Hyperglycemic emergencies in a tertiary health facility
Clinical presentation and predictors of mortality
Keywords:
Hyperglycemic emergencies, Diabetes Ketoacidosis, Hyperglycemic Hyperosmolar State, mortalityAbstract
Abstract
Aim: To assess the clinical presentations and predictors of mortality of hyperglycemic emergencies (HE)
in persons with diabetes mellitus (DM) presenting in a tertiary health facility in Nigeria.
Methods: This was a two-year retrospective review of hospital records of persons with DM in a tertiary
hospital in Nigeria. We retrieved data on person’s demographics, clinical and laboratory characteristics
into Microsoft Excel and analyzed with STATA version 14.
Results: A total of 195 (42.4%) out of 460 persons admitted with DM fulfilled the eligibility criteria.
Diabetic ketoacidosis (DKA) was present in 42.6%, mixed hyperglycemic emergency (MHE) in 34.9%
and hyperglycemic hyperosmolar state (HHS) in 22.5%. Mortality in HE was 8.7%. The common clinical
presentation were: osmotic symptoms (71.3%), tachypnoea (46.7%), tachycardia (42.6%). Elevated anion
gap (89.2%) and anemia (80.5%) were the common laboratory findings. Infections (86.7%), noncompliance (79.5%) and newly diagnosed DM were the common precipitants of HE. Significant
predictors of mortality were: duration of DM between 5-9 years, Glasgow Coma Scale (GCS) < 8,
hypotension, and hypokalemia.
Conclusion: HE is still a common cause of hospitalization and mortality in persons with DM; and
features such osmotic symptoms, tachypnea and high anion gap metabolic acidosis should alert the
clinician.
References
International Diabetes Federation. Diabetes Atlas. 9th ed. Brussels, Belgium: International Diabetes Federation, 2019.
Kitabchi AE, Umpierrez GZ, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2009; 32 (7):1335- 43. https://doi: 10.2337/dc09-9032
Goguen J, Gilbert J. Hyperglycemic emergencies in adults: diabetes Canada clinical practice guideline expert committee Can J Diabetes 2018; (42), S109 – S114. https://doi.org/10.1016/j.jcjd.2017.10.013
Kitbachi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes. Diabetes Care 2006; 29 (12):2739-48. https://doi.org/10.2337/dc06-9916
Savage MW, Dhatariya KK, Kilvert A, Rayman G, Rees JA, Courtney CH, Hilton L, at al, for the Joint British Diabetes Societies. Joint British Diabetes Societies guidelinefor the management of diabetic ketoacidosis. Diabetic Med. 2011; 28 (5):508–15. https://doi:10.1111/j.1464-5491.2011.03246.x
Chiasson JL, Aris-Jilwan N, Belanger R et al. Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state. CMAJ 2003; 168 (7):859 - 66
Kitbachi AE, Fisher JN, Murphy MB, Rumbak MJ. Diabetic ketoacidosis and the hyperglycemic hyperosmolar nonketotic state. In Joslin’s Diabetes mellitus. 13th ed. Kahn CR, Weir GC, Eds. Philadelphia, Lea & Febiger, 1994, p.738 – 770
Chung ST, Perue GG, Johnson A, Younger N, Hoo CS, Pascoe RW, Bayne MS. Predictors of hyperglycemic crises and their associated mortality in Jamaica. Diabetes Res Clin Pract 2006; 73 (2): 184-190. DOI: 10.1016/j.diabres.2006.01.004
Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: A historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care 2014; 37 (11):3124-31. DOI: 10.2337/dc14-0984.
Fourtner SH, Weinzimer SA, Levitt Katz LE. Hyperglycemia, hyperosmolar non-ketotic syndrome in children with Type 2 diabetes. Paediatr Diabetes 2005; 6 (3):129-35. DOI: 10.1111/j.1399-543X.2005.00113.x
Huang CC, Kuo SC, Chien TW, Lin HJ, Guo HR, Chen WL, Chang SH et al. Predicting the hyperglycemic crises death (PHD) score: a new decision rule for emergency and critical care. Am J Emerg Med 2013; 31 (5): 830 - 834. DOI: 10.1016/j.ajem.2013.02.010
Dhatariya KK, Parsekar K, Skedgel C, Datta V, Hill P, Fordham R. The cost of treating diabetic ketoacidosis in an adolescent population in the UK: a national survey of hospital resource use. Diabet Med. 2019 Aug;36(8):982–987; DOI:10.1111/dme.13893.
Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017.
