The Use of a Clinical Pathway in the Management of Adult Patients with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State at a Private Tertiary Hospital in the Philippines

Presentation Number: SUN 627
Date of Presentation: April 2nd, 2017

Ma. Karen Celine Calapre Ilagan*1, Karen Elouie C Agoncillo2, Ruben Gutierrez Kasala3 and Perie Adorable Wagan2
1The Medical City, Quezon City, Philippines, 2The Medical City, 3The Medical City, Pasig, PHILIPPINES

Abstract

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the two most serious acute complications of diabetes mellitus. The management of these hyperglycemic emergencies in the inpatient setting continues to pose a challenge for different healthcare providers. Worldwide, the use of clinical pathways and protocols have been used in the management of hyperglycemic emergencies while it is still not widely accepted in our local setting. In 2010, The Medical City (TMC) Section of Endocrinology and Metabolism developed a clinical pathway for hyperglycemic crisis. This pathway was formulated based on the 2010 ADA recommendations for the management of DKA and HHS and has adapted the use of the Markovitz insulin infusion protocol. This retrospective cross-sectional study compared the clinical outcomes and safety of the use of a clinical pathway in the management of DKA and HHS among adult patients admitted in a private tertiary hospital in the Philippines from January 2010 to April 2016. Clinical outcomes included time to target CBG goal, length of hospital stay, length of ICU stay, and mortality. Safety outcomes included number of hypoglycemic events and number of hypokalemic events. A total of 95 patients were included in this study and they were divided into 2 main groups: pathway group (n=60) and non-pathway group (n=35). Results of the study showed that patients in the pathway group had a shorter duration of insulin drip (18.6±1.8 hours vs. 24.8 hours ±5.2 hours, p=0.163) and shorter time to reach CBG goal (9.2±1.4 hours vs. 13.6±2.2 hours, p=0.085) compared to the non-pathway group. Hypoglycemic events occurred less frequently in the pathway group compared to the non-pathway group (25% vs. 28.5%, p=0.810). In terms of hypokalemic events, patients in the pathway group had significantly more hypokalemic events compared to the non-pathway group (54.2% vs. 28.6%, p=0.019), which was primarily due to more frequent and regular monitoring of serum potassium in the pathway group. In terms of hospital stay, patients in the pathway group had lesser number of hospital days (6.8±0.6 days vs. 8.6±2.1 days, p=0.324) but length of ICU stay between the two groups is similar (1.8±0.5 days vs. 1.9±0.5 days, p=0.885). Lastly, patients in the pathway group had no mortality while 3 patients in the non-pathway group expired (0 vs. 8.6%, p=0.047). Two out of the three mortality in the non-pathway group expired due to myocardial infarction while one expired due to multi-organ failure secondary to septic shock. Direct causality of mortality of patients due to complications of DKA and HHS was not determined in this study. Overall, this study showed that the use of a clinical pathway appears to have a positive impact in the management of DKA and HHS in private tertiary hospital in the Philippines.

 

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