Hiperglikemia, hipoglikemia,

hiperosmolar asidosis non

ketotik

Pengampu: Prof. dr. Burhanuddin Nst, SpPK-

KN,KGEH
 Hiperglikemi
– Didefenisikan sebagai kadar glukosa darah yang tinggi dari
rentang kadar puasa normal 126 mg/dL darah.
– Disebabkan :
– Ketiadaan insulin absolut  DM Tipe 1
– Kurang responsivitas sel thdp insulin dan defisiensi sekresi  DM Tipe 2
– Hiperkortisolemia  Cushing syndrome
– Keadaan akut  hormon tiroid, prolaktin, growth hormone
jangka panjang  diabetagenik
– Stimulasi saraf simpatis dan epinefrin kelenjar adrenal (Stres).
 Hipoglikemi
– Kadar glukosa darah yang kurang dari 50 mg/dL darah.
– Disebabkan :
– Fasting & Exercise
– Drug-induced hypoglycemia
» Sulfonylurea
» Metformin
» Insulin
» Ethanol
» Salicylates
– Insulinoma
– Extrapancreatic neoplasms
– Adrenocortical insufficiency
– Hypopituitarism
– Massive liver disease
 Diabetes mellitus
• Diabetes berasal dari bahasa yunani  “mengalirkan
atau mengalihkan”
• Mellitus dari bahasa latin  manis atau madu
• Diabetes mellitus  kedaan hiperglikemia akibat
ketiadaan absolut insulin & penurunan relatif
insensitivitas sel terhadap insulin.
• Epidemiologi ± 200 juta penderita DM di dunia
Glucose tolerance is classified into three categories
based on the FPG:

·         Normal:  FPG < 5.6 mmol/l (100 mg/dl)

· IFG: FPG >5.6 mmol/l (100 mg/dl) but <7.0 mmol/l (126 mg/dl)
·         Diabetes: FPG >7.0 mmol/l (126 mg/dl)
 ADA Recommendations for Diagnosing Diabetes

·         Diabetes symptoms (polyuria, polydipsia,  polyphagia,  increased fatigue, weight loss, blurred vision, growth
impairment) exist and casual plasma glucose ³200 mg/dl (11.1 mmol/l)

o        Note: casual is defined as any time of day without regard to time since last meal;
OR
·         FPG >126 mg/dl (7.0 mmol/l);
OR
·         Plasma glucose ³200 mg/dl (11.1 mmol/l) during an OGTT

If any of these test results occur, testing should be repeated on a different day to confirm the
diagnosis.
Hub. konsentrasi glukosa urin dgn KGD
 Komplikasi akut pada DM
• Ketoasidosis Diabetik (DKA)
• Koma Nonketotik Hiperglikemia Hiperosmolar
(Hyperosmolar hyperglycemic state (HHS)
• Dawn phenomenon (fenomena fajar)
• hipoglikemia
 Diabetic ketoacidosis
• DKA is a medical emergency with mortality rate about 5% it may the initial
manifestation of type 1 DM or may result from increase insulin requirement in
type 1 DM during the course of stress such as infection, trauma, surgery or MI
• Type 2 DM may develop ketoacidosis under severe stress
Precipitating factors:
• Acute infection
• Omission or reduction of the dose
• New onset of type 1 DM (about 25% pts of type 1 are 1st time diagnosed
when they present with ketoacisdosis)
 DIAGNOSIS
 Hyperglycemia
Usually > 250 mg/dl
 ketonuria and hyperketonemia
Urinary ketones strongly
 Metabolic acidosis
Blood PH< 7.3
Serum bicarbonate <15 meq/l
Pathophysiology
Hypoglycemia leads to hyperosmotic diuresis causing:
• Dehydration
• Hypovolemia
• K, Na and other electrolytes depletion.

Metabolic acidosis cause:

 Hyperventilation
 Negative inotrophic effect on the heart
 Peripheral vasodilatation (hypotension
 CLINICAL FEATURES
Features of dehydration and acidosis
Symptoms :
– Intense thirst
– Polyuria
– Nausea, vomiting
– Abdominal pain
 Signs
• Dry tongue, inelastic skin & sunken eyes.
• Kussmaul's respiration (rapid & deep breathing)
• Abdominal tenderness
• Hypotension
• Tachycardia
• Rapid weak pulse
• Fruity breath odor of acetone
• Hypothermia
• Level of consciousness is variable. Level of consciousness
depend on serum osmolality, not on level of acidosis. When
serum osmolality exceeds 320-330 mosml/l, CNS depression
 Investigation
• Blood glucose and electrolytes hourly for 3 hours and then
every 2-4 hours there after
• Urinary ketones every 4 hours
• Elevated anion gap (normal 12±2)
• Anion gap=Na+-(Cl -+HCO3 -)
• ABGs show low pH, low bicarbonate
• TWBCs:- high
• Chest x-ray
• ECG
• Urea & creatinine
• Plasma osmolality
 Management
• DKA is a medical emergency and should be
treated in hospital.
• The principles of treatment is :-
– Fluid replacement
– Insulin IV OR IM
– Potassium replacement
– Antibiotics if infections are present
 Hyperosmolar hyperglycemic state

• Hyperosmolar hyperglycemic state (HHS) is preferred

terminology over nonketotic hyperosmolar coma. HHS is
distinguished from DKA by the absence of significant
ketosis. It is a relatively common presentation of new onset
diabetes. Similar to DKA, precipitating factors include
noncompliance, myocardial infarction, stroke, infection,
pregnancy, and trauma. Drugs such as thiazide diuretics, ᵦ-
blockers, and steroids also predispose to this condition.
 Clinical Features
• Clinical features are dehydration and stupor or coma
due to hypersmolality. Nausea , vomiting and
abdominal pain are much less common because there
is no acidosis. There is no hyper-ventilation as seen in
DKA
 Investigations
• Severe hyperglycemia, blood glucose 600-2400
mg/dl but ketone bodies in urine are absent.
• Plasma osmolality > 310 mosml/l
OSM darah = 2 (Na +K) + Glukosa /18 + Ureum/6
OSM darah = 2 x Na (mEq/L) + Glukosa darah (mg/dl)/18

• Serum bicarbonate > 15meq/l

• ABGs show normal pH.
• Normal anion gap
 Management
• Treatment is similar to ketoacidosis
TERIMA KASIH