You are on page 1of 13

T na a p sa a iju n u tk

PENATALAKSANAAN KETOASIDOSIS DIABETIK (KAD)


W iaGoea De Gd Ag n Bu ia a r tr, wa e u g dy s Ba inS FImuP n a iDaa F Un dRS S n lhDe p s r ga / M l e y kt lm, K u / UP a ga n aa Emalwia oea y h oc m i rg tr@ a o .o :
ABS TRACT Dib t Keo sd ss(DKA)i mea oi dsu b n e ds r e ta b sg e b tish p r lc mi,a io i,a d a ei c ta io i s tb l itr a c io d r h t e in d y ra y egy e a cd ss n c k tss whc o eo v r s ro sa uemea oi c mpiain o da ee mel u .I I d n sateicd n ewa n ts eo i, ih n f ey eiu c t tb l o l t c c o f ib ts l ts n n o e i h n ie c i s o o hg c mp r ta tewe tr c u tis b ttemo tl y i si hg . n y u g a etemo tl y c n b p e e td b e ry ih o ae h n h sen o nre , u h rai s t l ih I o n g h t l rai a e rv ne y al t da n ss rt n la d p o tte t n a c r ig t i sp to h soo y S c e f l o DKA te t n n e sc re t n o ig o i, ai a n r mp rame t c o dn o t ah p y ilg . u c sul f o rame t e d o rci f o d hd ain h p r lc mi, cd ss a dee toyedsu b n e ie t c t no c mo bdp e ii t nfco,a dtemo t e irt , y egy e a a io i, n lcr lt itr a c ,d ni ai f o r i rcpt i a tr n h o o ao s i o tn o ewa c niu mo i rn . ete t n weea e u t o ud tea y s f ce tis l tea h , h rp o mp ra t n s ot e n nt ig Th rame t r d q ae f i h rp , u in n ui h rp y tea y f o n p tsim, iab n t, h s h tma n su h p rho e cc n i o , n a t it a miitaina c r igt idc t n oa su bc r o ae p o p a, g e im, y ec lrmi o dt n a d ni oi d nsrt c o dn o n iai . i b c o o Th i o tn o ewa as a r e sf rtea y c mpiain s ta tetea y n tt ma ewo s nn c n i o o te e mp ra t n s lo wan s o h rp o l t s o h t h h rp o o k c o re ig o dt n f h i p t ns ai t. e Ke wo d : ib t , eo cd ss ma a e n y r s da ei k ta io i, n g me t c

P ENDAHULUAN Keo sd ss da ei (KAD) a aa k a a n ta io i ib t k d lh e d a d k mp n a i e a a a mea oi y n dtn a oe e o e s s k k c u n tb l a g i d i lh k a tis hp r l e a a io i, d n k tss tr tma ra iegi mi, sd ss a eo i, eua k ds b b a oe d se s is l a s lt turlt . ie a k n lh e in i n ui b ou aa eai 1 n f KAD d n Hiperosmolar Hyperglycemia State (HHS a ) a aa 2 k mpia ia u mea oi da ee mel u d lh o l s k t tb l ib ts l ts k k i y n p l g s ru d n me g n a n a . Ke u a g ai eis a n n a c m y wa da k a a n tre u d p ttra ip d Dib tsM el u e d a es b t a a ejd a a a ee l ts i (DM )ie1 d n2, s iu KAD lbhs rn djmp i t p a me kp n e i eig i u a p d DM t e1.KAD mu g i meu a a ma ie ts aa i 2 p n kn r p k n nfsa i a ld r DM t e1 aa mu g i meu a a a ia wa ai i p tu n kn r p k n kb t d r p nn k tn k b th n is l p d DM t e 1 ai e ig aa e uu a n ui a a n i p p d k a a n ifk i ta ma ifr mik r ,aa a a e d a n e s, ru , n ak o ad tu k lia lin a3 ean n an y .

EP DEM I I OLOGI Daak mu i sd AmeiaS rk t Ro h se, t o nt i a rk eia, c e tr me u jk a b h n nu k n a wa isd n KAD s b s r 8/ 0 n ie e e a 10 0 p se DM p rth n u tk s mu k lmp k u r a in e a u nu e a eo o mu, s d n k nu tkk lmp ku rk rn d r 30th n e a g a nu eo o mu u a g ai a u s b s r 13, 10 0 p se DM p r th n1 S mb r e ea 4/ 0 a in e au . u e li me y b ta isd n KAD s b s r4, 8/ 0 an n e uk n n ie e ea 6 10 0 p se DM p rth n4, KAD dlp r a b ra g u g a in e a u .5 i o k n etn g n a jwa u tklbhd r 10 .0 p se y n drwa p r a b nu e i ai 00 0 a in a g ia t e 6 th n d Ameia S rk t Waa p n d t k mu i s au i rk eia. lu u aa o nt a d I d n sa b lm a a a a n a isd n KAD d i n o e i eu d , g k y n ie i I d n sa t a s b n a d n g r b rt me gn a n o e i i k e a y k i e aa aa, n ig t d p e ae s DM t e 1 y n rn a .La o a isd n rv ln i i p a g e d h p rn n ie KAD d I d n sau mn ab rs ld r d t r ma i n o e i mu y ea a ai aa u h s kt a tr tmap d p se DM t e2. a id n eua a a a in i 1 p

126

J Peny Dalam, Volume 11 Nomor 2 Mei 2010

An k k main p se d n a KAD d n g r ga e t a a in e g n i e aa mau k rn d r 5% p d b n a s ne,b b rp j u a g ai a a a y k e tr e ea a s mb rli me y b ta 5 10 2, 10 5, tu 9 u e an n e uk n % 2 % aa 10 1. e a g a d kii d n a s rn s d r a a % S d n k n i l k e g n aa a e eh n n d np se u i lnu a g ak maind p t n a a a a in sa a jt n k e t a a a me c p i 25 50 An k k main me jd lbh t g ip d %. g a e t a na i e i i g a a n b b rp k a a ny n me y ra KAD, e ets p i, e ea a e d a a g n eti s p ri e ss s o b rt ifr mik r a u y n la , a inu i y k ea, n ak o ad k t a g u s p se sa lnu,k d rgu o a d rh a ly n t g i u e a a jt a a lk s aa wa a g i g, rmi n d n k d r k a a n d rh y n rn a .Ke t n a a a e s ma aa a g e d h mai a p d p se KAD u i mu au mn ad p t iid r a a a in sa d mu y a a dhn ai d n a da n ss c p t p n o aa y n tp td n e g n ig o i e a, e g b tn a g e a a rso a s s a d n a p tsoo iy .P d p se a in l e u i e g n ao ilgn a a a a in k lmp ku i lnu, e y b bk mainlbhs rn eo o sa a jt p n e a e t e i eig a dpc oe fko p n a id s r y . iiu lh a tr e y kt a an a1 M e gn a p nig y p n o aa rso a d n n ig t e t n a e g b tn a in l a n tp tu tk me g id r k main p d p se KAD e a nu n hn ai e t a a a a in u i mu a ma atl a ii k nme iaa a tna g sa d , k ui n n a a s mbc rk n e tn p n tlk a a n KAD ds ra d n a k mpia i e aaa s n a ieti e g n o l s k a ia p n tlk a a n y . e a a p n a uu na a kb t e aaa s n a n a S b g i e d h la k n djls a s c r rn k stna g fko p n eu d n i a k n e aa ig a e tn a tr e c ts a e k i rada n ssKAD. rt i ig o i e P ATOF S OLOGIKETOAS DOS SDI II I I ABETI K KAD dtn a oe a a y hp r l e aa io i i d i lh d n a iegi mi,sd ss a k mea oi,d n p nn k tn k n e ta ik tn y n tb l k a e ig aa o s nrs eo a g b rd r aa sr ua iKeo sd ss r p k na ia ee a d lm ik ls. ta io i meu a a kb t d r k k rn a aa iee t tsis l y n tra i ai e u a g n tu n fki a n ui a g ejd n b ra a d n a p nn k tnh r nk nrrg ltr es ma n e g n e ig aa o mo o tae uao (gu a o , ae oa n k rio, a growthh lk g n k tk lmi, o t ld n s ormon) . Ke u h les b t n a iak np r b h np o u s d a a tre u me g kb ta eu a a r d k i d n p n eu rn gu o a d n me ig ak n l oii a e g laa lk s a nn k ta i l s p s d n p o u s b n a k tn Hiegie a tra i a r d k i e d eo . p r l mi ejd k a ia p nn k tn p o u s gu o ah p rd n gna kb t e ig aa r d k i lk s e a a ijl (gu o e g n ss d n gio e oii)d n p n r n n lk n o e e i a l g n l s a e u u a k s ui s s gu o a p d jrn a p rfr P nn k tn t ia i lk s a a aig n eie. e ig aa l gu o e g n ss a ia d r t g iy k d rs b ta lk n o e e i kb t ai i gn a a a u srt n n n ab hd a (aa i,a ttd ngieo p d h p r o k r o irt lnn lka, a l r l a a e a, s d ngua np d gna) a d rp nn k tna t i s a ltmi a a ijld n ai e ig aa ki t va e zm gu o e g nk (f so n lpr v tk r o sls / n i lk n o e i o f e o iu a ab k i e a P CK,r ko e1, bf sa, a pr v t ab k i s ) EP fu ts 6 io ftd n iu a k r o sl e. a P nn k tn p o u s gu o a h p r me u jk a e ig aa r d k i lk s e a n nu k n
P n tlk a a n Keo sd ssDib t (KAD) e aaa s n a ta io i a ei k Wira Gotera, Dewa Gd Agung Bud e iyasa

