Initial Serum Lactate Predicts Subsequent Deterioration in Emergency Department Patients with Sepsis
CCCF ePoster library. Fernando S. Oct 4, 2017; 198110; 110
Dr. Shannon Fernando
Dr. Shannon Fernando
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Initial Serum Lactate Predicts Subsequent Deterioration in Emergency Department Patients with Sepsis

Shannon M. Fernando, MD, MSc1,2; Douglas P. Barnaby, MD, MS3; Christophe L. Herry, PhD4; Nathan I. Shapiro, MD, MPH5; Andrew J. E. Seely, MD, PhD2,4,6


1. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

2. Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, ON

3. Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY

4. Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON

5. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA

6. Department of Surgery, University of Ottawa, Ottawa, ON

Background: Early Emergency Department (ED) identification of septic patients at risk of subsequent deterioration is necessary in order to optimize disposition. High-risk patients admitted directly from the ED to the ICU have better outcomes than those admitted to the floor first. Initial ED serum lactate level has been associated with 28-day mortality, but there is little evidence on its use in predicting short-term deterioration. Furthermore, potentially reflecting an independent mode of deterioration, we hypothesized the addition of respiratory rate (RR) to lactate may improve prediction of deterioration.      
Objectives: We evaluated the ability of initial serum lactate to predict short-term deterioration in a population of patients presenting to the ED with sepsis.
Methods: Prospective cohort study of ED patients (age ≥ 18) screened and treated for sepsis (i.e. ≥2 SIRS criteria and physician suspicion of infection). Lactate and vital signs were obtained within 2 hours of ED arrival. Main outcome was deterioration within 72 hours (defined as any of: death; ICU admission > 24 hours; intubation; vasoactive medications >1 hour; or non-invasive positive pressure ventilation >1 hour). Patients with existing DNR/DNI orders and/or meeting an endpoint within 1 hour of arrival were excluded.
Results: 985 patients presenting to either of two urban high-volume EDs were enrolled, of whom 84 (8.5%) met the primary outcome. 293 patients (29.7%) were discharged home, and all were followed-up at 72 hours. Initial serum lactate ≥ 4.0 had a specificity of 97.4% (95% CI, 94.1-100%), but a sensitivity of 27.4% (17.8-36.9%) for predicting deterioration. Positive likelihood ratio of deterioration for a lactate ≥ 4.0 was 10.7 (6.3-18.3). Of patients with a lactate ≥ 4.0, 4 (8.7%) were discharged home, and did not reach an endpoint at 72 hours. Lactate < 2.0 had a sensitivity of 66.0% (62.8-69.1%) and specificity of 66.7% (55.5-76.6%) for ruling out 72-hour deterioration. Positive likelihood ratio of ruling out deterioration for a lactate < 2.0 was 1.98 (1.46-2.69). Of patients with a lactate < 2.0, 224 (56.1%) were discharged home. Combining RR with lactate (AUC: 0.72, 0.66-0.79) did not significantly improve predictive capability than lactate alone (AUC: 0.70, 0.64-0.76).  
Conclusions: Initial lactate ≥ 4.0 is predictive of deterioration within 72 hours in ED patients with sepsis. We did not observe added predictive value with the addition of RR. Further study of factors to predict subsequent deterioration in patients with sepsis in the ED are necessary to improve the prevention of deterioration.


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