COLLECTING JURNAL 1

KEPERAWATAN GAWAT DARURAT 2

KETOASIDOSIS DIABETIKUM

Untuk Memenuhi Tugas Mata Kuliah Keperawatan Gawat Darurat 2

Disusun oleh

ANI SUCIATI

A11601244

PROGRAM STUDI S1 KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN MUHAMMADIYAH

GOMBONG

2018
A. JUDUL DAN ABSTRAK JURNAL

1. Pyruvate Dehydrogenase Activity Is Decreased in Emergency

Department Patients With Diabetic Ketoacidosis
Abstrac
Objectives: The pyruvate dehydrogenase complex (PDH) is an
essential enzyme in aerobic metabolism. Ketones are known to inhibit
PDH activity, but the extent of this inhibition is unknown in patients with
diabetic ketoacidosis (DKA).
Methods: We enrolled adult patients presenting to the emergency
department in hyperglycemic crisis. Patients were classified as DKA or
hyperglycemia without ketoacidosis based on laboratory criteria.
Healthy controls were also enrolled. PDH activity and quantity were
measured in isolated peripheral blood mononuclear cells. We
compared PDH values between groups and measured the relationship
of PDH values to measures of acid–base status.
Results: Twenty-seven patients (17 with DKA) and 31 controls were
enrolled. Patients with DKA had lower PDH activity and quantity
compared to the two other groups. PDH activity was significantly
correlated with serum bicarbonate and pH and inversely correlated with
the anion gap.
Conclusions: DKA is associated with greater suppression of PDH
activity than hyperglycemia without ketoacidosis, and this is correlated
with measures of acid–base status. Future studies may determine
whether PDH depression plays a role in the pathophysiology of DKA
and whether modification of PDH could decrease time to DKA
resolution.

2. A randomized controlled trial of one bag vs. two bag system of

fluid delivery in children with diabetic ketoacidosis: Experience
from a developing country

Abstract
Purpose: To compare one vs. two bag systemwith respect to blood
glucose variability (BGV), time for resolution ofacidosis and incidence
 of hypoglycemia, hypokalemia, and cerebral edema in childrenwith
diabetic ketoacidosis (DKA).
Material and methods: In an open labelled randomized controlled
trial, thirty consecutive patients ≤12 years with DKA were randomized
to either one (n = 15) or two bag (n = 15) system of intravenous fluid
delivery. The two bags had similar electrolyte but differing dextrose
concentration (none vs. 12.5%) and changing the rate of fluid,
delivered different dextrose concentrations. BGV was primary
outcome while hypoglycemia (blood glucose, BG b 50 mg/dL),
hypokalemia (serum potassium b 3.5 mEq/L), time to resolution of
acidosis and cerebral edema were secondary outcomes.
Results: The one and two bag systems had similar BGV parameters;
median hourly absolute BG change (mg/dL) [44 (30–74.5) vs. 36 (31–
49); p = 0.54], mean of standard deviation of BG measurements [65.1
(25.1) vs. 65.5 (26.8); p = 0.96] and median number of undesirable
events (hourly blood sugar change ≥50 mg/dL) [4.5 (1.75–6.0) vs. 5.0
(3.0–8.0); p = 0.31]. The incidence of hypoglycemia [42.9% (n = 6) vs.
26.7% (n = 4); p = 0.45] and hypokalemia [64% (n = 9) vs. 67% (n =
10); p = 0.23], and mean (SD) time to resolution of acidosis [20.3
(14.8) and 20.3 (7.0); p = 0.59] were similar in both the groups. None
had cerebral edema.
Conclusions: The one and two bag systems were similar to each
other with respect to BGV, incidence of complications and time to
resolution of acidosis.

3. Fluid Management in Pediatric Patients with DKA and Rates of

Suspected Clinical Cerebral Edema
Abstract
Background/Objective—To compare DKA outcomes 6 years before
and 6 years after changing rehydration fluids from ½ normal saline to
Lactated Ringer's and decreasing the total intended fluid volume
administered in the first 24 hours from 3500 mL-m-2-day-1 to ≤ 2500
mL- m-2-day-1 at Texas Children's Hospital (TCH) in response to
recommendations by the ESPE, LWPES, and ISPAD in 2004.
 Subjects/Methods—A retrospective cohort study was conducted in
which 1868 admissions for DKA were identified and reviewed. The
cohort was divided into 2 groups: Group A, 1998-2004 and Group B,
2004-2010. Subjects with suspected clinical cerebral edema and
adverse outcomes were identified.
Results—Although not statistically significant, there was an equal
number (n=3) of adverse outcomes (death or neurological damage) in
each group despite more than double the admissions in Group B
(1264) compared to Group A (604). Overall, the incidence of
suspected clinical cerebral edema was more than double for those
admissions in which fluid resuscitation was initiated at an outside
hospital versus at TCH (13.6% vs 5.3%, p<0.001).
Conclusions—Decreasing the intended fluid rate during the initial 24
hours to 2500 mL-m-2-day-1 and increasing the IV fluid sodium
content did not significantly decrease the incidence of adverse
outcomes in children with DKA. However, children transferred from
outside hospitals had a higher incidence of suspected clinical cerebral
edema. Thus, we need to more readily share our management
protocols with the emergency rooms of local referring hospitals to
potentially decrease the incidence of suspected clinical cerebral
edema and adverse outcomes in children transferred with DKA.

