Handling
Diabetes mellitus, if not managed properly can lead to the occurrence of various chronic diseases, such as serebrovaskuler disease, coronary heart, blood vessel leg, eye disease, kidney and nerve. If the blood glucose level can always be better, hopefully all the chronic difficult can be prevented, at least resist.
Manage diabetes mellitus in the short term objective is the complaints / symptoms and to maintain healthy and feeling comfortable. For the longer term, more objective, namely to prevent penyulit, both makroangiopati, mikroangiopati and neuropati, with the final goal morbiditas reduce mortality and DM.
To achieve this, various efforts made to improve metabolik aberration that occurred in DM patients, such as deviation of blood glucose, lipid, and various aberration that also affect the achievement of long-term goals, such as blood pressure and body weight.
Main pillars of the management of Diabetes mellitus:
1. Education
Education initials are important both in making families feel safe and able to deal with insulin injections, blood glucose test, test keton urin, hipoglikemia, and other penatalaksaan they should do. This usually requires the presence of both parents for about 3 days (but depending on the speed of learning).
2. Diet / medical nutrition therapy
Medical nutrition therapy is a therapy that is non farmakologis recommended for the diabetisi. Medical nutrition therapy, in principle, this is a pattern of eating that is based on the nutrient status diabetisi and diet modifications based on individual needs.
Goals of nutrition therapy for patients with diabetes mellitus type 1 is:
- Maintaining the blood glucose level near normal with the way insulin therapy on dietary patterns of each individual exercise and physical activity.
- Obtain blood pressure and lipid content is optimal.
- Provide enough calories and maintain ideal body weight, growth and development is normal.
- Reducing risk factors and prevent the occurrence of complications, both acute (hipoglikemia, a disease not related to diabetes), chronic (hypertension, hiperlipidemia, kidney disease, kardiovaskuler disease, complications, and other micro and makrovaskuler).
- Improving health with the selection of the appropriate type of food.
Planning must be adjusted according to the eating habits of each individual. Number of entries calorie foods that come from carbohydrate is more important than the source or type of karbohidratnya.
Standard is recommended that food with the composition:
- Carbohydrate: 60-70%
- Protein: 10-15%
- Fat: 20-25%
Exchange system created in 1950 by the American Dietetic Association, the American Diabetes Association, and the U.S. Public Health Service used as a tool to control your diet, and indicate the type of food that can be consumed by diabetic patients. Category of food that enter into the exchange system is divided into 6 groups: rice / bread, meat, vegetables, fruit, milk and fat. Each portion can be because it contains nutrients that are similar in the amount of calories, carbohydrates, protein and fat.
Now five years of data available to show that glucose control in children who get a diet "sugar limited" freedom to eat food with other appropriate taste, diet versus an exchange of special American Diabetes Association (initially developed to control body weight and are still useful when the body weight is a problem). If you use the exchange diet, calorie Feed 24 hours is calculated as 1000 kkal plus the additional 100 kkal per year until 2500 kkal age. Calories are usually divided into 55% from carbohydrate, 20% of the protein, and 25% from fat. Snack is provided at the time of peak insulin activity, or before exercise to prevent hipoglikemia (usually 3-4 hours in the afternoon and sometimes at 10-11 pm) and dense snack containing protein and fat should be consumed consistently before bedtime to prevent hipoglikemia nokturna.
3. Insulin
Most children with medium or heavy ketonuria is not asidosis and so does not suffer dehydration requiring fluid therapy intravena, beginning diterapi (treatment is usually the way) with regular insulin intramuskular (per hour) or sub kutan (every 2-3 hours) with a dose of 0,1-0,2 units per kg body weight. If ketonuria is reduced, a mixture of regular insulin with insulin starts working long with dose 0,5-1,0 units per kg (total dose) per 24 hours. When there is no ketonuria at the beginning, usually indicates insulin endogen production of larger, initial dose is usually 0,25-0,5 units per kg body weight per 24 hours. Duapertiga of the total dose is usually given in the morning and 1 / 3 in the afternoon, more good 30-60 minutes before eating. Children under the age of 4 years and usually only need ½ to 2 units of regular insulin, children aged 4-12 years old need 1-5 units of regular insulin, and puber children need 5-10 units of regular insulin. The remaining doses of insulin given as a long-term. Doses are usually strictly monitored through the first week on the phone and dititrasi appropriate monitoring of blood glucose at home. At puberty, insulin dose increased in general and can reach up to 1.5 units per kg body weight per 24 hours. (11)
Method infus intravena low dose continuously, where the main dose of 0.1 U / kg regular insulin, followed by a infus constant 0.1 U / kg / hour. This method is effective, simple and easy to understand the physiological, and has received wide as insulin delivery method is selected during ketoasidosis. This measure provides a continuous insulin in plasma is steadily approaching the peak reached in normal individuals during oral glucose tolerance test. Presumably, the same steady level attained at the cellular level and allows the response metabolik steady without fluctuations that have occurred in the insulin injection in snatches. Worries that the insulin can be attached to the glass and the pipe was not based, and effective delivery of insulin can be given without the use of albumin or gelatin is added to the infusat. Moreover, insulin can be given infus drops with gravity without the use of special pumps, pumps, although such help. Set infus to insulin associated with a separate pipe infus used for fluid and electrolyte therapy recommended dose adjustments so that each can be separately .. After the amount of insulin for the first 6-8 hours is calculated, this amount is added to the bottles 250-500 ml 0.9% physiological salt.
Farmakokinetik the insulin used
Type of Insulin ONSET drug peak time duration drug effects
Lispro, aspart, glulisine 5 - 15 minutes 45 - 75 minutes 2 - 4 hours
Regular 30 minutes ± 2 - 4 hours 5 - 8 hours
NPH ± 2 hours 6 - 10 days 18 - 28 hours
Insulin glargine ± 2 hours There is no peak of 20 -> 24 hours
Insulin detemir ± 2 hours There is no peak of 6 - 24 hours
4. Sports / physical training
Patients with diabetes, physiological response, depending on the sport at the time of the plasma insulin level at the time. This response increase the risk of a patient on hypoglycemia especially when doing physical activities, the more weight in terms of intensity, duration and frequency.
Children who follow sports require monitoring of blood glucose level is greater (before, after, and when doing activities that are in long time) and giving the right dose of insulin.
In the child with a dose of insulin that remains, should be given a snack before exercise. Some children even require additional carbohydrate after exercise because the exercise intensity can affect the blood glucose level due to increased release katekolamin, so that often occur during sports hypoglycemia if not traet as above.
In the patients who use insulin pumps, insulin infuse value given should be reduced 30 to 70% for physical activity to prevent hypoglycemia.