p tg n ssua y n b ra g u g jwa tr a a ao e e i tma a g etn g n a b eh d p k a a nhp r l e ap d p se d n a KAD. e d a iegi mi a a a in e g n k S lnun a k a a n hp r l e a d n k d r ea jty , e d a iegi mi a a a k k tn y n t g i me y b b a du e i o moi eo a g i g n n e a k n irss s t k y n a a me g kb ta hp v lmi d np n r n n a g k n n a iak n io oe a a e u u a glomerular ltration rate. Ke d a y n trk i a a n a g ea hr a a me eb r k hp r l e a M e a ime y n k n mp r u u iegi mi. k ns k ag me d s r p nn k tn p o u s b n a k tn tlh n a ai e ig aa r d k i e d eo ea dp ljr s lma ii Ko ia i d se s is l ieaai ea n. mbn s e in i n ui n d n p nn k tn k n e ta ih r n k nrrg ltr a e ig aa o s nrs o mo o tae uao me y b b a a t a i h r n l a e y n s n i f n e a k n ki s o mo i s a g e st v p i p d jrn a lma .P nn k tn a t i s iia a a a aig n e k e ig aa ki t n k n va me c h til ei me jd gieo d n a a lma me a rgi rd na i l r l a s m e k s s b b s(f f acidF A) Diea u b h gieo e a ree atty / F . k th i a wa l r l s meu a a s b ta p nig u tk gu o e g n ss r p k n u srt e t n nu lk n o e e i p d h p r s d n k np n eu rna a lma b b s a a e a, e a g a e g laa s m e k e a y n b re ia da u ia s b g i rk ro ua a g elbh n is msk n e a a p e u s r tma d r k ta i. ai eo sd P d h p r a a lma b b s do sd s a a e a, s m e k e a ik ia i me jd b n a k tn y n p o e n a dsi ls na i e d eo a g r s s y it a i mu tr tma oe gu a o . P nn k tn k n e ta i eua lh lk g n e ig aa o s nrs gu a o me u u k nk d rmalonyl coenz A (Co lk g n n r n a a a yme A)d n a c r me g a a k n es pr v t na i e g n aa n h mb t o v ri iu a me jd acetyl Co A meau ihbs acetyl Co A carb ylase, lli n iii ox e zm p ra y n dh mb t a asne i a a lma n i etma a g ia a p d itss s m e k b b s Malonyl Co A me g a a camitine palmitoyle a. n h mb t transf erase I (CP I,e zm u tk ta s sei k s T ) n i nu rn e tr a i d r f acyl Co A me jd f acyl camitine, a g ai atty na i atty yn me g kb ta o sd s a a lma me jd b n a n a iak n k ia i s m e k na i e d k tn CP I dp ru a u tk p r id h n a a eo . T ielk n nu epn a a s m lma b b s k mi k n ra tmp t dma a a a e k e a e t o di e a i n sm o lma tr k ia i P nn k tn a t i sf acyl Co e k eo sd s. e ig aa ki t atty va A d n CP Ip d KAD me g kb ta p nn k tn a T aa n a iak n e ig aa k tn e e i. eo g n ss6 F AKTOR P ENCETUSKETOAS DOS SDI I I ABETI K T r a a s ktr 20 p se KAD y n b r ed p t e i a % a in a g au dk th ime d rt DM u tk p ra k l y .P d iea u n ei a nu etma ai a a a n p se KAD y n s d h dk th iDM s b lmn a a in a g u a iea u e eu y , 80 d p t ie ai d n afko p n eu , e naa % a a dk n l a a y a tr e c ts s me tr 20 lin at a dk th i a trp n eu n a1, % an y i k iea u fko e c ts y .6 d 127

Absolute insulin eficiency Or

Stress,I nfection orinsufficient insulin intake

Counterregulatory H om ones n G lucagon n Cortisol n Catecholam inee n G row th

n Lipolysis

p G lucose utiilzation

n Protolysis p Protein Synthesis

n G lycogenolysis

n G luconeogenic substrates n FFA to Liver n Ketogenesis p Alkall Reserve Ketoacidosis Lactic Acidosis n G luconeogonesis H yperglycem ia G lucosuria ( osm otic diuresis) Loss of w aterand electrolytes

D ehydration I ardRe a F n t n mp ie n l u ci o
Ga a 1. g nP tsoo i mb r Ba a ao ilg KAD13

H yperosm olarity

F ko p n eu treig d r KAD a aa a tr e c ts es rn ai d lh ifk i d n dp r ia a s b g i p n eu lbh n e s, a iekrk n e a a e c ts e i 6-8 d r 50 k s s KAD. P d ifk i a a tra i ai % a u a a n e s k n ejd p nn k tn s k e ik rio d n gu a o s hn g e ig aa e rs o t l a lk g n e ig a s tra ip nn k tn k d rg l d rh y n b r k a ejd e ig aa a a ua aa a g ema n . F ko lin a a aa cereb ascular accid a tr an y d lh rov ent, alcoh ab ol use, p n rai s ifr jnu g ta ma a k e t i, n ak a tn , ru , t 128

ph eoch romocytoma, o a, DM t e 1 y n b r bt i p a g au dk th id n ds o t uts (k p th n aa trp iea u a ik ni i n a e au a ) tu ea i 1, is l ia e u t 2, n ui n d k a. 5-8 n Ke au a a a p ma aa is l dp n au i p th n k n e k in n ui ie g r h n oe u r ens d n fko k mo bd p n ei . lh mu, ti a a tr o r i e d rt 5 a F ko li y n jg dk th i s b g i p n eu a tr an a g u a iea u e a a e c ts KAD a aa ta ma k h mi n p mb d h n d n d lh ru , e a l , e e a a , a a
J Peny Dalam, Volume 11 Nomor 2 Mei 2010

srsp ioo i.I fk iy n dk th ip l g s rn te sk lgs n e s a g iea u ai eig n me c ts a KAD a aa ifk is lrn k mi d n n eu k n d lh n e s au a e h a p e mo i.6 P e mo i aa p n a i p r lin a n u na5, n u na tu e y kt au an y d p t me e g r h o sg n s d n me c ts a aa mp n au i k ie a i a n eu k n g g l a a , e ig ah r ss ll dp r aia s b g i a a n p s s hn g au eau ieh t n e a a k k a a ny n s ru d na a me u u k nk mp n a i e d a a g eis a k n n r n a o e s s rs iao i d r a io i mea oi. e prtrk ai sd ss tb l 2 k I fk ili d p tb r p ifk irn a s p ri n e s an a a eu a n e s ig n e et sk lesion aa ifk i tn g r k n Ob t b tn in tu n e s e g o o a . a-o aa yn a g me e g r h mea oime k r o irt mp n au i tb l s ab hd a s p rik rio tr i,tizd p na dn ,d n o a e et o t seod ha i, e tmiie a b t k smp tmi t (s p ri d b tmi d n tr uai) i ao mei e et o ua n a eb tl , k n d p t n eu k nKAD. a-o a li y n dk th i a a me c ts a Ob t b tan a g iea u d p t n eu k nKAD da trn ab t bo e, b t a a me c ts a inaa y ea lk ro a a t sk t ,d n fnti, P d p se u i mu a ni ioi a e i n p k o a a a in sa d d n a DM t e 1,ma aa p ioo i y n ds ra egn i p s lh sk lgs a g ieti k lia ma a me eia k nrb s p d 20 ean n kn mb rk n o tiu i a a % KAD b r ln .F ko y n me n uk n k llin eua g a tr a g mu c la eaaa p n g n a is l p d p se mu a da trn a e g u a n n ui n a a a in d inaa y k tk tn u tk p nn k tn b rt b d n d n a ea ua nu e ig aa ea a a e g n p r ak n k nr l mea oi, k tk tn tra iy eb ia o to tb l k ea ua ejdn a hp gie a d n srs a ia p n a i k o i.6, io l mi, a te kb t e y kt r nk4, 7 k Na n d miin s rn k l fko p n eu KAD mu e ka , eig ai a tr e c ts t a dtmu a d nii a a me c p i 30 d r i k i k n a n d p t n a a 20 d e % ai s mu k s sKAD, k nttp h ln t a me g rn i e a au a a ea i a iii k n u a g d 9, d mp ky n dt uk na ia KAD i s n ii 10 a a a g i mb la kb t i t e dr. u DI AGNOS SKETOAS DOS SDI I I I ABETI K La g a p ra y n h r s imbl a ap se n k h etma a g au da ip d a in KAD tr ii ai n mn ssd np meis a sky n edr d r a a e i a e rk a n i a g c p td n tl itr tmame eh t a p tn ijln e a a ei eua t mp r ai n ae s aa k n p s sau me tl sau gna d n k r iv s ua, a a , tts na, tts ijl a ado a k lr d n sau hd a i La g a -ln k h iih r s d p t a tts irs. n k h a g a n au a a me e tk n jns p meis a lb rtru y n n nu a e i e rk a n a o ao im a g h r s s g r dlk k n s hn g p n tlk a a n au e ea i u a , e ig a e aaa s n a a d p t e eadmua tn aa a y p n n a n1 a a s g r i lia p d n a e u d a . M e kp n g jl DM y n t a tr o to s iu eaa a g i k ek nr l d mu g i tmp k d lm b b rp h r, p r b h n n kn a a aa e ea a ai eu a a mea oi y n k a u tk KAD ba a y tmp k tb l a g h s nu k is n a a a d lm jn k wa t p n e (< 24 jm) Umu y aa a g a ku e d k a . mn a p n mp k n s lr h g jl d p t tmp k aa e a a a eu u eaa a a a a tu
P n tlk a a n Keo sd ssDib t (KAD) e aaa s n a ta io i a ei k Wira Gotera, Dewa Gd Agung Bud e iyasa