Benoit SR, Zhang Y, Geiss LS, Gregg EW, Albright A. Trends in Diabetic Ketoacidosis Hospitalizations and In-Hospital Mortality - United States, 2000-2014. MMWR Morb Mortal Wkly Rep 2018; 67 (12):362-365. DOI: 10.15585/mmwr.mm6712a3
Ajayi EA, Ajayi AO. Pattern and outcome of diabetic admissions at a federal medical center: A 5-year review. Annals of African Medicine 2009; 8 (4): 271-275 DOI: 10.4103/1596-3519.59584
Adeloye D, Ige JO, Aderemi AV, Adeleye N, Amoo EO, Auta A, Oni G. Estimating the prevalence, hospitalization and mortality from type 2 diabetes mellitus in Nigeria: a systematic review and meta-analysis. BMJ Open 2017; 7: e015424. Doi:10.1136/bmjopen-2016-015424
Anumah F, Ohwovoriole A. Serum biochemistry in Nigerians with hyperglycemic
emergencies. Ethn Dis. 2008;18(1):26-30.
Okoro EO, Yusuf M, Salawu HO and Oyejola BA. Outcome of diabetic hyperglycaemic emergencies in a Nigerian cohort. Chinese Journal of Medicine 2007; 2(2):77-82
Ogbera OA, Awobusuyi J, Unachukwu C, Fasanmade O. Clinical features, predictive factors and outcome of hyperglycemic emergencies in a developing country. BMC Endocrine Disorders 2009, 9:9. Doi:10.1186/1472-6823-9-9.
Kitbachi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001; 24 (1): 131-153. https://doi.org/10.2337/diacare.24.1.131
Wachtel TJ, Tetu-Mouradjian LM, Goldman DL, Ellis SE, O’Sullivan PS. Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island. J Gen Intern Med 1991; 6 (6): 495-502. DOI: 10.1007/BF02598216.
Mackowiak PA, Wasserman SS, Levine MM. A critical appraisal of 98.6-degree Fahrenheit, the upper limit of normal body temperature, and other legacies of Carl Reinhold August Wunderlich. JAMA 1992; 268 (12):1578—80.
World Health Organization. Thermal protection of the newborn: A practical guide. World Health Organization; Geneva: 1997. Report No.: WHO/RHT/MSM/97.2.
Gopinathannair R, Sullivan RM, Olshansky B. Slower heart rates for healthy hearts: time to redefine tachycardia? Circ Arrythm Electrophysiol. 2008; 1:321–3. doi: 10.1161/CIRCEP.108.835264.
Palatini P. Need for a revision of the normal limits of resting heart rate. Hypertension 1999; 33:622–5. doi: 10.1161/01.HYP.33.2.622.
Cretikos MA, Bellomo R, Hillman K, Chen J, Finfer S, Flabouris A. Respiratory rate: the neglected vital sign. Med J Aust 2018; 188: 657- 659. doi: 10.5694/j.1326-5377.2008.tb01825.x
Petridou ET, Antonopoulos CN. (2017). Injury Epidemiology. International Encyclopedia of Public Health, 258–274. doi:10.1016/b978-0-12-803678-5.00233-2
Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, Ramirez A et al. 2020 International Society of hypertension Global Hypertension Practice Guidelines. Hypertension 2020; 75 (6):00-00. Doi:10.1161/HYPERTENSIONAHA.120.15026
Worthley LI. Shock: A Review of Pathophysiology and management. Part 1. Crit Care Resusc 2000; 2 (1): 55 – 65.
Sterns RH. Disorders of plasma sodium – causes, consequences, and correction. N Engl J Med 2015; 372: 55-65. DOI:10.1056/NEJMra1404489
Gumz ML, Rabinowitz L, Wingo CS. An Integrated view of potassium homeostasis. N Engl J Med 2015; 373: 60 – 72. DOI: 10.1056/NEJMra1313341.
Kraut JA, Madias NE. Serum Anion Gap: Its uses and limitations in clinical medicine. Clin J Am Soc Nephrol 2007; 2: 162–174, 2007. doi: 10.2215/CJN.03020906
Arieff AI, Carroll HJ. Hyperosmolar nonketotic coma with hyperglycemia: abnormalities of lipids and carbohydrate metabolism. Metabolism 1971; 20 (6):529-538. https://doi.org/10.1016/0026-0495(71)90001-1
Hoffman R, Benz EJ Jr, Silberstein LE, Heslop H, Weitz J, Anastasi J. Hematology: Basic Principles and Practice. 6th ed. Philadelphia, Pa.: Elsevier/Saunders; 2013: Table 164-20.
World Health Organization. The global prevalence of anaemia in 2011. Geneva: World Health Organization; 2015.
Stoner GD. Hyperosmolar hyperglycemic state. Am Fam Physician. 2005;71(9):1723-1730.
