical Diabetes. 2009; 27 (1): 4-16

Page 11: Emergency Diabetes Mellitus

Diagnosis Type 2 DMDiagnosis Type 2 DM

Lifestyle changesLifestyle changes

A1C (%)* A1C (%)*

6.5-76.5-7 7-87-8 8-108-10

Oral CombinationOral# :•SU•Metformin•AGI•TZD•MeglitinidesSpecific condition:•Short/Rapid-acting Insulin analog•Pre-mixed Insulin analog

Oral CombinationOral# :•SU•Metformin•AGI•TZD•MeglitinidesSpecific condition:•Short/Rapid-acting Insulin analog•Pre-mixed Insulin analog

Monotherapy* :•Metformin•AGI•TZDSpecific Condition:•SU •Meglitinides•Short/Rapid-actingInsulin analog

Monotherapy* :•Metformin•AGI•TZDSpecific Condition:•SU •Meglitinides•Short/Rapid-actingInsulin analog

Combination Oral+Insulin :•Metformin•TZD•SU•Long-acting Insulin•Short/Rapid-acting Insulin analog•Pre-mixed Insulin analog•NPH•Other Combination

Combination Oral+Insulin :•Metformin•TZD•SU•Long-acting Insulin•Short/Rapid-acting Insulin analog•Pre-mixed Insulin analog•NPH•Other Combination

>10>10

Insulin Therapy:•Short/Rapid-acting Insulin analog•NPH or Long-acting Insulin•Pre-mixed Insulin analogIn selected Patients with A1C> 10% OHO Combination might be effective

Insulin Therapy:•Short/Rapid-acting Insulin analog•NPH or Long-acting Insulin•Pre-mixed Insulin analogIn selected Patients with A1C> 10% OHO Combination might be effectiveTarget

AchievedTarget

AchievedTarget

not Achieved

Targetnot

Achieved

TargetAchieved

TargetAchievedTarget

AchievedTarget

Achieved

TargetAchieved

TargetAchieved

Targetnot

Achieved

Targetnot

Achieved Targetnot

Achieeved

Targetnot

Achieeved

Targetnot

Achieved

Targetnot

AchievedIntensificationTherapy OR

IntensificationTherapy OR

ContinueTreatmentContinue

Treatment

ContinueTreatmentContinue

Treatment IntensificationTherapy OR

IntensificationTherapy OR Continue

TreatmentContinue

Treatment IntensificationTherapy OR

IntensificationTherapy OR

ContinueTreatmentContinue

Treatment

Intensification of Insulin Treatment

Basal+bolus

Intensification of Insulin Treatment

Basal+bolus

Algorithm for Management of Type 2 DM without Metabolic Decompensation Indonesian Society of Endocrinology 2007

ContinueContinue

<6.5<6.5

Blood Glucose Monitoring (FPG, PPG, Bed time)

*surrogate average blood glucosemight be used

Page 12: Emergency Diabetes Mellitus

Management of HyperglycemiaIn PatientsGeneral Principles:

Maximal blood glucose control, avoiding hypoglycemia Meticulous, Prudent, IndividualizedManagement of T2DM synchronized with other disease management

In critically ill patients, more over in metabolic decompensation, the blood glucose target should be more aggressive and achieved quicker

Page 13: Emergency Diabetes Mellitus

Sasaran Glukosa darah yang dianjurkan

Pasien Tidak Kritis : Senormal mungkin(110 – 180 mg/dL)Insulin mungkin diperlukanSedekat mungkin dengan 130 mg/dL

Pasien Kritis: Senormal mungkin (110 – 180 mg/dL)Umumnya memerlukan insulinSedekat mungkin dengan 110 mg/dL

* Beberapa Institusi mungkin menganggap nilai ini terlalu over agresif karena kepedulian akan risiko hipoglikemia

A D A Clinical Practice RecommendationDiabetes Care. 2007;3(suppl 1): S 32-33

Page 14: Emergency Diabetes Mellitus

The Nice-Sugar StudyICU setting 3 or more consecutive days

Intensive (81-108 mg/dL)Conventional (<180 mg/dL)Outcome mortality at 90 days

3054 intensive control vs. 3050 conventional Similar characteristic baselinePrimary outcome available for 3010 and 3012 respectively

829 (27.5 %) mortality in intensive control, OR 1.14751 (24.9%) mortality in conventional group

Severe hypoglycemia (< 40 mg/dL)206 (6.8%) in intensive control15 (0.5 %) in conventional group

The NICE Sugar study investigators. Intensive vs. conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-97

Page 15: Emergency Diabetes Mellitus

Blood Glucose TargetCritically ill surgical patients: as normal as possible

(110 – 140 mg/dL)*Insulin is needed, IV protocolClose to 110 mg/dL (A)

Critically ill non surgical pts: as normal as possible (110 – 140 mg/dL)*Insulin is needed, IV protocolKeep BG < 140 mg/dL (C)

Non critically ill: as normal as possible, no specific goalsInsulin is preferredFBG <126 mg/dL, Random BG<180-200 mg/dL (E)

* Some institutions might considered this blood glucose target as over aggressive due to their cautious attitude toward hypoglycemia