b r e a g lbh a u d n p se d p t tmp k ek mb n e i k t a a in a a a a me jd KAD tn a g jl aa tn a KAD na i ap eaa tu a d s b lmn a Ga aa kii ka i tr s k e eu y . mb rn l s lsk ema u n rwa a p l ra p l isa d n p l a i,p n r n n i y t oi i, oi p i, a oi ga e u u a u d f b rt b d n mu th s kt p r t d hd a i lma , ea a a , na , a i eu, e irs, e h cloud of ing sensoria, a a hr y k ma P meis a d n k in a o . e rk a n kii tr s k tr o k l y n me u u ,rs ia i l s ema u u g r ui a g n r n e prs n t Ku s u, tkk r i, hp tn i p r b h n sau sma l a iada ioe s, eu a a tts me tl s o , a k ma Le i d r 25% p se KAD na, y k d n o . bh ai a in me jd mu th na y n tmp k s p ri k p. na i na -mu th a g a a e et o i P r ain lbh h r sdb rk n u tk p se d n a eh t e i au ieia nu a in e g n a hp tr ak rn me u jk a p o n ssy n lbh ioemi ae a n nu k n r g o i a g e i b r k De ka p l p se d n a ab ominal pain, u u . miin ua a in e g n d k rn g jl iid p tmeu a a a ia aa s b a ae a eaa n a a r p k n kb t tu e u h idk s d r p n eu n a k u u n a p d p se n ia i ai e c ts y , h s s y a a a in mu a Ev la ilbh lnu dp ru a j ag jl ii d . au s e i a jt ielk n i eaa n k t a me ak d n a k rk id hd a id n a io i i k mb i e g n o e s e irs a sd ss d mea oi. tb l k
T b l 1. Krtra da n si KAD me u u American ae i i ig o t e k n rt Diab etes Association7 P rmee aa tr KAD Rig n S d n na eag > 250 > 250 7, 25-7, 7,0 24 30 0 -7,

Guad rh(mgd) l aa /l p atr H rei S r m bk r o a/ eu iab n t HCO3 15-18 10 (< - 15) (mEql / ) Keo u ie tn rn + + Keo s r m tn eu + + Os ll a s r m ee t moai s eu fki t f v ra e v ra e aib l aib l (mOs k ) m/g Ano g p in a > 10 > 12 Alr/ et P r b h ns n o il tu eu a a e s ra aa Alr et do y r ws me tl bu d t n na o tn ai o Caaa : ttn -

Bea rt > 250 < 0 7,0 < 10

v ra e aib l > 12 Su o/ tp r c ma o

P n u u a k tn s r m d n u ie me k i e g k rn eo eu a rn ma a meo era s nto r sd td e k i i p u ia r Os ll a s r m ee t (mOs k )= 2X moai s eu fki t f m/g Na(mEql + Glk s (mgd)18 / ) u oa /l/ + Ano g p= Na (Cl in a +HCO3- )(mEql / )

P ENAT ALAKS ANAAN KET OAS DOS SDI I I ABETI K P n tlk a a n KAD b ria mut a tra e aaa s n a esft l fko il i s hn g me ru a p n e aa trtu tr oe e ig a melk n e d k tn esr ku lh 129

d ke d n p rme i y n b ru a . ed p tb n a o tr a aa ds a g etg s T r a a a y k s k l p d ma p n tlk a a n KAD p d l eau e ai e o n e aaa s n a a a i rtr t k d kea ,d n h n a n a s mu i t a diui e o trn a e d k y e a t i k i t u d k s c r k tt s k l d n ds s ak n d n a k n ii e aa ea e ai a ie u ia e g n o ds p n ei . lm me aaa s n p n ei KAD s t p e d rt Daa a n tlk a a e d rt a ei a r ma s kt e d k y me l i e o naa ds b t u h a ih n a n a mi k p d ma tu ie u i s b g iintegrated care path eaa way.P d ma iih r s e o n n au dlk a a a s b g i n me t y d lm rn k i s n k n e a ama a a si a aa a g a n me c p itja trp.S u itrk i me u jk a n a a uu n ea i td ea hr n nu k n s b a integrated care path euh way d p tme eb ii aa mp r ak h sl k i p n tlk a a nKAD s c r sg i k n7 a ia hr e aaa s n a e aa in a . Ke eh sln p n tlk a a n KAD me b rai a e aaa s n a mb th a k rk i d hd a i hp rl e a a io i uu k n o e s e irs, iegi mi, sd ss k d n k lia ee toi ie t k s fko p e ii s a ean n lkr l , d ni a i a tr rspt i t a k mo bd d n y n tr e t g a aa p ma tu n o r i, a a g ep ni n d lh e na a p se tr sme eu .7 Beiu iib b rp h ly n a in eu n r s3, rk t n e ea a a a g h r sdp r aia p d p n tlk a a nKAD. au ieh t n a a e aaa s n a k 1 Te a i ar n . r p c ia P irtsua p d p n tlk a a n KAD ro i a tma a a e aaa s n a a aa trp c ia .T rp is l h n aee t j a d lh ea i arn8 ea in ui a y fki i n fk c ia db rk n p d th p a ltrp d n h n a arn ieia a a a a wa ea i a a y d n a trp c ia s j a a me u t a a g l e g n ea i arn aa k n mb a k d r ua d rh me jd lbh rn a .S u ime u jk a aa na i e i e d h td n nu k n bh a wa s lma e a jm p ra , lbh d r ea mp t a etma e i ai 80 p n r n n k d rg l d rh ds b b a oe % e u u a a a ua aa ie a k n lh 2, e ae a t a e t u n etma rhd a i 11 Olh k rn i ,h lp nig p ra e irs. y n h r sdp h mi d lhp n nu ndst arn a g au ia a a aa e e ta i ic ia y n tra i Bean a k k rn a c ia y n a g ejd. rty e u a g n arn a g tra idp n au ioe d rs hp r l e ay n ejd ie g r h lh u a i iegi mi a g k tra i f n s gna, a intak c ia p n ei . ejd, u g i ijl d n e arn e d rt 11 a Ha ii iadp r ia a d n a p meis a kii ln bs iekrk n e g n e rk a n l s n 2 aa d n a me g u a a r mu s b g i eiu: tu e g n n g n k n u s e a a b rk t Fluidd cit = (06 X b rt a a d lm k ) e , ea b d n aa g X (correctedNa140 / ) CorrectedNa= Na+ (k d rg l d rh / 5 a a ua aa -5)3, Ru s li y n d p t dp k i u tk mu an a g a a ia a nu me e tk n d rjt d hd a i a aa d n a n nu a eaa e irs d lh e g n me g i n o moai ss r m ttld n corrected n ht g s ll a eu oa a u t serum sod concentration. ium 130

Os ll a s r m ttl moai s eu oa = t 2 X Na(mEql + k d rgu o ad rh (mgd)18 / ) a a lk s aa /l/ + BUN/ 8 2, Serum sod ium concentration d p t dk rk i a a io e s d n a me a a k n1, mEql ipk n ia 10 e g n n mb h a 6 / t e ak n 0 a mgd k d rg l d rh d aa k d rg l 10 mg /l a a ua aa i ts a a ua 0 / d.Ni icorrected serum sod l l a ium concentration > 140d no moai ss r m ttl 330mOs k ar a s ll a eu oa > t m/g i 12 me u jk a d st arny n b rt P n nu n n nu k n e i c ia a g ea. e e ta d rjt d hd a i d n a g jl kii s rn k l eaa e irs e g n eaa l s eig ai n s k rdk ra a , a n d miin b b rp g jl u a iejk n n mu e ka e ea a eaa kii y n d p t me oo g u tk me e tk n l s ag aa n n ln nu n nu a 13 d rjt e irs a aa . : eaa d hd a i d lh - 5% : p n r n n tr o k l , me rn e u u a u g r ui t mb a mu o ak rn ,a iada k s eig tkk r i - 10 % :capillary rell time 3 d t ,maa ei k t c wo g o n - > 10 :p lu atr p rfrlma ,hp tn i % us s rei eie e h ioe s, s o , l ui y k oi ra g Re u i s c ia h n a n adlk k ns c r s st i arn e d k y i u a e aa a a a rsfT r en aa aa p n g ninc ia s b s r g e i. ag ty d lh e g a t arn e e a a 50 d r k k rn a c ia d lm 8 12 jm % ai e u a g n arn aa a p ra d nss n ad lm 12 16 jm b rk ty .9 etma a ia y aa a eiun a5, M e u u p r ia n b n a a l ttlk k rn a n r t ekra a y k hi oa e u a g n , c ia p d p se KAD s b s r 0ml g arn a a a in e e a 10 / BB, tu k aa 2, 9 5, s b s r5 8 l e. P d p se d wa a trp e ea ir t a a a in e s , ea i c ia a l ln s n db rk n u tk e s a s arn wa a g u g ieia nu k p n i v lme c ia ita a k lr d n e srv s ua ou arn nrv s ua a k ta a k lr 7, d n me jg p ru i gna.9 T r a a b b rp a na a ef s ijl ed p t e ea a k nr v rie tn jnsc ia y n dp r u a a . o to es tna g e i arn a g ieg n k n T d k a a uikii y n me u t a k lbh n ia d j l k a g mb ki n ee ia n k 2 p ma aa s lhs t jnsc ia .Ke a y k na l e k in aa au e i arn b n a a hi me y rn a p ma aa c ia soo i (Na n aa k n e k in arn ilgs Cl 09%)s b g iea i wa u tkrs sts c ia . , e a a trp a l nu e u i i arn a Carn soo i (Na 09%) db rk n ia ilgs Cl , ieia d n a k c p tn15 20ml g jm aa lbh e g n e e aa / BB/ k a tu e i s lmajm p ra (1 1, l e)S b a s mb r ea a etma 5 i r. e u h u e t me eia p tnu p a t p mb ra c ia mb rk n eu jk rki e ein arn s s b g ib rk t 1 l e p d jm p ra ,1 l e e a a eiu: i r a a a etma t ir t d lm 2 jm b rk ty , e da 1 l e s t p4 jm aa a eiun a k mu in i r ei t a a
J Peny Dalam, Volume 11 Nomor 2 Mei 2010