Ogbera OA, Chinenye S, Onyekwere A, Fasanmade O. Prognostic indices of diabetes mortality. Ethn Dis 2007; 17 (4): 721-5.
Oguejiofor O, Odenigbo C, Onwukwe C. Diabetes in Nigeria: Impact, Challenges, Future Directions. Endocrinol Metab Synd 2014; 3(2). DOI: 10.4172/2161-1017.1000130
Ekpebegh CO, Long-Mbenza B, Akinrinmade A, Blanco-Blanco E, Badri M, Levitt NS. Hyperglycemic crises in the Eastern Cape province of South Africa: High mortality and association of hyperosmolar ketoacidosis with a new diagnosis of diabetes. S Afr Med J 2010; 822-826. doi:10.7196/samj.4319
Chijioke A, Adamu AN, Makusidi AM. Mortality patterns among type 2 diabetes mellitus patients in Ilorin, Nigeria. JEMDSA 2010; 15(2):79-82
Ojobi JE, Dunga J, Ogiator MO, Mbaave P, Bello RN. Indications and outcome of admission of diabetic patients into the medical wards in a Nigerian tertiary hospital-A 2-year review. Jos Journal of Med 2017; 11(2): 53-8
Nkpozi MO, Ezeani IU, Korubo IF, Chinenye S, Chapp-Jumbo A. Outcome of hyperglycemic emergencies in a tertiary hospital, South East, Nigeria. Sahel Med J 2019; 22:47-54. DOI: 10.4103/smj.smj_71_17
Uloko AE, Adeniyi AF, Abubakar LY, Yusuf SM, Abdu A, Gezewa ID, Uloko AT. Pattern of diabetes admissions in a Northern Nigerian tertiary center. Nig End Prac 2013; 7(1): 15-20
Umoh VA, Out AA, Enang OE, Okereke QO, Essien O, Ukpe I. The pattern of diabetic admissions in UCTH Calabar, South Eastern Nigeria: a five-year review. Nig Health J 2012; 12 (1):7-11.
Edo AE. Clinical profile and outcomes of adult patients with hyperglycemic emergencies managed at a tertiary care hospital in Nigeria. Nig Med J 2012; 53(39. 121-125. DOI: 10.4103/0300-1652.104378
Ezeani UI, Eregie A, Edo AE. Pattern of presentation, socio-demographic and clinical characteristics of patients presenting with hyperglycemic emergencies in a Nigerian Hospital. Pioneer Med J 2013; 3 (5):1-15
Olugbemide O, Bankole I, Akhuemokhan K, Adunbiola P. Clinical profile and outcome of hyperglycemic emergencies at a rural hospital in southern Nigeria. Afr J of Dia Med 2017; 25 (2): 16-18
Desse TA, Eshetie TC, Gudina EK. Predictors and treatment outcome of hyperglycemic emergencies at Jimma University Specialized Hospital, southwest Ethiopia. BMC Res Notes 2015; 8:553
Fox CS. Cardiovascular Disease Risk Factors, Type 2 Diabetes Mellitus, and the Framingham Heart Study. Trends Cardiovasc Med. 2010; 20 (3): 90-95.
Ginsberg HN, MacCallum PR. The obesity, metabolic syndrome, and Type 2 diabetes mellitus pandemic: Part 1. Increased cardiovascular disease risk and the importance of atherogenic dyslipidemia in persons with the metabolic syndrome and type 2 diabetes mellitus. J Cardiometab Syndr. 2009; 4: 113-119.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2022 African Journal of Tropical Medicine and Biomedical Research
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
The data collected from registered and non-registered users of this journal falls within the scope of the standard functioning of peer-reviewed journals. It includes information that makes communication possible for the editorial process; it is used to informs readers about the authorship and editing of content; it enables collecting aggregated data on readership behaviors, as well as tracking geopolitical and social elements of scholarly communication.
This journal’s editorial team uses this data to guide its work in publishing and improving this journal. Data that will assist in developing this publishing platform may be shared with its developer Public Knowledge Project in an anonymized and aggregated form, with appropriate exceptions such as article metrics. The data will not be sold by this journal or PKP nor will it be used for purposes other than those stated here. The authors published in this journal are responsible for the human subject data that figures in the research reported here.
Those involved in editing this journal seek to be compliant with industry standards for data privacy, including the European Union’s General Data Protection Regulation (GDPR) provision for “data subject rights” that include (a) breach notification; (b) right of access; (c) the right to be forgotten; (d) data portability; and (e) privacy by design. The GDPR also allows for the recognition of “the public interest in the availability of the data,” which has a particular saliency for those involved in maintaining, with the greatest integrity possible, the public record of scholarly publishing.
