Diabetic Ketoacidosis Management and Treatment Outcome at Medical Ward of Shashemene Referral Hospital, Ethiopia: A Retrospective Study

Abstract

Background: Diabetic Ketoacidosis (DKA) is the most common and yet potentially life-threatening acute complication of diabetes that progresses rapidly to death and requires immediate medical intervention. Objective: To assess the DKA management and treatment outcome/in-hospital mortality and its predictors among hospitalized patients with DKA at the Medical ward of Shashemene Referral Hospital (SRH). Method: A retrospective study was conducted at the Medical Ward of SRH from 01 February 2015 to 31 January 2017. A systematic random sampling technique was used to select study subjects based on the inclusion criteria. Thus, of 236 reviewed charts, only 225 patients with DKA fulfilled inclusion criteria. Treatment outcome was considered good for patients who have shown improvement at discharge, while poor for patients who left against medical advice or died in the hospital. Logistic regression analysis was done to determine independent predictors for treatment outcome/in-hospital mortality using SPSS version 20 with statistical significant at P ⩽ .05. Results: Of 225 patients with DKA, 124 (55.1%) were male. Regular insulin was prescribed to all patients and antibiotics were administered to 87 (38.7%). Potassium supplementation was given only for 28 (12.4%). Non-adherence to insulin treatment (n = 91; 40.4%) and infection (n = 66; 29.3%) were the principal DKA precipitating factors. Even though 73.8% of hospitalized patients with DKA have shown good treatment outcomes, DKA contributed 12% in-hospital mortality. The result of multivariate logistic regression analysis shown that hypoglycemia is the only independent predictor for in-hospital mortality[ P = .03]. Moreover, the independent predictors for poor DKA treatment outcome were found to be smoker [ P = .04], Urinary tract infection (UTI) relative to other co-morbid condition [ P < .001], severe hypokalemia which increase risk of poor treatment outcome by around 4 times [ P = .02], and use of Metronidazole as a concurrent medication relative to other concurrent medication [ P = .03]. Conclusion: There was a high in-hospital mortality rate due to correctable causes. This mortality is unacceptable as it was majorly related to the poor practice of potassium supplementation and hypoglycemia due to insulin. Thus, clinicians and stakeholders should have to focus on modifiable factors (hypokalemia, UTI, and hypoglycemia) to reduce poor treatment outcome/in-hospital mortality.

ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state

“…The serum potassium concentration may decrease rapidly during treatment, predisposing to cardiac arrhythmias. Severe hypokalemia (<2.5 mmol/L) is an independent marker of poor treatment outcome and mortality 132,133 …”

“…Severe hypokalemia (<2.5 mmol/L) is an independent marker of poor treatment outcome and mortality. 132,133 Potassium replacement is required regardless of the serum potassium concentration, except if renal failure is present. 125,134 • If the child is hypokalemic, start potassium replacement at the time of initial volume expansion and before starting insulin therapy.…”

Treatment outcomes of diabetic ketoacidosis among diabetes patients in Ethiopia. Hospital-based study

“…In Ethiopia, mortality from DKA was found be high [ 20 ]. A retrospective study conducted at Shashemene Referral Hospital reported that DKA contributed 12% in-hospital mortality [ 21 ]. Another study conducted in Hiwot Fana Specialized University Hospital indicated that about 11% of patients with diagnosis of DKA died in hospital [ 22 ].…”

“…However, these strategies have not been appropriately implemented in Ethiopia. In addition, the cost and lack of medication supplies, presence of comorbid conditions, inappropriate insulin storage, medication non-adherence, electrolyte disturbance and smoking habits complicated the prevention and treatment of DKA in Ethiopia [ 21 , 23 , 24 ]. There was limited data on treatment outcomes including hospital stay, glycemic control during hospitalization and in-hospital mortality related to DKA in north Ethiopia.…”

Type 1 diabetes in limited resource settings: Where are we and where do we need to go?

“…Hypoglycemia and hypokalemia have been associated with poorer outcomes in DKA in LRS. [6] Clinical and biochemical monitoring, especially for electrolytes and blood glucose https://ispae-jped.com/…”