Kegawatan Endokrin

Diabetic Emergency

Ns. Chiyar Edison., Skep., MSc

Prologue

• Gluconeogenesis?

• Glycogenolysis?

• Glycolysis?

• Lipolysis?

• Glycogenesis?

Diabetic Emergencies

• Diabetic Ketoacidosis (DKA)

• Hyperosmolar Hyperglycemic Status (HHS)

Hyperglycemia Crisis

• Mild

• Moderre

• severe

Hypoglycemia

Diabetic Emergency

Hypoglycemia Hyperglycemia

Diabetic

Ketoacidosis (DKA)

Hyperosmolar Hyperglycemia

State (HHS)

Hyperglycemia Crisis

DKA consists of the biochemical triad of hyperglycemia, ketonemia and high anion gap metabolic acidosis

HHS is an acute diabetes mellitus complication characterized by elevated in plasma osmolality in hyperglycemic patient

Both DKA and HHS are characterized by hyperglycemia and absolute or relative insulinopenia. Clinically, they differ by the severity of dehydration, ketosis and metabolic acidosis

Gosmanov, A. R., Gosmanova, E. O., & Kitabchi, A. E. (2018). Hyperglycemic crises: diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar state (HHS). In Endotext [Internet]. MDText. com, Inc..

Osmotic diuresis

Sumber gambar:

https://creativemeddoses.com/topics-list/osmotic-diuretics-aquaretics-without-natriuresis/

Nursing Assessment

•Recognizing DKA’s trias in clinical signs

• Recognizing the precipitation

factors

Assessment

Ketoasodosis Diabetikum (KAD)

Hiperglikemia

KAD

DKA diagnostic

• GDS>250 mg/dl

Hyperglycemia

• Ph < 7.3

• HC03 < 15 mmol

Acidocis

• Keton + blood or urine

Ketosis

Clinical findings DKA and HHS

Kusmaul breathing

(DKA)

Poor skin

turgor Dehydration Weakness

Hypotension Tachychardia Altered

mental status Nausea

Vomiting

DKA Classification

Laboratory findings

Gosmanov, A. R., Gosmanova, E. O., & Kitabchi, A. E. (2018). Hyperglycemic crises: diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar state (HHS). In Endotext [Internet]. MDText. com, Inc..

Laboratory findings

Gosmanov, A. R., Gosmanova, E. O., & Kitabchi, A. E. (2018). Hyperglycemic crises: diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar state (HHS). In Endotext [Internet]. MDText. com, Inc..

Precipitating Factors

Infection

Discontinuation or inadequate insulin therapy

pancreatitis

Myocardial infarction

Cerebrovascular

accidents Drugs

Treatment

• Prioritas lakukan inisiasi terapi cairan kristaloid

• Target 8-12 jam pertama, dehidrasi terkoreksi 50%

• 15-20 ml/KgBB Nacl 0,9% per jam

Fluid resuscitation

• Mulai diberikan saat status hidrasi diperbaiki

• Diberikan secara bolus dan atau drip

Insulin therapy

• Manajemen Hiponatremia

• Manajemen hypokalemia atau hyperkalemia

• Manajemen Bikarbonat

Electrolyte

management

June 9, 2022 17

Nursing Assessment

• Recognizing DKA’s trias in clinical signs

• Recognizing the

severity dehydration

• Recognizing the

precipitation factors

Assessment

Nursing Diagnosis

• Fluid deficit volume

• Ineffective

breathing pattern

• Risk of Decreased Cardiac perfusion

Nursing

Diagnosis

Nursing Intervention

Independent

• Shock position

• monitoring MAP or systolic pressure

• Monitoring urine output

• Monitoring status mental

• Observation ECG

Collaboration

• Access IV fluid therapy

• Oxygen therapy

• Insulin therapy management

• Electrolyte therapy management

Evaluation

MAP 70 mmHg

Absent of dehydration

Urine output: diuresis 0.5-1 cc/KgBB/hours Osmololality serum (285-295 mmol/L)

Laboratory : blood glucose level, blood gas analysis, Keton

HIPOGLIKEMIA

Hypoglycemia

Low blood glucose level

the result of the interplay of relative or absolute insulin

excess and compromised physiological defenses against

falling plasma glucose concentrations

Hypoglycemia Causes

Incorrect insulin administration

Insufficient exogenous carbohydrate

Decreased endogenous glucose production

Increased utilization of carbohydrate of hepatic glycogen stores Increased insulin sensitivity

Delayed gastric emptying Decreased insulin clearance

Hypoglycemia

Classification (IHSG, 2018)

