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Table 11 shows comparison of outcome of hyperglycaemic emergencies seen in UBTH
Table 11. COMPARISON OF OUTCOME OF HYPERGLYCAEMIC EMERGENCIES SEEN IN UBTH
DKA= Diabetic ketoacidosis, HHNK= Hyperosmolar hyperglycemic non ketotic state, Mixed DKA/HHNK= Mixed Diabetic ketoacidosis/Hyperosmolar hyperglycemic non ketotic state, NNHS= Normo osmolar non ketotic hyperglycemic state, df= degree of freedom, X2= Yates chi-square.
A comparison of outcome of hyperglycaemic emergencies shows no statistically significant difference (p=0.97) in the number of patients discharged home based on the type of hyperglycaemic emergency. Furthermore, a total of 5 patients died out of which 3 had HHNK, 1 had each of DKA and NNHS. Of note is that the highest number of mortality was recorded in the HHNK group of hyperglycaemic emergencies: three of the five deaths occurred in this group.
There was no recorded mortality in the mixed DKA/HHNK class of hyperglycaemic emergencies as all the ten patients admitted were treated and discharged while each of DKA and NNHS recorded one death. Also 3 patients died within 24hours of admission while 2 patients died after 24hours of admission. The two mortalities that occurred after 24hours of admission were in HHNK patients while each of DKA, HHNK and NNHS recorded one death within 24hours of admission.
PARAMETER
DKA n= 29
HHNK n= 53
NNHS n=13
MIXED
n=10 X2 df P
DISCHARGED HOME
28 50 12 10 1.34 6 0.97
DEATH WITHIN 24 HOURS
1 1 1 0
DEATH AFTER 24 HOURS
0 2 0 0
- 65 - 4.2.8. Outcome of hyperglycaemic emergencies
Table 12 shows factors associated with outcome in persons with hyperglycaemic emergencies.
FACTORS DISCHARGED
n= (100)
DEATH
<24HRS n=2
DEATH
>24HRS n=3
X2 df P
BMI
Normal 20 0 0 9.62 6 0.14
Underweight 1 0 1
Overweight 49 2 2
Obese 30 0 0
SMOKING
Yes 7 0 0 1.57 2 0.46
No 93 2 3
DEHYDRATION
Absent 4 0 1 10.87 6 0.09
Present 96 2 2
FEVER
Present 50 2 3 1.70 2 0.43
Absent 50 0 0
LEVEL OF CONCIOUSNESS
Altered 9 0 1 0.73 2 0.69
Conscious 91 2 1
HbA1c
Normal 4 1 0 2.75 2 0.25
Elevated 96 1 3
WBC
Normal 19 0 0 0.08 2 0.96
Elevated 81 2 3
HYPOKALAEMIA
Present 20 1 1 0.51 2 0.97
Absent 80 1 2
HYPOGLYCAEMIA
Yes 13 0 2 3.26 2 0.19
No 87 2 1
DURATION OF DM
< 10 years 72 2 3 0.19 2 0.91
≥ 10 years 28 0 0
DM=Diabetes mellitus, HbA1c- Glycated hemoglobin, WBC= White blood cell count, BMI= Body mass index, X2= Yates chi-square.
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A comparison of factors associated with outcomes in persons with hyperglycaemic emergencies show that higher BMI was associated with higher mortality: eighty percent of those that died were overweight (four out of the five subjects that died were overweight while the fifth subject was underweight). Furthermore, elevated WBC was also associated with higher mortality: the WBC was elevated in all the mortalities. Of note is the fact that the presence of dehydration and fever were also associated with high mortality. Also, the level of dehydration was associated with a poor outcome as four (80%) out of the five subjects that died had dehydration at presentation. The fifth mortality had no dehydration. Temperature was higher in the patients that died in this study as all the five patients that died had fever at presentation. The Glycated hemoglobin was elevated in all the five subjects that died. Overall, only two of these five mortalities had hypokalemia, thus hypokalaemia was not a predictor of mortality in this study since the three other patients that died did not present with hypokalaemia. Hypoglycaemia was not worse in those that died as two out of the five mortalities had hypoglycemia during the course of treatment while the other three patients did not develop hypoglycaemia.
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Table 13 shows the outcome of hyperglycemic emergencies according to co-morbidity TABLE 13. OUTCOME OF HYPERGLYCAEMIC EMERGENCIES ACCORDING TO CO-MORBIDITY
X2= Yates chi-square, df=degree of freedom, p=p-value.