s mp i a intrhd a iS mb ranme y rn a a a p se ee irs. u e li n aa k n 1 1, l p d jm p ra , ea jty 250 50 5 t a a a etma s lnun a 0 2 ml a p d jm b rk ty .P tnu ii au lh / m a a a eiun a eu jk n h r sa j ds s ak n d n a sau hd a ip se .P l a ie u ia e g n tts irs a in i h n i c ia s lnun a tr a tn d r sau hd a i arn ea jty eg nu g ai tts irs, k d ree toi s r m, a p n eu rnu ie P d a a lkr l eu d n e g laa rn . a a t u mn a c ia Na 045% db rk nj ak d r mu y , arn Cl , ieia i a a k n tim s r m t g i 150mEql, a db rk n aru eu i g (> n / d n ieia ) u tk me g o e s p nn k tn k d rNa s r m nu n k rk i e ig aa a a + eu (correctedserum sod ium) e g n k c p tn4 14 d n a e e aa ml g jm s raa a p r id h n c ia a tr / BB/ k a et g r epn a a arn naa 3, itad ne srs llrtra i e aag a u l 4, nr a k ta eua ejd s c r rd a. 7 P ma aa c ia Rig r La tt (RL) e k in arn ne ka ds rn a u tk me g rn i k mu g ia iaa k n nu n ua g e n kn n tra iy hp r lrmi y n u mn a ejd p d ejdn a ieko e a a g mu y tra i a a p ma aa n r l aie d nb r a ak nstronge k in o ma s l 14 a ed s r a n ion th eory u tk a io i (S e r h nu sd ss twat ypoth esis)2 . S mp i s a ii t a dd p ta aa a y n a a a t n i k ia ak n ls n a g d me a ik n tna g k u tn a p ma aa RL y kn a e tn e nu g n e k in db n ig a d n a Na 09%. Jk k d rNa ia dn k n e g n Cl , ia a a s r m rn a ttpa me eg n k nc ia Na eu e d h ea lh mp r u a a arn Cl 09%. eea f n s gna dnliif s arnh r s , S tlh u g i ijl ii ,n u c ia au a me g n u g 20 30 mEqlKaim (2/ KCld n n ad n / l u 3 a 1/ KP 4)s mp ip se sa i d n d p tma a . 3 O a a a in tbl a a a kn Ke eh sln trp c ia dtnu a d n a b rai a ea i arn i tk n e g n e mo i rn h mo ia k (p r ak n tk n n nt ig e dn mi o eb ia eaa d rh ,p n u u a c ia ma u d n k la,d n aa ) e g k rn arn s k a eu r a p meis a kii. e rk a n l s n P mb ra c ia h r s d p t me g a t e ein arn au a a n g ni p r ia n k k rn a c ia d lm jn k wa t ekra e u a g n arn aa a g a ku 24 jm p ra . eu a a o moai ss r m t a a etma P r b h n s ll a eu i k t d mee ii3 mOs k H2O/ m. a ap se d n a lbh m/g j P d a in e g n a k lia gna,a tn aa h ttr tmao a gta ean n ijljnu g tu aieua rn u , h r sdlk k np ma tu no moai ss r m d n au i u a e na a s ll a eu a a t p nlin f n s jnu g gna,d n sau me tl e i a u g i a tn , ijl a tts na a y n b r e ia u g n s lma rs sts c ia a g ek sn mb n a ea e u i i arn a u tk me g id r o ela c ia ito e i. nu n hn ai v ro d arn ar g nk Unu i p ma a g n Central Venous Pressure tk t e s n a u (CVP mo i r d p t s n a me oo g Keia ) nt a a a g t n ln . t o k k d r uad rhme c p i mgd, arndg ni a a g l aa n a a 250 /lc ia ia t aa dtmb h a d n a c ia y n me g n u g tu i a k n e g n arn a g n a d n a
P n tlk a a n Keo sd ssDib t (KAD) e aaa s n a ta io i a ei k Wira Gotera, Dewa Gd Agung Bud e iyasa

d xr s s p ri(d xr s 5%,d xr s 5% p d e to e e et e to e e to e aa Na 09%,aa d xr s 5% p d Na 045%) Cl , tu e to e a a Cl , u tk me g id r hp gie a d n me g rn i nu n hn ai io l mi a k n ua g k mu gn ne e s rb a a ia p n r n ng l e n ia d ma ee rl kb t e u u a ua 2, d rhy n trauc p t 3, 14 aa a g ell e a. 5,


T b l P r ia njmlhttl e st i d nee toi p d a e 2. ekra u a oa d i ar a lkr l a a t p se KAD7 a in No 1 2 3 4 5 6 7 8 P r ia njmlhd st ekra u a e i T tl i (l e) oa ar i r t Ai (ml g r / ) k Na (mEqk ) + /g Cl (mEqk ) /g K+ (mEqk ) /g P O4- (mmo/g l ) k M g2+ (mEqk ) /g Ca (mEqk ) 2+ /g Ni i l a 6 10 0 7 10 35 35 57 12 12

2 Te a i s l . r p In u i n T rp is l h r s s g r dmua s s a ea i n ui au e ea i li e a t n 1 s tlhda n ss eea ig o iKAD d nrhd a i a gme d i a e irsy n ma a. S mb r li me y b ta p mb ra is l u e an n e uk n e ein n ui n dmua s tlh da n ss KAD dtg k a d n i li eea ig o i i akn a e 12 p mb ra c ia tlhdmua. P ma aa is l e ein arn ea i li e k in n ui n a a me u u k nk d r o mo gu a o , e ig a k n n r n a a a h r n lk g n s hn g me e a p o u s b n a k tn d h t p lp s n n k n r d k i e d eo i ai ee a a , a a lma b b sd r jrn a lma ,p lp s n s m e k e a ai aig n e k ee a a a a a n d r jrn a oo d n me ig ak n s m mio ai aig n tt a nn k ta 1, 6 ui s s gu o a oe jrn a . S mp i th n t ia i lk s lh aig n l a a au 1970 np n g n a is l u mn as c r b ls -a e g u a n n ui mu y e aa ou n ita e a ita s ua, tu u s b ua . nrv n ,nrmu k lraa p n u k tn S jk p re g h n th n 1970 n p oo o ea etn a a a u -a r tk l p n eoa n KAD d n a d i is l ita e a e g lla e g n rp n ui nrv n n d ssrn a mua dg n k nd nme jd p p lr o i e d h li iu a a a na i o ua. Caaii inu k nk rn lbhmu a me g nr l r n da jr a ae a e i d h n o to d ss is l , me u u k n k d r gu o a d rh o i n ui n n r n a a a lk s aa lbh lmb t ee is l c p t me g i n , e i a a, fk n ui e a n n hl g a ma u n a k l m k ita e lbh lmb t sk y ai u e nrs l e i a a, k mpia i hp gie a d n hp k lmi lbh o l s io l mi a io ae a e i k k s dkt P mb ra is l d n a if sita e a e ii1 e ein n ui e g n n u nrv n . n d ssrn a a aa trp pl a p d KAD y n o i e d h d lh ea i i h n a a i ag 131