B. DAFTAR KUMPULAN JURNAL

N Author Tahun Sampel Metode Hasil Kesimpulan

o
1 Lars W. 2016 We enrolled PDH activity Twenty-seven patients (17 DKA is associated
Andersen, adult patients and quantity with DKA) and 31 controls with greater
MD, presenting to were were enrolled. Patients suppression of PDH
Katherine the emergency measured in with DKA had lower PDH activity than
M. Berg, department in isolated activity and quantity hyperglycemia
MD, hyperglycemic peripheral compared to the two other without ketoacidosis,
Sophia crisis. Patients blood groups. PDH activity was and this is correlated
Montissol, were classified mononuclear significantly correlated with measures of
Christoph as DKA or cells. We with serum bicarbonate acid–base status.
 er hyperglycemia compared and pH and inversely Future studies may
Sulmonte, without PDH values correlated with the anion determine whether
Julia ketoacidosis between gap. PDH depression
Balkema, based on groups and plays a role in the
Michael N. laboratory measured pathophysiology of
Cocchi, criteria. the DKA and whether
MD, Healthy relationship modification of PDH
Richard E. controls were of PDH could decrease time
Wolfe, also enrolled. values to to DKA resolution.
MD, measures of
Ashok acid–base
Balasubra status.
manyam,
MD,
Xiaowen
Liu, PhD,
and
Michael
W.
Donnino,
MD
2 N. 2017 In an open The two bags The one and two bag The one and two
Dhochak, labelled had similar systems had similar BGV bag systems were
MD, M. randomized electrolyte parameters; median hourly similar to each other
Jayashree controlled trial, but differing absolute BG change with respect to BGV,
, MD, thirty dextrose (mg/dL) [44 (30–74.5) vs. incidence of
DNB, consecutive concentration 36 (31–49); p = 0.54], complications and
Professor patients ≤12 (none vs. mean of standard time to resolution of
, S. years with 12.5%) and deviation of BG acidosis.
Singhi, DKA were changing the measurements [65.1
MD, randomized to rate of fluid, (25.1) vs. 65.5 (26.8); p =
Professor either one (n = delivered 0.96] and median number
15) or two bag different of undesirable events
(n = 15) dextrose (hourly blood sugar
system of concentration change ≥50 mg/dL) [4.5
 intravenous s. BGV was (1.75–6.0) vs. 5.0 (3.0–
fluid delivery. primary 8.0); p = 0.31]. The
outcome incidence of hypoglycemia
while [42.9% (n = 6) vs. 26.7%
hypoglycemi (n = 4); p = 0.45] and
a (blood hypokalemia [64% (n = 9)
glucose, BG vs. 67% (n = 10); p =
b 50 mg/dL), 0.23], and mean (SD) time
hypokalemia to resolution of acidosis
(serum [20.3 (14.8) and 20.3 (7.0);
potassium b p = 0.59] were similar in
3.5 mEq/L), both the groups. None had
time to cerebral edema.
resolution of
acidosis and
cerebral
edema were
secondary
outcomes.
3 Daniel S 2016 A retrospective The cohort Although not statistically Decreasing the
Hsia, cohort study was divided significant, there was an intended fluid rate
M.D.1, was conducted into 2 groups: equal number (n=3) of during the initial 24
Sarah G in which 1868 Group A, adverse outcomes (death hours to 2500 mL-m-
Tarai, admissions for 1998-2004 or neurological damage) in 2-day-1 and
M.D.2, DKA were and Group B, each group despite more increasing the IV
Amir identified and 2004-2010. than double the fluid sodium content
Alimi, reviewed. Subjects with admissions in Group B did not significantly
M.D.3, suspected (1264) compared to Group decrease the
Jorge A clinical A (604). Overall, the incidence of adverse
Coss-Bu, cerebral incidence of suspected outcomes in children
M.D.3, edema and clinical cerebral edema with DKA. However,
and adverse was more than double for children transferred
Morey W outcomes those admissions in which from outside
Haymond were fluid resuscitation was hospitals had a
, M.D.1,4 identified. initiated at an outside higher incidence of
hospital versus at TCH suspected clinical
(13.6% vs 5.3%, p<0.001). cerebral edema.
Thus, we need to
more readily share
our management
protocols with the
emergency rooms of
local referring
hospitals to
potentially decrease
the incidence of
suspected clinical
cerebral edema and
adverse outcomes in
children transferred
with DKA.
 DAFTAR PUSTAKA

Michael W. Donnino, L. D. (2016). Pyruvate Dehydrogenase Activity Is

Decreased in Emergency Department Patients With Diabetic
Ketoacidosis. Academic Emergency Medicine, 685-688.

Morey W Haymond, D. d. (2016). Fluid Management in Pediatric Patients with

DKA and Rates of Suspected Clinical Cerebral Edema. Pediatr Diabetes,
1-13.

S. Singhi, N. M. (2018). A randomized controlled trial of one bag vs. two bag
system of fluid delivery in children with diabetic ketoacidosis: Experience
from a developing country. Journal of Critical Care, 340-345.
LAMPIRAN

1. Jurnal 1

2. Jurnal 2
3. Jurnal 3