A comparison of outcome of hyperglycaemic emergencies according to co-morbidity shows a statistically significant difference in the influence of the number of co-morbidity on mortality (p=0.05). Overall, two out of the five patients that died had at least one co-morbidity and these patients both had cerebrovascular accidents: of note is that in three of the five patients that died, no co-morbidity was identified. Among the patients that were discharged, two of them had two or more co-morbidities. Hypertension was the commonest co-morbidity seen in this study. Other co-morbities seen includes mental illness, renal diseases, liver diseases, human immune deficiency virus, pulmonary tuberculosis, spondylosis. Fifty of the patients did not present with any co-morbidity.
The co-morbidities that patients with hyperglycaemic emergencies presented with in this study is shown in figure 8 below:
PARAMETER NONE
NUMBER OF COMORBIDITY
1 ≥ 2 X2 df P
DISCHARGED HOME 47 51 2 9.58 4 0.05
DEATH WITHIN 24 HOURS
1 1 0
DEATH AFTER 24 HOURS
2 1 0
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Figure 10: showing the various co-morbidities seen in this study.
DISTRIBUTION OF VARIOUS CO-MORDITIES
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Table 14 shows the influence of demographic parameters on outcome.
Table 14. INFLUENCE OF DEMOGRAPHIC PARAMETERS ON OUTCOME.
DM = Diabetes mellitus, df = degree of freedom, x2= Yates chi-square
A comparison of influence of demographic parameters on the outcome of hyperglycaemic emergencies shows no statistically significant difference between demographic parameters (age, sex, marital status, level of education) and outcome. Furthermore, the table shows a higher number of mortality among the males (80%) as compared to female subjects (20%). Also all the mortality recorded were in subjects with secondary and tertiary levels of education. The married subjects had the highest mortality rates (80%).
PARAMETER
DISCHARGED HOME
n=100
DIED
n=5 X2 df p
AGE GROUP (YEARS) 20-29 30-39 40-49 50-59 60-69 70-79 80-89
8 11 11 28 26 11 5
1 1 1 0 1 1 0
0.9 3
6 0.9
9
SEX Male Female
49 51
4 1
0.8 0
1 0.3
7 MARITAL
STATUS Single Married Divorced
Widow/widower
11 71 1 17
1 4 0 0
4.6 5
3 0.2
0
LEVEL OF EDUCATION No education Primary Secondary Tertiary
8 28 34 30
0 0 2 3
1.1 9
3 0.7
6
SMOKING Yes No
7 93
0 5
0.0 9
1 0.7
6
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Table 15 shows the association between precipitating factors of hyperglycaemic emergencies and outcome.
Table 15. ASSOCIATION BETWEEN PRECIPITATING FACTORS OF HYPERGLYCAEMIC EMERGENCIES AND OUTCOME.
FACTORS
DISCHARGED HOME
n=100
DEATH WITHIN 24 HOURS
n= 2
DEATH AFTER 24 HOURS
n=3 X2 df P
Infection 57 (57%) 1 (50%) 1 (33.3%) 9.32 12 0.68
CVA 11 (11%) 0 0
Fracture 1 (1%) 0 0
Newly diagnosed 15 (15%) 0 0
None adherence 13 (13%) 1 (50%) 2 (66.7%)
RTA 3 (3%) 0 0
CVA= Cerebrovascular accident, RTA= Road traffic accident, UTI= Urinary tract infection, X2
= Yates chi square, df= degree of freedom, p= p-value.
A comparison of influence of precipitating factors on outcome of hyperglycaemic emergencies shows that non adherence to medications accounted for the highest number of deaths (3 out of the total 5 deaths): two of these patients also had cerebrovascular accidents. This is followed by diabetic foot ulcers which accounted for the remaining two deaths. There was no statistically significant difference on the influence of precipitating factors on outcome (p>0.05). Infection was the most common precipitant of hyperglycaemic emergencies seen in UBTH (57%): the different types of infections included malaria, diabetic foot ulcer, pneumonia, urinary tract infection, and cellulitis. This was closely followed by non adherence to drugs (15.2%), newly diagnosed DM (14.3%) and diabetic foot ulcer (13.3%). Of note is a patient who presented with hyperglycaemic emergency and fracture involving the left humerus.
- 71 - CHAPTER FIVE