• A glucose alert value of 3.9 mmol/L (70 mg/dL) or less

Level 1

• A glucose level of <3.0 mmol/L (<54 mg/dL) is sufficiently low to indicate serious, clinically important hypoglycemia

Level 2

• Severe hypoglycemia, as defined by the ADA , denotes severe cognitive impairment

requiring external assistance for recovery

Level 3

Hypoglycemia clinical findings

• Feeling shaky

• Being nervous or anxious

• Sweating, chills and clamminess

• Irritability or impatience

• Confusion

• Fast heartbeat

• Feeling lightheaded or dizzy

• Hunger

• Nausea

• Color draining from the skin (pallor)

• Feeling sleepy

• Feeling weak or having no energy

• Blurred/impaired vision

• Tingling or numbness in the lips, tongue or cheeks

• Headaches

• Coordination problems, clumsiness

• Nightmares or crying out during sleep

• Seizures

Hypoglycemia

Treatment

Tatalaksana Hipoglikemia (PABDI, 2015)

Pasien Sadar

• pemberian gula murni

sebesar 30 gram (2 sendok makan) atau sirup permen gula murni

Pasien tidak sadar

• Pemberian larutan

Dekstrosa 40% sebanyak 50 ml dengan bolus

intravena (IV)

• Pemberian cairan

Dekstrosa 10% per infus, 6

jam per kolf (500 cc)

Tatalaksana Hipoglikemia (PAPDI, 2015)

•bila: GDS < 50 mg/dl, berikan bolus Dekstrosa 40% 50 ml IV ,

• GDS <100 mg/dl, berikan bolus Dekstrosa 40% 25 ml IV

Evaluasi I

•Periksa GDS setiap 1 jam setelah pemberian Dekstrosa 40%, bila:

•GDS <50 mg/dl, berikan bolus Dekstrosa 40% 50 ml IV

•GDS <100 mg/dl, berikan bolus Dekstrosa 40% 25 ml IV

•GDS 100-200 mg/dl, tanpa bolus Dekstrosa 40%

•GDS >200 mg/dl, pertimbangkan menurunkan kecepatan drip Dekstrosa 10%

Evaluasi II

• Setelah evaluasi II, dilakukan 3 kali berturut- turut hasil GDS > 100 mg/dl, lakukan

pemantauan GDS setiap 2 jam

Evaluasi III

Tatalaksana Hipoglikemia (PAPDI, 2015)

• Setelah tahap 3 dilakukan 3 kali

berturut-turut hasil GDS > 100 mg/dl, lakukan pemantauan GDS setiap 4 jam

Evaluasi IV

•Bila GDS > 100 mg/dl sebanyak 3 kali berturut- turut, sliding scale setiap 6 jam:

•GDS < 200 mg/dl, jangan berikan insulin

•GDS 200-250 mg/dl, berikan 5 unit insulin

•GDS 250-300 mg/dl, berikan 10 unit insulin

•GDS 300-350 mg/dl, berikan 15 unit insulin GDS > 350 mg/dl, berikan 20 unit insulin

Evaluasi

V

Nursing Management

• hypoglycemia signs

• Blood glucose level

• Vital signs

• Peripheral color

• Status mental

• Tremors

• anxiety

• Precipitate factors

Assesment

Nursing Management

• Ineffective airway clearance

• Risk for Unstable Blood Glucose

• Risk of injury

Nursing

diagnosis

Nursing Management

• Maintaining Airway patency

• Oral intake glucose

• IV glucose solution

• Monitoring vital signs

• Monitoring status mental

• Risk of fall management

• Provide education

Intervention

Nursing Management

• Absent of hypoglycemia signs

• Absent of hyperglycemia signs

• Stable vital signs

Evaluation

Thanks….

References

• Gosmanov, A. R., Gosmanova, E. O., & Kitabchi, A. E. (2018). Hyperglycemic crises:

diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar state (HHS).

In Endotext [Internet]. MDText. com, Inc..

• Ratner, R. E. (2018). Hypoglycemia: new definitions and regulatory implications. Diabetes Technology & Therapeutics, 20(S2), S2-50.

• Pasala, S., Dendy, J. A., Chockalingam, V., & Meadows, R. Y. (2013). An inpatient hypoglycemia committee: development, successful implementation, and impact on patient safety. Ochsner Journal, 13(3), 407-412.

• PAPDI.(2015). Panduan Praktik Klinik. Internal Publishing: Jakarta

• Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N. (2009). Hyperglycemic crises in adult patients with diabetes. Diabetes care, 32(7), 1335-1343.

• Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans:

Guidelines for individualizing client care across the life span. FA Davis.