ds b ta oe b b rp l eau, e a g a ADA ie uk n lh e ea a i rtrs d n k n t me g nu k n is l ita e a t a db rk n n a jr a n ui nrv n i k ieia n d p d KAD d rjt ig n aa eaa rn a . Jk t a tr a a hp k lmi (K < 3, ia i k ed p t io ae a d 3 mEql,d p tdb rk n is l rg lr015 uk / a a ieia n ui e ua , /g ) n BB,diuid n a if sk niu 01 uk BB/ m i t e g n nu o t k n , /g j a (5 7 ujm) Jk k d rk l m < 3, mEqlma a / . ia a a ai a u 3 / , k h r sdk rk i a uuu tkme c g hp r u u a au io e s d h l nu n e a eb r k n hp k lmi y n a a d p t me g kb ta io ae a a g k n a a n a iak n 6, 12 ai a jnu g I s l d ss rn a ba a y rt mi a tn . n ui o i e d h is n a n me u u k n g l d rh d n a k c p tn 50 75 n r n a ua aa e g n e e aa mgd/ m,s ma s p rip mb ra is l d ss /l a j a e et e ein n ui o i n lbht g i Jk g l d rht a me u u s b s r e i i g. ia ua aa i k n r n e e a n d 50mgd d r nli wa p d jm p ra , eis /l ai i a l a a a etma p rk a a sau hd a i a in Jk sau hd a i n u u i tts irs p se . ia tts irs me c k p, if s is l d p tdn ik n 2 k l l a s t p n u n ui a a iak a n ai i t ei p a jm s mp itra a p n r n ng l d rhk n tn a a a ec p i e u u a ua aa o sa a tr 50 75 mgd/ m. t ak d rg l d rh naa /l a Kei a a ua aa j k me c p i mgd,u u k nif sis l me jd n a a 250 /ltr n a n u n ui na i n 00 01 uk BB/ m (3 6 ujm)d ntmb h a ,5 , /g j a / ,a a akn a 6, 7 if sd xr s 5 10 n u e to e %. S tlh i k c p tn p mb ra is l eea t e e aa e ein n ui u n aa k n e ta id xr s h r sds s ak n u tk tu o s nrs e to e au ie u ia nu me l aanligu o as mp ik a a n a io i mei r i lk s a a e d a sd ss h a me ak P d k n iikii p mb ra is l mb i. a a o ds l k e ein n ui n n ita e a t a d p t db rk n ma a is l nrv n i k a a ieia , k n ui d n db rk n d n a d ss 03 i (04 06 i) ieia e g n o i , u , , u/ k BB y n tr a ime jd s tn a d sss c r g a g eb g na i ee g h o i e aa ita e a d n s tn a n a lg s c r s b ua nrv n a ee g h y a i e aa u k tn aa ita s ua,s lnun a db rk n is l tu nrmu k lr ea jty ieia n ui n s c r ita s ua aa s b ua 01 i/g e aa nrmu k lr tu u k tn , uk BB/ jm, ea jty p oo o p n tlk a a n y s ma a s lnun a r tk l e aaa s n a n a a s p ri e eind i ita e a12 e etp mb ra rp nrv n . P r ak n k tn mi me ru a wa t eb ia eo e a melk n ku lbh lma d rp d hp r l e a P n u u a ei a aia a iegi mi. e g k rn k ln s n -OHB (b t hd o s b t a) p d a gu g ea ir k i ui t a a r d rh meu a a meo ay n lbh ds k iu tk aa r p k n td a g e i iu a nu p ma tu n KAD. S lmatrp -OHB b r b h e na a ea ea i eu a me jd a a a eo s tty n me a d k nb h na i s m s ta ea, a g n n a a a wa k tss me u u . S lma trp KAD h r s eo i mb r k ea ea i au dp rk a k d r ee toi gu o a BUN,s r m ieis a a lkr l , lk s , t eu 132

k e t i,o moai s d n d rjtk a a n v n rai n s ll a , a eaa e s ma e a n t s t p 2 4 jm, u e li me y b ta b h ei a a s mb r an n e uk n a wa k d r gu o a k plr dp rk a t p 1 2 jm. a a lk s a i e ieis i a a 6 P d KAD rn a ,is l rg lrd p tdb rk n aa ig n n ui e ua a a ieia n s c r s b ua aa ita s ua s t p jm e aa u k tn tu nrmu k lr ei a a d n a ee t ts y n s ma d n a p mb ra e g n fki a a g a e g n e ein ita e a p d k d rg l d rh y n rn a d n nrv n a a a a ua aa a g e d h a k eton b ies y n rn a .Efki ts p mb ra od a g e d h e t a e ein is l d n a ita s ua d n s b ua a aa n ui e g n nrmu k lr a u k tn d lh n s ma n mu ijk is b ua lbh mu a d n a , a n ne s u k tn e i dh a k rn me y kta p se .P se d n a KAD u a g n a i n a in a in e g n k rn a h r sme d p ta ig n au n a ak n priming d ose is l n ui n rg lr04 06 uk BB,s tn a d sss b g i e ua , , /g ee g h o i e a a b ls d n s tn a d ss d n a s b ua aa ou a ee g h o i e g n u k tn tu ijk inrmu k lrS lnun adb rk nis l ne s ita s ua. ea jty ieia n ui n s b ua aa ita s ua 01 uk BB/ m. u k tn tu nrmu k lr , /g j a Krtra rs ls KAD da trn a a aa i i e ou i e inaa y d lh k d rg l d rh < 20 mgd, eu bk r o a a a ua aa 0 /l s r m iab n t 18 mEqlp v n >7, d na ing p 12 mEql / H e a 3, a no a , / . S a iij ap se NP lnuk nis l ita e a a tn,i a in O,a jta n ui nrv n k n d np mb ra c ia d ndtmb hd n a is l a e ein arn a i a e g n n ui a n rg lr s b ua s s a k p ru n s t p 4 jm. e ua u k tn e u i e ela ei a a P d p se d wa a d p tdb rk n 5 i is l a a a in e s a a ieia u n ui n tmb h ns t pk n ia g l d rh50mgd p d a a a ei e ak n ua aa a /l a a g l d rhd aa 150mgd d nd p t i n k ta ua aa i ts /l a a a dt g ak n i 20i u tkg l d rh 30 mgd. t ap se u nu ua aa 0 /l Kei a in k d p tma a ,jd ld ssmut e h r sdmua aa k n a wa o i l p l au i li i d n a me k ik mbn s d sssh aa rapid e g n ma a o ia i o i ort tu acting insulin d n intermed a iate aa long acting tu insulin s s a k b th nu tkme g nr l lk s e u i e uu a nu n o to gu o a d rh aa . Le i mu a u tk mea u a ta ss ii bh d h nu lk k n rn ii n d n a p mb ra is l s a p g s b lm ma a e g n e ein n ui a t a i e eu n kn aa s a ma a maa T r s a is l ita e a tu a t k n lm. eu k n n ui nrv n n s lma 1 2 jm s tlh p r a t n rgme ea a eea eg ni e i n a dmua u tk me sia k d r is l pa ma i li nu ma t n a a n ui ls k n y n a e u tP n h ninis l t a iads ra a g d k a. e g e t n ui i -t ieti a n b b d n a p mb ra is l s b ua y n tra a e g n e ein n ui u k tn a g elmb t n d p t n a iak nk nr l a gb r k s hn g a a me g kb ta o to y n u u , e ig a dp ru a s dktov ielk n e ii erlapping p mb ra is l e ein n ui n ita e a d n s b ua . P se y n dk th i nrv n a u k tn a in a g iea u
J Peny Dalam, Volume 11 Nomor 2 Mei 2010

da ee s b lmn ad p t ieia is l d n a ib ts e eu y a a db rk n n ui e g n n d ssy n db rk n s b lm t un aKAD d n o i a g ieia e eu i ly mb a s lnun a ds s ak n s p ru y . P d p se ea jty ie u ia e eln a a a a in DM y n b r ,n ui a l e d k y 05 1, u a g au is l wa h n a n a , n 0 / k BB/ai db rk n tr a ime jd s k rn n a g h r, ieia eb g na i e u a g y 2 d ss d lm rgme y n tr s k sh d n o i aa e i n a g ema u ort a long acting insulin s mp id sso t ltra a, a a o i pi ma ec p i d a et ad ssh ra iidb rk n p g h r d n u p ri o i ain n ieia a i ai a g s p ria y db rk ns r h r s b g i e et n a ieia o e ai e a a split- ed g mix 6, 7 d ose. Ak in a p se DM t e 2 d p tk la hr y a in i p a a eu r r ma s kt d n a a t ib t o a d n trp u h a i e g n ni a ei rl a ea i d k 7 de. it 3 Na ru . ti m P n ei d n a KAD k d n -k d n e d rt e g n a aag aag me u y i a a n tim s r m y n rn a , lh mp n a k d r aru eu a g e d h oe k rn lv lg l d rh y n t g i Unu t p ae a e e ua aa a g i g. tk i n a p nn k tng l d rh10 mgd d aa 10 mgd e ig aa ua aa 0 /l i ts 0 /l ma ak d rn tim da u ia lbh t g i 1, k a a aru is msk n e i i g 6 n mEqld rp d k d ry n du u.Hio armi / aia a a a a g ik r p n te a me ru a k rk i j a lv l n tim ma i melk n o e s i e e aru k sh rn a s tlh p n e u in ee ii Co th p d e d h eea e y s aa fk n. no , a a o a g d n a k d r g l d rh 60 mgd d n rn e g n a a ua aa 0 /l a lv l aru y n du u 130 ma alv l aru e e n tim a g ik r , k e e n tim y n s b n r y s b s r130 + (1, x 5)= 138, a g e e an a e e a 6 s hn g t a me ru a k rk i d n h n a e ig a i k d melk n o e s a a y me ru a p mb ra c ia n r l aie(Na melk n e ein arn o ma s l n Cl 09%) S b l n ak d rn tim d p tme ig a , . e ai y a a aru a a k nn k t s tlh dlk k n rs sts c ia d n a n r l eea i u a e u i i arn e g n o ma a a s l e oe k rn n r ls l e me l ik d r ai lh ae a o ma ai n n mi k a a i n tim lbht g i ai a a n tim e srs llr aru e i i g d r k d r aru k ta eua n s a i ds mpn oe k rn artn a n tim a t t ia ig lh ae a i a p aru u a a b r id h k ita eua s hn g a a k n epn a e nrs llr e ig a k n me ig ak nk d rn tim8. eu n tim y n nn k ta a a aru S r m aru a g lbht g i aia a150mEql melk nk rk i e i i g d rp d n /me ru a o e s 7 d n a Na 045%. e g n Cl , 4 Kai m . l u M e kp ntr a a k k rn a k l m s c r s iu ed p t e u a g n ai e aa u ttl d lm tb h (s mp i 3 5 mEqk BB) oa aa u u a a /g , hp r ae a rn a s mp i s d n s rn k l iek lmi ig n a a e a g eig ai
P n tlk a a n Keo sd ssDib t (KAD) e aaa s n a ta io i a ei k Wira Gotera, Dewa Gd Agung Bud e iyasa

