Evaluation of a simple management protocol for hyperglycaemic crises using intramuscular insulin in a resource-limited setting.
BACKGROUND
Management of hyperglycaemic crises requires expensive and labour-intensive procedures that are not achievable in all clinical settings. Intramuscular (IM) insulin therapy is a more feasible alternative, but remains insufficiently evaluated. We report here on an audit of clinical outcomes of a simple management protocol that involves IM insulin therapy, careful rehydration and inexpensive monitoring in a resource-limited setting.


METHODS
In June 2006, we began the routine use of a protocol based on IM insulin administration, careful rehydration and affordable monitoring for the management of hyperglycaemic crises in Yaoundé Central Hospital. Clinical records of patients admitted for hyperglycaemic crises 6 months before and 6 months after introduction of the protocol were independently coded and compared for clinical outcomes, including the 48-hour death rate as a primary endpoint. Secondary endpoints were blood glucose (BG) normalization and duration of hospital stay.


RESULTS
A total of 112 patients' files fulfilled the inclusion criteria, including 57 before and 55 after the introduction of the IM protocol (intervention). Patients of the pre-intervention group were aged 56.4+/-2.1 years versus 53.9+/-2.3 years in the intervention group (p=0.41), with 23% versus 40%, respectively, with newly diagnosed diabetes (p=0.05), and 45% versus 41%, respectively, with significant ketosis on admission (p=0.84). As for the primary endpoint, 15.8% of the pre-intervention group died within 48 hours of admission versus 3.6% in the intervention group (p=0.03). BG was normalized within 24 hours of admission in 28.1% patients of the pre-intervention group versus 90.9% of the intervention group (p<0.001). However, the overall duration of hospitalization was similar in both groups. Septic shock, ketosis and high serum creatinine on admission were associated with poor outcomes in both groups.


CONCLUSIONS
The proposed protocol using IM insulin can be safely used to treat hyperglycaemic crises, with mortality rates comparable to those in specialized centres in developed countries.
Sobngwi
E
E
Department of Endocrinology and Metabolism, National Obesity Centre, Yaounde Central Hospital, Yaounde, Cameroon. sobngwieugene@yahoo.fr
Lekoubou
A L
AL
Dehayem
M Y
MY
Nouthe
B E
BE
Balti
E V
EV
Nwatsock
F
F
Akwo
E A
EA
Effoe
V S
VS
Balla
V T
VT
Mamdjokam
A S
AS
Siaha
V
V
Tabi
C A
CA
Mvom
A
A
Djam
I
I
Mbanya
J C
JC
D001786:Blood Glucose / Q000032:analysis; D002163:Cameroon; D002985:Clinical Protocols; D016903:Drug Monitoring / Q000191:economics; D004630:Emergencies; D005260:Female; D005440:Fluid Therapy; D006801:Humans; D006943:Hyperglycemia / Q000188:drug therapy* / Q000401:mortality; D007273:Injections, Intramuscular; D007328:Insulin / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D007657:Ketone Bodies / Q000652:urine; D007902:Length of Stay; D008297:Male; D008485:Medical Audit; D008507:Medically Underserved Area; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D014556:Urine
D001786:Blood Glucose; D007328:Insulin; D007657:Ketone Bodies