感染、心跳不快、癌症史與嚴重昏迷是老人罹患高血糖危症的獨立死亡預測因子
Infection, absence of tachycardia, cancer history, and severe coma are the independent
mortality predictors in the geriatric patients with hyperglycemic crises
黃建程 1、許建清 1、林宏榮 1、郭浩然 2、蘇世斌 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. Because mortality increases with age and early detection
as well as intervention may be benificial, it is particularly important to identify patients at risk
within the geriatric population
Objective: We investigated individual mortality predictors in geriatric patients with
hyperglycemic crises and combined these factors to predict the prognosis of the patients.
Methods: This study was conducted in a university-affiliated medical center. Consecutive
elderly (≥ 65 years old) patients who visited our Emergency Department (ED) between
January 2004 and December 2010 were prospectively enrolled when they met the criteria of a
hyperglycemic crisis. A total of one hundred fifty-six elderly patients were enrolled.
Information for a number of variables for each patient was recorded (Table 1). We used
30-day in-hospital mortality as the primary endpoint. All analyses were done using SPSS 16.0
for Windows. The significant  level was set at 0.1 for univariate variables that are included
in a multiple logistic regression analysis of risk for 30-day in-hospital mortality. Significance
was set at p < 0.05 (two tailed).
Results: Age itself was not an independent mortality predictor. Infection, absence of
tachycardia, cancer history, and severe coma were independently associated with 30-day
in-hospital mortality (Table 2). These four predictors were then combined to predict the
prognosis (Table 3). The presence of at least one of the four predictors had a sensitivity of
100% (95% CI: 82.2-100), specificity of 19.6% (95% CI: 13.4-27.5), PPV of 17.7% (95% CI:
11.8-25.6), and NPV of 100% (95% CI: 84.1-100). With at least two of these predictors
present, the sensitivity was 95.7% (95% CI: 76.0 to 99.8), the specificity was 71.4 (95% CI:
62.8-78.8), the PPV was 36.7% (95% CI: 24.9-50.2), and the NPV was 99.0% (95% CI:
93.5-100). With at least three of these predictors present, the sensitivity was 34.8% (95% CI:
17.2-57.2), the specificity was 97.0 (95% CI: 92.0-99.0), the PPV was 66.7% (95% CI:
35.4-88.7), and the NPV was 89.6% (95% CI: 83.1-93.9). With all four predictors present, the
sensitivity was 4.3% (95% CI: 0.2-24.0), the specificity was 100.0 (95% CI: 96.5-100.0), the
PPV was 100.0% (95% CI: 5.5-100.0), and the NPV was 85.8% (95% CI: 79.1-90.7).
Conclusions: The mortality risk apparently rises with the number of independent mortality
predictors. Zero percent mortality was found in the patients without any of the predictors. In
the patients with all four predictors, 100% died. This finding may help physicians make
decisions about the geriatric patients with hyperglycemic crises.
Table 1. Univariate analysis of variables of 156 elderly patients with hyperglycemic crises
Variable
Age, mean ± SD
Survival
30-Day In-hospital
All
(n = 133)
Mortality (n = 23)
(N = 156)
p-value
78.4  7.0
81.0  6.8
78.7  7.0
0.095
Age subgroup, %
Young elderly (65-74 years)
33.0
26.1
32.1
0.631
Moderately elderly (75-84 years)
42.9
39.1
42.3
0.822
Old elderly ( ≥ 85 years)
24.1
34.8
25.6
0.305
Gender: Male (%)
42.1
47.8
42.9
0.609
Altered mental status (%)
52.6
82.6
57.1
0.006
Severe coma (GCS ≤ 8) (%)
19.5
52.2
24.4
0.001
Hypotension (SBP < 90) (%)
5.3
21.7
7.7
0.018
Absence of tachycardia (HR ≤ 100) (%)
28.6
52.2
32.1
0.025
Tachypnea (RR > 20) (%)
33.1
34.8
33.3
1.000
Hypertension
61.7
60.9
61.5
1.000
Diabetes
83.5
87.0
84.0
1.000
Stroke
27.8
39.1
29.5
0.323
Chronic renal insufficiency
19.5
30.4
21.2
0.270
Cancer
9.8
34.8
13.5
0.004
Nursing home resident
3.8
13.0
5.1
0.096
Bedridden
20.3
30.4
21.8
0.282
Nasogastric feeding
15.8
17.4
16.0
0.766
811.6 ± 290.6
768.5 ± 271.5
805.2 ± 287.4
0.509
13000.0 ± 6181.3
13100.0 ± 5242.3
13000.0 ± 6036.7
0.914
12.9 ± 2.7
12.3 ± 3.0
12.8 ± 2.8
0.382
340.1 ± 26.8
340.2 ± 30.6
340.1 ± 27.3
0.984
Serum creatinine (mg/dL)
2.4 ± 1.5
3.1 ± 1.7
2.5 ± 1.5
0.078
Blood PH†
7.4 ± 0.1
7.4 ± 0.1
7.4 ± 0.1
0.126
Infection
54.1
95.7
60.3
< 0.001
Poor control
60.9
65.2
61.5
0.818
New-onset diabetes
17.3
13.0
16.7
0.768
DKA
2.3
13.0
3.8
0.042
HHS
89.4
78.3
87.8
0.162
8.3
8.7
8.4
1.000
Medical history (%)
Laboratory data (mean  SD)
Blood glucose (mg/dL)
WBC (cells/mm3)
Hemoglobin (g/dL)
Osmolality*
Precipitating factors (%)
‡
Subgroup diagnosis (%)
Mixed DKA/HHS
*
Effective serum osmolality: 2[measured Na+ (mEq/L)] + [glucose (mg/dL)]/18.
†
87.8% (137/156) patients had this test.
‡
Patients may have more than 1 precipitating factor.
SD, standard deviation; GCS; Glascow coma scale; SBP, systolic blood pressure; HR, heart
rate; RR, respiratory rate; WBC, white blood cell count; DKA, diabetic ketoacidosis; HHS,
hyperosmolar hyperglycemic state.
Table 2. Multivariate logistic regression modeling using univariate comparison p < 0.1
Variable
Odds Ratio (95% CI)
Infection
Absence of tachycardia (Heart rate ≤ 100 beats/min)
Cancer history
Severe coma (Glascow Coma Scale ≤ 8)
38.69 (4.09-365.72)
14.06 (3.68-53.77)
8.86 (2.23-35.29)
5.28 (1.53-18.21)
CI, confidence interval.
p-value
0.001
< 0.001
0.002
0.008
Table 3. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value
(NPV) of the number of independent mortality predictor for 30-day in-hospital mortality
Variable number
Sensitivity
Specificity
PPV
NPV
≥1
≥2
≥3
4
100
95.7
34.8
4.3
19.6
71.4
97.0
100
17.7
36.7
66.7
100
100
99.0
89.6
85.8
All data are %.