tra i Ha ii tra i k rn s it k l m d r ejd. l n ejd ae a hf ai u ai ita e k e srs l lhk rn a io i, e u a g n nrs l e k ta e oe ae a sd ssk k rn a is l ,d n hp ro ii s s hn g trp is l , n ui a ietnst , e ig a ea i n ui n a n k rk ia io i,d n p n mb h n v lme c ia o e s sd ss a e a a a ou arn a a me u u k nk n e ta i aim s r m. tk k n n r n a o s nrs k l u eu Unu me c g hhp k lmi, e g a t nk l m dmua n e a io ae a p n g ni ai i li a u s tlhk d r aim s r m k rn d r 5,, u e eea a a k l u eu u a g ai 0 s mb r li me y b ta nli 5 mEqlUmu y , 30 an n e uk n i 5, a / . mn a 20 mEqk l m (2/ KCl a 1/ KP ai u 3 dn 3 O4) a at pl e pd i i r a t c ia if sc k pu tkme l aak d rk l m arn n u u u nu mei r a a ai h u s r m d lm range n r l4 5 mEql Ka a g eu aa o ma / . dn k d n p se KAD me g lmihp k lmi y n a a g a in n aa io ae a a g sg i k n P d k s stre u, e g a t nk l m in a . a a a u es b tp n g ni ai a u h r s dmua d n a trp KCl40 mEql d n au i li e g n ea i / a , trp is l h r s dtn a hn g k d rk l m ea i n ui au i d ig a a a ai n u u > 3, mEqlu tk me g id r ai aaa g g l 3 / nu n hn ai rt mi tu a a jnu g d n k lma a oo p r a a a .7 T rp a tn a ee h n tt en p s n6, ea i k l m dmua s a trp c ia s d h dmua, ai u i li a t ea i arn u a i li d n t a dlk k n j at a a ap o u s u ie a i k i u a i i k d r d k i rn , d a k d tr a a k lia gna,aa k d r k l m > 6 ed p t ean n ijl tu a a ai u 16 mEql / . 5 Bi a b n t . kroa P ma aa bk r o a p d KAD ma i e k in iab n t a a sh k nr v ril P d o to esa. a a p > 7,, p n e ain H 0 e g mb l a a t tsis l me lkl oii d nme eb ii ki a n ui mbo i l s a n p s mp r ak k ta io i tn a p mb ra bk r o a. S u i eo sd ss a p e ein iab n t td rn o p o p ki tlh g g l me u jk a a d m r s e t ea f aa n nu k n b i k u tn a aa k r ga p d p r b h n ak e nu g n tu eu in a a eu a a mo bdtsaa mo tl a d n a trp bk r o a r ii tu rai s e g n ea i iab n t a t p d p se KAD d n a p a tr 6, 7, a a a in e g n H naa 9 1. T d k dd p ta su i rn o p o p ki y n ia ia ak n td a d m r s e t a g f me eaai p ma aa bk r o a p d KAD mp ljr e k in iab n t a a d n a nlip < 6, M e g th ib h a io i egn i H a 9. n ea u a wa sd ss b rt n e a k nb n a ee v s ua y n t a ea me y b b a a y k fk a k lr a g i k d dign a ,a a n ac k pbjk a ame e tk n i ik n tmp k y u u i s n n a n nu a b h p d p se d wa a d n a p < 6, 10 a wa a a a in e s e g n H 9, 0 mmo n tim bk r o a dtmb h a k d lm 40 l aru iab n t i a k n e aa a 0 ml arnsoo i d ndb rk nd n a k c p tn c ia ilgs a ieia e g n e e aa 20 ml a P d p se d n a p 6, 7,,50 0 / m. a a a in e g n H 9 j 0 mmo n tim bk r o a dc mp rd lm 20 ml l aru iab n t ia u aa 0 133

c ia soo i d n db rk n d n a k c p tn arn ilgs a ieia e g n e e aa 20 ml a Naru bk r o a t a dp ru a 0 / m. tim iab n t i k ielk n j d 7, 15 j ap > 7,. S b g i n n tim bk r o a, i H k 0 e a ama a aru iab n t is l me u u k n k d r k l m s r m, oe n ui n n r n a a a ai u eu lh k rn i p mb ra k l m h r str sdb rk n ae a t e ein ai u u au eu ieia s c r ita e a d n dmo i r s c r b r aa e aa nrv n a i nt e aa ek l. o S tlh i p d rh v n dp rk a s t p 2 jm eea t H aa e a ieis ei u a a s mp ip me jd 7,,d n trp h r sdua g a a H na i 0 a ea i au iln i s t p2 jm j ap ru7 ei a a i el. k 6 Fo f t . sa M e kp n k d r f sa tb h s c r s iu aa o ft u u e aa k s lr h n me g lmi p n r n n hn g 1, e eu u a n aa e u u a ig a 0 mmo/g l BB,k d rf sa s r m s rn k l n r l k a a o ft eu eig ai o ma aa me ig a. Ka a f sa me u u d n a tu nn k t d r o ft n r n e g n trp is l .S u ia a p o p ki g g lu tk ea i n ui td c k r s e t a a nu n f me u jk a ee me g nu g a d r p mb ra n nu k n fk n u tn k n ai e ein f sa p d h sl k ip se KAD, a trp f sa o ft a a a ia hr a in d n ea io ft b re ia d p tme y b b a hp k lmi b rt elbh n a a n e a k n io ae a ea tn a b kia a y ttn s Ba ama a u u tk a p u t d n a ea u . g i n p n nu me g id rlma n aoo rn k d njnu gs ra n hn aie h y tta g a a a tn et d p e p r a a a y n ds b b a hp f sae a e rs en p s n a g ie a k n io o ftmi, p mb ra f sa s c r h t aimu g i k d n e ein o ft e aa ai t n kn a a g -h k d n didk sk n p d p se d n a k lia a a g i ia ia a a a in e g n ean n n jnu g a e a aa d p e ip r a a a d np d a tn , n mi, tu e rs en p s n a a a mee a d n a k d rs r m p sa < 1, mgd. rk e g n a a eu o ft 0 /l Keiadp ru a , 30mEql aim f sa d p t t ielk n 20 k /k l u o ft a a dtmb h a p d trp c ia y n tlhdb rk n i a k n a a ea i arn a g ea ieia . a Unu i dp ru a p ma tu n s c r k niu7 tk t ielk n e na a e aa o t . u n Be ea ap n l i n a jr a p ma aa k l m b rp e ei me g nu k n e k in ai t u f sa r t k rn mee a p ra a a a d p t o ft ui ae a n rk ec y k n a a me u u k n hp r lrmi s tlh trp d n a n r n a ieko e a eea ea i e g n me aa ip mb ra a in Cl P mb ra f sa mb ts e ein no . e ein o ft jg me c ts a hp k le a smtmai p d u a n eu k n io as mi i o t a a s 9 b b rp p se . e ea a a in 7 M a n su . g eim Bis n atr a a d st g e im s b s r a a y ed p t e i ma n su e e a 1 2 mEqlp d p se KAD.Ka a ma n su / a a a in d r g e im iijg dp n au ioe p ma aa o a s p ri n u a ie g r h lh e k in b t e et

du ei y n d p tme u u k n k d rma n su irt a g a a n r n a a a k g e im d rh Geaa k k rn a ma n su s n a s l aa . jl e u a g n g e im a g t ui t dnlid n s rn tmp n t dh d n a g jl ii a a eig u a g i i e g n eaa n a ia k k rn a k lim,k l m aa n tim. kb t e u a g n asu ai u tu aru Geaa y n s rn dlp r a a aa p rse i, jl a g eig i o k n d lh ae tsa a te r s a rmo, p me k r o e a, a i s, k jn , d n ap p d l gt i ea g a a ai a jnu g P se ba a y me u jk a rt mi a tn . a in is n a n nu k n g jl p d k d r 1, mgd.Jk k d r y d eaa a a a a 2 /l ia a an a i b wa n r l ds ra g jl, ma a p mb ra a h o ma ieti eaa k e ein 7 ma n su d p t iet a g a . g e im a a dp ri n k n mb 8 Hi e k o e ka i o i s lmatr p . p r lr mi sd ss ea ea i Olh k rn p ri a g n p n eu rn k t e ae a et n a e g laa eo mb a i d lm u ies lmafs a ltrp,s b ta cd aa rn ea a e wa ea i u srt aa b h n tr n n bk r o a a a me u u . tu a a u u a iab n t k n n rn S b ga d st bk r o a a a dg ni d n a e a in e i iab n t k n ia t e g n if sin ko ia p d s jmlh b s rs l u tk n u o lrd a a eu a e a ai nu n me g o e s d hd a i P d k b n a a p se n k rk i e irs. a a e a y k n a in a a me g lmi s b a k a a n hp r lrmi kn n aa e u h e d a ieko e k d n a bk r o a y n rn a d n a a in g p e g n iab n t a g e d h e g n no a y n n r l Ke d a ii meu a a k lia a g o ma. a a n n r p k n ean n y n rn a d nt a a a b r a a ad lm wa t a g ig n a i k k n eb h y aa d ku 12 24 jm j ap mb ra c ia ita e at a a i e ein arn nrv n i k k d db rk ntraulma3 ieia ell a . 9 Pe a aa s a tr a a In e s y n M e y ra . n t lk a n e h d p fk i a g n e t i Aniit adb rk ns s a d n a idk s, t oi ieia e u i e g n n ia i b k 3 tr tmatr a a fko p n eu tra iy KAD. eua eh d p a tr e c ts ejdn a Jk fko p n eu ifk i eu d p t i mu a , ia a tr e c ts n e s b lm a a dt k n e ma a a t it a y n dpl a aa a t it a k ni oi a g ii h d lh ni oi b k i b k 5 s e tu la . p kr m u s 1 . r p Pe c g h n tr a a Deep Vein 0 Te a i n ea a eh d p Thrombosis (DVT) T rp p n e a a DVT db rk n tr a a ea i e c g h n ieia eh d p p n ei d n a rsk t g i tr tma tr a a e d rt e g n iio i g, eua a n eh d p p n ei y n t a s d ri e d rt a g i k a a,mmo i s s, rn ta a d bl a io a g u , i d nhp r s lr ea. ssy n da jr a 50 0 a ieo moa b rtDo i a g inu k n 0 i t p8 jm s c r s b ua . ui a a e aa u k tn16

