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Predicting the hyperglycemic crisis death (PHD) score: a new decision rule for emergency and critical care

Published:April 22, 2013DOI:https://doi.org/10.1016/j.ajem.2013.02.010

      Abstract

      Background

      We investigated independent mortality predictors of hyperglycemic crises and developed a prediction rule for emergency and critical care physicians to classify patients into mortality risk and disposition groups.

      Methods

      This study was done in a university-affiliated medical center. Consecutive adult patients (> 18 years old) visiting the emergency department (ED) between January 2004 and December 2010 were enrolled when they met the criteria of a hyperglycemic crisis. Data were separated into derivation and validation sets—the former were used to predict the latter. December 31, 2008, was the cutoff date. Thirty-day mortality was the primary endpoint.

      Results

      We enrolled 295 patients who made 330 visits to the ED: derivation set = 235 visits (25 deaths: 10.6%), validation set = 95 visits (10 deaths: 10.5%). We found 6 independent mortality predictors: Absent tachycardia, Hypotension, Anemia, Severe coma, Cancer history, and Infection (AHA.SCI). After assigning weights to each predictor, we developed a Predicting Hyperglycemic crisis Death (PHD) score that stratifies patients into mortality-risk and disposition groups: low (0%) (95% CI, 0-0.02%): treatment in a general ward or the ED; intermediate (24.5%) (95% CI, 14.8-39.9%): the intensive care unit or a general ward; and high (59.5%) (95% CI, 42.2-74.8%): the intensive care unit. The area under the curve for the rule was 0.946 in the derivation set and 0.925 in the validation set.

      Conclusions

      The PHD score is a simple and rapid rule for predicting 30-day mortality and classifying mortality risk and disposition in adult patients with hyperglycemic crises.
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      References

        • Kitabchi A.E.
        • Umpierrez G.E.
        • Miles J.M.
        • et al.
        Hyperglycemic crises in adult patients with diabetes.
        Diabetes Care. 2009; 32: 1335-1343
        • Wachtel T.J.
        • Tetu-Mouradjian L.M.
        • Goldman D.L.
        • et al.
        Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island.
        J Gen Intern Med. 1991; 6: 495-502
        • Kitabchi A.E.
        • Umpierrez G.E.
        • Murphy M.B.
        • et al.
        Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association.
        Diabetes Care. 2006; 29: 2739-2748
        • Chung S.T.
        • Perue G.G.
        • Johnson A.
        • et al.
        Predictors of hyperglycaemic crises and their associated mortality in Jamaica.
        Diabetes Res Clin Pract. 2006; 73: 184-190
        • MacIsaac R.J.
        • Lee L.Y.
        • McNeil K.J.
        • et al.
        Influence of age on the presentation and outcome of acidotic and hyperosmolar diabetic emergencies.
        Intern Med J. 2002; 32: 379-385
        • Magee M.F.
        • Bhatt B.A.
        Management of decompensated diabetes. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome.
        Crit Care Clin. 2001; 17: 75-106
        • Carroll P.
        • Matz R.
        Uncontrolled diabetes mellitus in adults: experience in treating diabetic ketoacidosis and hyperosmolar nonketotic coma with low-dose insulin and a uniform treatment regimen.
        Diabetes Care. 1983; 6: 579-585
        • National Center for Health Statistics
        National hospital discharge and ambulatory surgery data [article online].
        (Accessed 24 January 2009)
        • Fishbein H.A.
        • Palumbo P.J.
        Acute metabolic complications in diabetes.
        in: National Diabetes Data Group. Diabetes in America. Bethesda (MD): National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. 1995: 283-292
        • Wang J.
        • Williams D.E.
        • Narayan K.M.
        • et al.
        Declining death rates from hyperglycemic crisis among adults with diabetes, U.S., 1985–2002.
        Diabetes Care. 2006; 29: 2018-2022
        • Efstathiou S.P.
        • Tsiakou A.G.
        • Tsioulos D.I.
        • et al.
        A mortality prediction model in diabetic ketoacidosis.
        Clin Endocrinol (Oxf). 2002; 57: 595-601
        • Kitabchi A.E.
        • Umpierrez G.E.
        • Murphy M.B.
        • et al.
        Management of hyperglycemic crises in patients with diabetes.
        Diabetes Care. 2001; 24: 131-153
        • Teasdale G.
        • Jennett B.
        Assessment of coma and impaired consciousness. A practical scale..
        Lancet. 1974; 2: 81-84
        • Knaus W.A.
        • Draper E.A.
        • Wagner D.P.
        • et al.
        APACHE II: a severity of disease classification system.
        Crit Care Med. 1985; 13: 818-829
        • Bone R.C.
        • Sibbald W.J.
        • Sprung C.L.
        The ACCPSCCM consensus conference on sepsis and organ failure.
        Chest. 1992; 101: 1481-1483
        • Laupacis A.
        • Sekar N.
        • Stiell I.G.
        Clinical prediction rules. A review and suggested modifications of methodological standards..
        JAMA. 1997; 277: 488-494
        • Tintinalli J.D.
        • Kelen G.D.
        • Stapczynski J.S.
        Emergency medicine: a comprehensive study guide.
        in: 6th ed. McGraw-Hill, New York2004: 1294-1304
        • Fagon J.Y.
        • Chastre J.
        • Novara A.
        • et al.
        Characterization of intensive care unit patients using a model based on the presence or absence of organ dysfunctions and/or infection: the ODIN model.
        Intensive Care Med. 1993; 19: 137-144
        • Lemeshow S.
        • Le Gall J.R.
        Modeling the severity of illness of ICU patients.
        JAMA. 1994; 272: 1049-1055
        • Gaglia J.L.
        • Wyckoff J.
        • Abrahamson M.J.
        Acute hyperglycemic crisis in the elderly.
        Med Clin North Am. 2004; 88: 1063-1084
        • Wasson J.H.
        • Sox H.C.
        • Neff R.K.
        • et al.
        Clinical prediction rules. Applications and methodological standards.
        N Engl J Med. 1985; 313: 793-799