癌症史、帶狀白血球增多與血清肌酸酐上升是感染引發高血糖危症之獨立死亡預測因子
Cancer history, bandemia, and serum creatinine are independent mortality predictors in
patients with infection-precipitated hyperglycemic crises
黃建程 1,2、許建清 1、林宏榮 1、郭浩然 2、蘇世斌 2,3
奇美醫學中心急診部 1、國立成功大學環境醫學研究所 2、奇美醫學中心家庭醫學科 3
Background: Hyperglycemic crises present a disease continuum of diabetic emergency
consisting of three subgroups: diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic
state (HHS), and mixed DKA/HHS. Infection is the most common precipitating factor and
cause of death in patients with hyperglycemic crises. Treating infection-precipitated
hyperglycemic crises includes using empiric antibiotics early; correcting dehydration,
hyperglycemia, and electrolyte imbalances; and frequent monitoring. Intensive care unit
admission, broad-spectrum antibiotics, and even novel therapy for infection may be beneficial
for patients with a high risk of mortality. However, these management options are costly and
not beneficial for every patient. Selecting high-risk patients who would most likely benefit is
more appropriate.
Objective: We investigated the independent mortality predictors of patients with
infection-precipitated hyperglycemic crises to facilitate clinical decision making.
Methods: This study was conducted in a university-affiliated medical center. Consecutive
adult patients (> 18 years old) visiting the Emergency Department between January 2004 and
December 2010 were enrolled when they met the criteria of an infection-precipitated
hyperglycemic crisis. One hundred forty-two patients were enrolled. Thirty-day mortality was
the primary endpoint.
Results: Univariate analysis of clinical and biochemical variables of 142 patient was showed
in Table 1 and Table 2. The infection source did not predict mortality. The presenting
variables that were independently associated with 30-day mortality in a multiple logistic
regression model were cancer history (odds ratio [OR], 7.4; 95% confidence interval [CI],
2.4-23.2), bandemia (OR, 7.0; 95% CI, 1.6-30.3), and serum creatinine (OR, 1.4; 95% CI,
1.1-1.8) (Table 3). The common sources of infection were the lower respiratory tract (30.3%),
urinary tract (49.3%), skin or soft tissue (12.0%), and intra-abdominal (6.3%).
Conclusions: Cancer history, bandemia, and serum creatinine level are three independent
mortality predictors for patients with infection-precipitated hyperglycemic crises. These
predictors are both readily available and valuable for physicians making decisions about risk
stratification, treatment, and disposition.
Table 1. Univariate analysis of clinical variables of 142 patient visits with hyperglycemic
crises precipitated by infection
30-day
PSurvival
All
Variable
mortality
(n = 115)
value
(n = 142)
(n = 27)
Age, mean ± SD
Elderly ( 65 years old), %
Gender: Male, %
Altered mental status, %
SBP, mean ± SD
Heart rate, mean ± SD
Body temperature, mean ± SD
Respiratory rate, mean ± SD
Medical history, %
Hypertension
Diabetes
Stroke
Chronic renal insufficiency
Cancer
Bedridden
67.5 ± 17.1
62.6
37.4
53.0
135.0 ± 32.0
118.1 ± 21.3
37.3 ± 1.2
72.4 ± 19.7
81.5
48.1
77.8
127.5 ± 36.7
106.0 ± 26.3
37.1 ± 1.4
0.200
0.073
0.303
0.029
0.289
0.013
0.387
68.4 ± 17.6
66.2
39.4
57.7
133.6 ± 32.9
115.8 ± 22.8
37.2 ± 1.2
22.1 ± 6.1
21.9 ± 6.5
0.898
22.1 ± 6.1
53.9
82.6
33.0
14.8
7.8
20.0
48.1
88.9
33.3
25.9
29.6
25.9
0.589
0.567
>0.95
0.166
0.005
0.600
52.8
83.8
33.1
16.9
12.0
21.1
Table 1 (Cont.). Univariate analysis of clinical variables of 142 patient visits with
hyperglycemic crises precipitated by infection
30-day
PSurvival
All
Variable
mortality
(n = 115)
value
(n = 142)
(n = 27)
Infection source, %*
Low respiratory tract
Urinary tract
Skin or soft tissue
Intra-abdominal
Meningitis
Bone/joint
Perianal abscess
Psoas muscle abscess
Sepsis without focus
Subgroup diagnosis, %
DKA
HHS
Mixed DKA/HHS
31.3
52.2
10.4
5.2
0.9
0.9
25.9
37.0
18.5
11.1
0.0
0.0
0.649
0.157
0.319
0.372
>0.95
>0.95
30.3
49.3
12.0
6.3
0.7
0.7
0.0
0.9
0.9
3.7
0.0
0.0
0.190
>0.95
>0.95
0.7
0.7
0.7
22.6
64.3
13.0
14.8
66.7
18.5
0.443
>0.95
0.538
21.1
64.8
14.1
SD, standard deviation; SBP, systolic blood pressure; DKA, diabetic ketoacidosis; HHS,
hyperosmolar hyperglycemic state.
*
Patient may have multiple infection sources.
Table 2. Univariate analysis of biochemical variables of 142 patient visits with hyperglycemic
crises precipitated by infection
30-day
PSurvival
All
Variable
mortality
(n = 115)
value
(n = 142)
(n = 27)
Laboratory data, mean ± SD
Blood glucose (mg/dL)
WBC (cells/mm3)
Hemoglobin (g/dL)
Platelet (1000/mm3)
Osmolarity (mOsm/kg)*
Serum creatinine (mg/dL)
Blood pH†
HbA1c (%)‡
Bandemia (> 10% band), %
739.9 ± 311.0
757.3 ± 259.8
15300.0 ± 6406 13700.0 ± 5909
13.1 ± 2.6
12.5 ± 3.0
247.5 ± 103.1
203.5 ± 82.2
335.6 ± 33.0
335.4 ± 28.6
2.2 ± 1.4
3.3 ± 2.7
7.4 ± 0.1
11.2 ± 3.2
4.3
7.3 ± 0.2
10.1 ± 2.7
14.8
0.788
743.2 ± 301.1
0.250 15000.0 ± 6324
0.314
12.9 ± 2.7
0.041
239.2 ± 100.7
0.985
346.5 ± 34.5
0.046
2.4 ± 1.8
0.208
0.183
0.047
7.4 ± 0.1
11.0 ± 3.1
6.3
SD, standard deviation; WBC, white blood cell count.
*
Effective serum osmolarity: 2[measured Na+ (mEq/L)] + [glucose (mg/dL)]/18.
†
90.1% (128/142) patients had this test.
‡
72.2% (83/115) survival patients had this test; 66.7% (18/27) 30-day mortality patients had
this test.
Table 3. Multivariate logistic regression modeling using a univariate comparison (P < 0.1)
Variable
Cancer history
Bandemia (> 10% band)
Serum creatinine
Elderly ( 65 years old)
Altered mental status
Heart rate
Platelet (1000/mm3)
Odds ratio (95% Confidence Interval)
Full Model
Final Model
4.5 (1.3-15.4)
6.2 (1.1-33.1)
1.4 (1.1-1.7)
2.1 (0.6-7.5)
2.6 (0.8-8.2)
0.9 (0.8-1.0)
0.9 (0.8-1.0)
NA: not available; variable not included in the final model
7.4 (2.4-23.2)
7.0 (1.6-30.3)
1.4 (1.1-1.8)
NA
NA
NA
NA
P-value
0.001
0.010
0.007