134

J Peny Dalam, Volume 11 Nomor 2 Mei 2010

Ga a 2. g nP n tlk a a nKAD 7 mb r Ba a e aaa s n a

Ga a 2. g np n tlk a a nKAD 7 mb r Ba a e aaa s n a

M o io i gTe a i n t rn rp S mu p se KAD h r sme d p ta e au s e a a in au n a ak n v la i lb rtru y n k mp e e sfema u p meis a a o ao im a g o rh n itr s k e rk a n d rh e g a d n a p o l i aema u p meis a aa ln k p e g n r kmitr s k e rk a n ee toi d na aii g sd rh P mb ra c ia d n lkr l a n l s a aa . e ein arn a t s p n eu rnu ieh r sdmo i rs c r h t ai a e g laa rn au i nt e aa ai t d n o -h dc ttt p jm.P meis a EKG h r sdk ra a iaa i a a e rk a n au iejk n k p d s t pp se , h s s y mee ad n a rsk e a a ei a in k u u n a rk e g n iio a 9 k r iv s ua. T r a a b r c m p n a a tna g ado a k lr ed p t ema a e d p t e tn fe u n ip meis a p d b b rp p rmee y n rk e s e rk a n a a e ea a aa tr a g a a ADA mee o n a ia p meis a gu o a d. rk me d sk n e rk a n lk s ,
P n tlk a a n Keo sd ssDib t (KAD) e aaa s n a ta io i a ei k Wira Gotera, Dewa Gd Agung Bud e iyasa

ee toi BUN, k e t i, o moai s d n d rjt lkr l , t rai n s ll a a eaa n t k a a n v n t p 2 4 jm s mp ik a a n sa i e s ma e a i a a a a e d a tbl tra a.S mb rli me y b ta p meis a g l ec p i u e an n e uk n e rk a n ua d rht p1 2 jm.P meis a k d r uad rhy n aa i a a 6 e rk a n a a g l aa a g s rn a aa p nigu tkme i i k s p mb ra eig d lh e t n nu nl e a i e ein a is l d n me g b h d ss is l k t a h sly n ui a n n u a o i n ui ei a i a n k n t a me a k n Keia k d rg l d rh 250 mg i k mu s a . t d k a a ua aa / d, ntrk d rg l d rhd p t e i jrn (t p4 l mo i a a ua aa a a lbh aa g i o a jm) Ka a ee tois r m dp rk ad lm itr a 2 a . d r lkr l eu ieis aa nev l t jm s mp i 8 jm trp. u a p mb ra k l m a a a6 a ea iJ mlh e ein ai u s s a k d rk l m,ea i o ft e u i n ia iT t e u i a a ai trp f sa s s a idk s. i k u i 135

trn a k d r aim d nf sa p d s a trp tra i ee d h a a k l u a o ft a a a tea iejd 7 4-6 jm s tlhmuan atrp. a eea liy ea i Ko l a i r p mp i s Te a i k Ko l a i a gp l gs rn d r KAD a aa mpi s y n ai eig ai k n d lh hp gie aoe k rn p n n a a y n b re ia io l mi lh ae a e a g n n a g elbh n k d n a is l , hp k lmi y n ds b b a oe e g n n ui io ae a a g ie a k n lh n p mb ra is l d ntrp a io id n a bk r o a, e ein n ui a ea i sd ss e g n iab n t n d n hp r l e a s k n e a ia p mb ra is l a iegi mi e u d r kb t e ein n ui k n y n t a k niu s tlh p r ak n tn a db rk n ag i k o t d n eea eb ia a p ieia is l s b ua .Umu y p se KAD y n tlh n ui u k tn n mn a a in a g ea me ak me g lmihp r lrmi y n ds b b a mb i n aa ieko e a a g ie a k n oe p n g n a c ia s l ey n b re ia u tk lh e g u a n arn ai a g elbh n nu n p n g nin c ia d n ee toi d n noneg at a arn a lkr l a t anion gap metab olic acid osis s p riko d r c ia ita e a e et lr ai arn nrv n me g a t hln n ak ta ins p rig rm n tim n g ni i g y eo no e et aa aru a d n k l m s lma du e i o moi. Kean n a ai u ea irss s t k lia bo e k liitra is me tr d n t a a a ee ik mia n ejd e naa a i k d fk d kii sg i k n k c aip d k s sg g lgna a u l k in a e u l a a a u a a ijl k t n aa oiu i e srm. tu l ra k te 7 g Ed mas rb i mu y tra i a aa a -a a , e ee r u mn a ejd p d n k n k jrn p d d wa a T d k dd p ta d t y n p si aa g a a e s . ia ia ak n aa a g a t
T b l Ko l a i ia P n tlk a a nKAD5 a e 3. mpi s Akb t e aaa s n a k
Co l ain mpi t c o Hy o lc mi p gy e a Hy egy e a p r lc mi Hy o ae a p k lmi Hy ec lrmi p rho e c a io i cd ss Th o o mb l m r mb e oi s F udo ela li v ro d Cee rl d ma rb a e e Hy o i/c t p xaa ue rs iao i ite s e prtr dsrs s n r me y do Ca s ue I s l a miitain n ui d nsrt n o I tru t no is l ner pi f n ui o n c v rg o ea e I s l a miitain n ui d nsrt n o Biab n t c r o ae s p lme tt n u pe nai o I ta e o sNa ud nrv n u Cl is Urn r k ta i ls iay eo cd o s Hy ec a ua l sae p ro g lbe tt S v r d h d ain e ee e y rt o I ta e o sud nrv n u is Un n wn p sil d e k o , o sby u t rpdc re t no o a i o rci f o h p r s ll y y eo moai t

mo bdts a inKAD oe k rn e e s rb i a a r ii p se a lh ae a d ma ee rp d o a g d wa a Geaay n tmp k b r p p n r n n rn e s . jl a g a a eu a e u u a k s d rn ltr i p n r n n arousal, d n s kt e a aa , eag, e u u a a ai k p l. lia n u oo i d p tejd c p td n a e aa Kean n e r lgs a a tra i e a, e g n k jn ,ik nie sa p r b h n p pl b a iada ea g n o t n i, eu a a u i rdk r i, n , d n k g g ln rs ia i M e kp n me a imee e a e a aa e prs. s iu k ns d ma s rb i eu dk th itmp k y h l n meu a a ee r b lm iea u,a a n a a ii r p k n a ia d r ma u n a c ia k s s n n s rfp s t kb t ai s k y arn e u u a aa u a lwa me a ime o mo i,k t a o moai spa ma e t k ns s ss ei s lrt ls k a me u u s c r c p ts a trp KAD. Olh k rn n r n e aa e a a t ea i e ae a tr aa n a if r s tna g e e s rb i p d eb ts y n o ma i e tn d ma ee r a a o a g d wa a b b rp rk me d s db rk n p d rn e s , e ea a e o n a i ieia a a p n n a a n a a tr li p nlin kii y n e a g n n y , naa an e i a l s a g a n tp tdb n ig a d n a b kikii.P n e a a e a ia dn k n e g n u t l s e c g h n n y n tp t d p t me u u k n rsk e e s rb i ag ea aa n r n a iio d ma ee r p d p se rsk t g i da trn a p n g nin a a a in iio i g, inaa y e g a t n a c ia d n n tim s c r b ra a p d p se y n arn a aru e aa eth p a a a in a g hp r s lr(p n r n nma sma p d o moai s2 ieo moa e u u a k i l a a s ll a t mOs k H2O/ m) d n p n mb h n d xr s u tk m/g j , a e a a a e to e nu a 7 hd a i eiak d rg l d rhme c p i irs k t a a ua aa k n a a 250mgd. /l Hio s mi d n k lia y n jrn s p ri p k e a a ean n a g aa g e et e e p r n n ada d p t s b g i k mpia i d ma au o k r ik a a e a a o l s k