A D A Clinical Practice RecommendationDiabetes Care. 2009;32(suppl 1): S 32-33

Pemantauan kadar glukosa darah harus cermat

Page 16: Emergency Diabetes Mellitus

Hyper-glycemia Acidosis

Ketosis

DKA

Kitabchi and Wall

Hyperglycemia states•DM•HHNC •IGT•Stress

Metabolic Acidosis states•Lactic acidosis•Hyperchloremic acidosis•Salicylism

•Uremic acidosis•Drug-induced acidosis

Ketotic states•Ketotic hypoglycemia•Alkaholic ketosis•Starvation ketosis

Page 17: Emergency Diabetes Mellitus

DKA Episode and Mortality Rate at Dr. Cipto Mangunkusumo Hospital,

Jakarta

Year Number of Cases Mortality rate %

1983-84 (9 months) 14 31,41984-88 (48 months) 55 401995 (12 months) 17 -1997 (6 months) 23 18,71998-99 (12 months) 37 512002 (5 months) 39 15

Page 18: Emergency Diabetes Mellitus

Pathogenesis of DKA and HHNC

HHNCDKA

Page 19: Emergency Diabetes Mellitus

Precipitating Factors of DKA & HHNC Infection Cerebro vascular accident Pancreatitis Myocardial infarction Trauma Medication Newly diagnosed type 1 diabetes Discontinuation of or inadequate insulin Substance abuse Not found

Page 20: Emergency Diabetes Mellitus

Clinical Features of DKA

• Abdominal pain• Leg cramps• Nausea and

vomiting• Confusion and

drowsiness• Coma

• Polyuria and nocturia

• Weight loss• Weakness• Blurred vision• Kussmaul

respiration

Page 21: Emergency Diabetes Mellitus

DKA HHNC

HHNC

Page 22: Emergency Diabetes Mellitus

HHNC

Page 23: Emergency Diabetes Mellitus

Principal Management of DKA and HHNC

Page 24: Emergency Diabetes Mellitus

Hour Hydration Insulin K+Correction HCO3- correction

0 guyur 50 mEq per If pH• guyur six hour <7 7-7.1

>7.1• guyur Start hour 2

iv bolus iv, Cont by infusion

dst dst dst

Hour Hydration Insulin K+Correction HCO3- correction

0 guyur 50 mEq per If pH• guyur six hour <7 7-7.1

>7.1• guyur Start hour 2

iv bolus iv, Cont by infusion

dst dst dst

Management of DKA at Cipto Mangunkusumo Hospital, Jakarta

Management of DKA at Cipto Mangunkusumo Hospital, Jakarta

A B C D EA B C D E

Page 25: Emergency Diabetes Mellitus

Penatalaksanaan Ketoasidosis Diabetik

* 1 jam 2 kolf, 1 jam 1 kolf, dst * Na Cl Fisiologis * 1/2 N, 2A - Kalau Na > 150 mek/l

1. Rehidrasi Cepat

2. Insulin

Bolus 10 U IV. G.D setiap jamDrip 5 U/jam sampai g.d. < 200 mg/dl - D5 %Drip 2,5 U/jam sampai g.d. stabil 200 - 300 mg/dlDrip 1 U/jam + sliding scale g.d. tiap 4 jam Dosis terbagi 3-4 kali sehari

3.Kalium < 3,5 mek/L -- 50 mek/L3,5 - 5 mek/L -- 25 mek/L>5 mek/L -- 0

4. Na HCO3 pH < 7 - 7,15. Faktor Presipitasi

***Dosis Kecil 5 U IM *** Pemantauan dengan Urin

Page 26: Emergency Diabetes Mellitus

Suhendro 2008Pengukuran asam laktat perlu pada pengelolaan KADSerum laktat > 4 mmol/L petanda prognostik burukJika disertai kesadaran menurun prognostik buruk

Perlu pengelolaan yang ketat sejak awalPasang CVP segeraHidrasi dicapai dengan lebih cepat

Page 27: Emergency Diabetes Mellitus

Prevention (1)• Better access to medical care

– Intensive patients education– Effective communication acute illness

• Review sick-day management– Insulin treatment– Blood glucose goal– Treat fever and infection– Start easy digestible liquid diet

• Do not stop insulin or oral anti diabetes

Page 28: Emergency Diabetes Mellitus

Prevention (2)

• Increase BG monitoring during acute illness

• Check ketone bodies (either urine or blood) when BG > 300 mg/dL

Page 29: Emergency Diabetes Mellitus

Peran Dokter UmumPencegahan terjadinya Hiperglikemiadengan mengelola DM sebaik-baiknya

mencegah komplikasi kronik mencegah komplikasi akut DKAmenghindari komplikasi hipoglikemia

Page 30: Emergency Diabetes Mellitus

Jika menjumpai pasien tersangka komplikasi akut:Pastikan bukan hipoglikemia, kalau ragu,

jangan takut memberikan D40 Jika bukan hipoglikemia, tetapi KAD:

Infus NaCl dan segera kirim ke RSJikalau ada (misal di RS primer)

dapat diberikan insulin, kemudian rujukMemerlukan perawatan yang cermat, segera

di RS dengan peralatan yang memadai

Page 31: Emergency Diabetes Mellitus

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Hatur Nuhun