Impact of Initial Lactate Level on ED Management of Patients with Sepsis: A Multicentre Retrospective Cohort Study
CCCF ePoster library. Lo V. Oct 31, 2016; 155977; ORAL
Victor Lo
Victor Lo
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Topic: Quality Assurance & Improvement

Impact of Initial Lactate Level on ED Management of Patients with Sepsis: A Multicentre Retrospective Cohort Study


Lo, Victor1Su, Helen (Haitong)1; Lam, Yuet Ming1; Willis, Kathleen2; Pullar, Virginia2; Hubner, Ryan3; Tsang, Jennifer LY1,2,4

1
Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Canada; 2Niagara Health System, St. Catharines, Canada; 3Undergraduate Medicine, University of St. Andrews, St. Andrews, United Kingdom; 4Department of Medicine, McMaster University, Hamilton, Canada


Grant acknowledgements:
Dr. J.L.Tsang is supported by the McMaster Internal Medicine Research Award.

Abstract:

INTRODUCTION
Sepsis is 'a life-threatening organ dysfunction caused by a dysregulated host response to infection.' (1) Septic shock is 'a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.' (1) Lactate is a marker of organ hypoperfusion, thus organ dysfunction, and has been shown to be predictive of mortality (2, 3) and is a part of the new Sepsis-3 definition of septic shock. 

OBJECTIVES
To examine the role of initial lactate level in the management of sepsis in the emergency department (ED) and ultimately in-hospital mortality rate. 

METHODS
This is a multicentre retrospective cohort study of patients with sepsis with initial lactate level drawn in the ED of three community acute care centres from July 2011 to July 2015 in the Niagara Region, Ontario, Canada. Data was extracted from an existing comprehensive database compiled by a dedicated Regional Sepsis Coordinator . Institutional research ethics board approval was obtained.

RESULTS
A total of 2082 patients were included in the study. The median age was 72 years (IQR 60-81), and the mean initial lactate level was 3.48 ± 2.63 mmol/L. 46.1%, 24.4%, 15.1% and 14.0% of patients had normal (0-2.49 mmol/L), low (2.5-3.99 mmol/L), intermediate (4-5.99 mmol/L) and high (>/= 6 mmol/L) initial lactate level, respectively.  Door-to-antibiotics time decreased from 194 ± 156 min in the normal lactate group to 138 ± 135 min in the high lactate group (p< 0.05). Total fluid administration in first 6 hours increased from 1.9 ± 1.3L in the normal lactate group to 3.2 ± 1.9L in the high lactate group (p< 0.05). Central line insertion rates increased from 8.8% in normal lactate group to 47.8% in the high lactate group (p< 0.05). Intensive Care Unit (ICU) admission rate increased from 25.4% in normal lactate group to 54.5% in high lactate group (p< 0.05). Unadjusted in-hospital mortality for normal, low, intermediate and high lactate group was 13.9%, 21.7%, 32.9% and 57.2%, respectively. 

CONCLUSIONS
Higher initial lactate level correlates with more intensive ED management of sepsis including earlier antibiotics administration, more fluid resuscitation, increased chance of central line insertion and ICU admission. It also correlates with higher unadjusted in-hospital mortality rate.


References:

REFERENCES

  1. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774.
  2. Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah CV, et al. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med 2009;37:1670-7.
  3. Shapiro NI, Howell MD, Talmor D, Nathanson LA, Lisbon A, Wolfe RE, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med 2005;45:524–8. 


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