P e e t nCo rv ni / mme t o ns Ch c bo dgu o ee eyh e k lo lc s v r r Lo o eis l p oo o w-d s n ui r tc l n Ov ra is l if so a ds b ua e u elp n ui n u in n u c tn o s n is l o c da ei k ta io i rs le n ui n e ib t eo sd ss e ov n c Ch c p tsim e ey2 4 h e k oa su v r r

S p lme tfp tsim i < 5, mEqL u pe n i oa su s 3 /


Re ov sq iky s le uc l F e u nl ciial isg i c n rq e t l c l n in a t y n y Nod t t s p o t r p ya t a t oa uain aa o u p r p o h lci ni lg lt c c o M o i rttl o yip t n o tu nt oa b d n u a d up t o Ch c s r m s du e ey2 4 h e k eu o im v r r

Ch c s r m o mo il ye ey2 4 h e k eu s dai v r t r Re lc ud g a u l pa e is rd al y d e to e f lc s s /l De ra e o moi p e s r Ad d xr s i gu o ei < 250mgd ce s d s t rsu e c Av i c agn s du a art > 1 mmo/r od h r ig o im t ae l h la st ice s dln e d o n ra e u g Av i c a gn o moil ya art > 3 mmo/r od h n ig s l i t ae at l h wae c ne t tr o tn
J Peny Dalam, Volume 11 Nomor 2 Mei 2010

136

KAD. p k e atra i n iui e u u a tk n n Hio s mi ejd me gk tp n r n n e a a k li o moi y n meu a a a ia p nn k tn ood s t a g r p k n kb t e ig aa k k d r arnp d p r d np n r n ncompliance p r . a a c ia a a au a e u u a au P se d n a KAD y n me u y i rde t k ie a in e g n a g mp n a g a in o sg n av oo reilry n lb ry n du u p d a l le l-atroa a g e a a g ik r a a wa p n rk a n a aiag sd rh aa d n a r n ip d e eis a n l a aa tu e g n o k a a s p r p d p meis a sk tmp k y me u y i au a a e rk a n i a a n a mp n a rsk t g i nu me jd e e p r . iio i g u tk na i d ma au7 n RI NGKAS AN KAD a aa k a a n d k mp n a ik k c u n d lh e d a e o e s s e a a a mea oi y n dtn a oe tis hp r l e a tb l a g i d i lh ra iegi mi, k a k a io i, d n k tss y n meu a a s lh s t sd ss a eo i a g r p k n aa au k mpia i a u mea oi da ee mel u y n o l s k t tb l ib ts l ts a g k k i p l g s ru d n me g n a n a . Waa p n ai n eis a n a c m y wa lu u a g a isd n y d I d n sa t a b gt t g i n k n ie n a i n o e i i k e i i g d u n db n ig a n g r b rtk maina ia KAD ma i ia dn k n e aa aa, e t kb t a sh s rn djmp i dma a k main p d p se KAD eig i u a, i n e t a a a a in u i mu au mn ad p t iid r d n a da n ss sa d mu y a a dhn ai e g n ig o i c p tp n o aa y n tp t a rso a s s a d n a e a, e g b tn a g e a d n a in l e u i e g n p tsoo iy . b r a i np n tlk a a n KAD ao ilgn a Ke eh sl e aaa s n a a me uu k nk rk i e irs, iegie aa io i mb th a o e sd hd a ihp r l mi,sd ss k d n k lia ee toi ie t k s fko p e ii s a ean n lkr l , d ni a i a tr rspt i t a k mo bd d n y n tr e t g a aa p ma tu n o r i, a a g ep ni n d lh e na a p se tr sme eu .P n tlk a a n KAD meiui a in eu n r s e aaa s n a l t p trp c ia y n a e u t p mb ra is l y n ea i arn a g d k a, e ein n ui a g n me d itrp k l m, iab n tf sa, g e im, ma a,ea i ai bk r o a,o ftma n su u trp tr a a k a a nhp r lrmi s rap mb ra ea ieh d p e d a ieko e k et e ein a t it as s a d n a idk s. a try n s n a ni oi e u i e g n n ia i F ko a g a g t b k p nig p l u tk dp r aia a aa p n e aa et n ua nu ieh t n d lh e g n ln k tr a a k mpia i kb t ea i e ig atrp y n eh d p o l s a ia trp s hn g ea i a g k db rk nt a jsr me eb r kk n ii a in ieia i k u tu mp r u u o ds p se . d DAF AR RUJ T UKAN 1. S e n oP Keo sd ssDib t . n S d y o wo d . ta io i a ei I : u o o k AW, eio a i Al IS ma irt M , eit S t h d B, wi, i db aa S t i y a S e i r.Bu u aa Imu P n a i Daa 4t , dt s k jr l o e y kt lm. h e .J k ra P s tP n r i n De atme Imu d a at: u a e ebt a p re n l P n a iDaa F e y kt lm KUI 20 6.. ; 0 p1896-9.

Va Zy DG. a n ssa dte t n o da ei n l Dig o i n rame t f ib t c k ta io i. A F m P a 20 8; : eo cd ss S a rc 0 5039-49. 3. M a h rn U. a ei k ta io i. n M c h e s aa i Dib t eo cd ss I : P e c S , P p d ks M A, e i r. La g c re t J aaai dt s o n e u rn me ia da n ssa d te t n.49t e .Ne dc l ig o i n rame t h d w Yo k La g ; 10p1111-5. r : n e 20 .. 4. Cha s nJ Dig o i a dte t n o da ei iso L. a n ss n rame t f ib t c k ta io ia d h h p r lc mi h p r s lr eo cd ss n te y egy e c y eo moa sae Ca a in M e ia Aso it n J u n l tt. n da dc l s cai o o ra 20 3; 0 168(7)859-66. : 5. Ye i BR, p KC, le S Dig o i a d ha Ep s God n H. a n ss n ma a e n o da ei k ta io i i a ut. n g me t f ib t eo cd ss n d l c s Ho ptl h sca 20 8; 21-35. s i P y iin 0 15: a 6. Umperz GE, M u p y M B, Ki b c i AE. ire rh t ah a Dib t k ta io i a d h p r lc mi a ei c eo cd ss n y egy e c h p r s lr s n r me Dib ts S e tu y eo moa y d o . a ee p cr m 20 2; 0 15(1)28-35. : 7. Ameia Dib tsAso it n Hy egy e c rc n a ee s cai . p r lc mi o cii i da ee . a ee Cae20 4; rss n ib ts Dib ts r 0 27(1)94: 10 2. 8. Alet KG. Dib t a io i, h p r s lr b ri a ei cd ss y eo moa c c ma a dlci Acd ss I : c e KL, dtr o ,n at c io i.n Be k r ei . o P icpe a d p a t e o e d cioo y a d rn ils n rci f n o rn lg n c d mea oim. 3r e . P i d lha Lipn ot tb l s d hl ep i: p ic t a W i ims& W i is 20 4.. la l l n ; 0 p1438-49. k 9. En i ED, es eg RA. a ei k ta io i ns Krib r Dib t eo cd ss c a dteh p r lc mi h p r s lrs n r me n h y egy e c y eo moa y d o . I :Le i D,T yo S ,Olfk J ,e i r. n Rot h a lr I es y M dt s o Dib ts mel u a f n a na a d ciia a ee l ts u d me tl n l c l i n tx. nd e . hld lha Lipn ot i ims& e t2 d P i ep i: p ic tW l a a l W i is20 0p336-46. l n ; 0 .. k 10 Walc TM ,M ate DR.Re e ta v n e . l e a t ws h cn d a cs i te mo i rn a d ma a e n o da ei nh nt ig n o n g me t f ib t c k ta io i. JM e 20 4; eo cd ss Q d 0 97(12)773-80 : . 11. T a he b r DE. Dib t rc tn ag a ei k ta io i. c eo cd ss Ameia F mi rc n a l P y iin 20 5; y h sca 0 71(9) : 170 5-14. 12. Ki b c i Wal . a a e n o da ei t a h AE, lBM M n g me t f ib t a c k ta io i. Ameia F mi P y iin eo cd ss rc n a l y h sca 1999; : 60455-64. 137

2.

P n tlk a a n Keo sd ssDib t (KAD) e aaa s n a ta io i a ei k Wira Gotera, Dewa Gd Agung Bud e iyasa

13. Wofd r J Gls rN, p rigM A. a ei ls o e W, a e S el n Dib t c k ta io i i ifnsc i rn a da oe c ns eo cd ss n n a t, hl e , n d ls e t. d Dib tsCae20 6; a ee r 0 29(5)1150 : -6. 14. P wesAC.Dib tsmel u .I :J me o J o r a ee l ts n a s n L, i e i r Hars ns e d cioo y Ne Yo k dt . rio n o rn lg . w o r: Mc a Grw-Hi ; 0 p283-332. l 20 6.. l

15. Gu e s l O, Gu ap I On r O. Biab n t n ye rl , u c r o ae tea y i da ei k ta io i. Brt l Le h rp n ib t eo cd ss ai c s k Lit 20 9; 9(10 : sy 0 10 )453-4. 16. NN. Dib t k ta io i, e itxs s p i, a ei eo cd ss psa i, e ss c d s n u Th me ia su e tf r m. albe y p e . e dc l td n o u Av i l a fo r m: ht/www. d a uc m. Ac e s d t / p. me k a .o c se o : t J l 20 9. n10h uy 0

138

J Peny Dalam, Volume 11 Nomor 2 Mei 2010