Prognostic use of lactate to predict inpatient mortality in acute gastrointestinal hemorrhage

Utilizing point-of-care lactate testing for rapid prediction of clinical outcomes in patients with acute gastrointestinal bleeding in the emergency department

Objectives

We aimed to rapidly predict the prognosis of patients who present to the emergency department (ED) with acute gastrointestinal bleeding (AGIB) using point-of-care (POC) lactate testing.

Methods

This single-center retrospective observational study included 327 patients (survival group, 287; non-survival group, 40) who presented to the ED with AGIB between March 2021 and February 2022. We compared POC-measured lactate levels with laboratory-measured lactate levels using Pearson's correlation. Multivariate logistic regression analysis was used to identify early predictors of in-hospital mortality and correlated clinical outcomes. Receiver operating characteristic (ROC) curves were used to determine the optimal cutoff for POC-measured lactate levels for predicting in-hospital mortality, and the ROC curves for POC-measured lactate levels and AIMS65 scores were compared using the DeLong test.

Results

POC-measured lactate levels strongly correlated with laboratory-measured lactate levels (R2 = 0.82). Patients in the non-survival group had higher POC-measured lactate levels than did those in the survival group (2.6 mmol/L vs. 1.4 mmol/L, p < 0.001). POC-measured lactate level, age, systolic blood pressure, heart rate, and malignancy were identified as early predictors of in-hospital mortality (adjusted odds ratio [aOR] for POC-measured lactate levels: 1.15; 95 % confidence interval [CI] 1.02-1.30). The optimal POC-measured lactate level cutoff was 3.2 mmol/L. Areas under the ROC curves for POC-measured lactate level and the AIMS65 score were 0.70 and 0.73, respectively, showing statistical compatibility. Higher POC-measured lactate levels correlated with ICU admission, blood transfusion, and mechanical ventilation (aOR: 1.16, 95 % CI 1.05-1.27; 1.16, 1.04-1.30; and 1.31, 1.13-1.53, respectively]. Further, the hyperlactatemia subgroup (POC-measured lactate level ≥3.2 mmol/L) exhibited a lower survival probability in the Kaplan-Meier survival analysis (p < 0.01).

Conclusions

Our study shows that rapidly obtainable POC-measured lactate levels are valuable for predicting critical outcomes in AGIB patients and should be considered an early prognostic indicator for in-hospital mortality in the ED.

Timing of endoscopy in patients with elevated lactate levels and acute upper gastrointestinal bleeding; a retrospective comparative study

BACKGROUND/AIMS

While current guidelines recommend performing endoscopy within 24 h in case of acute upper gastrointestinal bleeding (AUGIB), the precise timing remains an issue of debate. Lactate is an established parameter for risk stratification in a variety of medical emergencies. This study evaluated the predictive ability of elevated lactate levels in identifying patients with UGIB, who may benefit from emergent endoscopy.

METHODS

We retrospectively analyzed all patients with elevated lactate levels, who presented to our emergency department between 01 January 2015 and 31 December 2019 due to suspected AUGIB.

RESULTS

Of 134 included cases, 81.3% had an Charlson comorbidity index of ≥3 and 50.4% presented with shock. Fifteen (11.2%) patients died and mortality rates rose with increasing lactate levels. Emergent endoscopy within 6 h (EE) and non-EE were performed in 64 (47.8%) and 70 (52.2%) patients, respectively. Patients who underwent EE had lower systolic blood pressure (107.6 mmHg vs. 123.2 mmHg; p = 0.001) and received blood transfusions more frequently (79.7% vs 64.3%; p = 0.048), but interestingly need for endoscopic intervention (26.6% vs 20.0%; p = 0.37), rebleeding (17.2% vs. 15.7%; p = 0.82) and mortality (9.4% vs. 11.4%; p = 0.7) did not differ significantly.

CONCLUSION

In conclusion, our findings support the recommendations of current guidelines to perform non-EE after sufficient resuscitation and management of comorbid illnesses.

Lactate level as a predictor of outcomes in patients with acute upper gastrointestinal bleeding: A systematic review and meta‑analysis

There remains no consensus on the prognostic value of lactate in predicting adverse outcomes such as mortality, rebleeding and higher intensive care unit (ICU) admission rates in patients with upper gastrointestinal bleeding (UGIB). The present study aimed to determine the prognostic accuracy of lactate level in predicting adverse clinical outcomes in patients with acute UGIB. Systematic literature search was conducted in PubMed Central, SCOPUS, EMBASE, MEDLINE, Google Scholar and ScienceDirect databases for studies published up to February 2023. Random-effects model was used for the meta-analysis and the results were presented as pooled standardized mean differences or odds ratio (OR) with 95% confidence interval (CIs). A total of 11 studies were included in the present review. Most of the studies had a high risk of bias. Pooled OR were as follows: 1.39 (95% CI: 1.29-1.51; I2=85%) for the prediction of mortality; 1.29 (95% CI: 1.17-1.42; I2=85.9%) for prediction of ICU admission, 1.14 (95% CI: 1.06-1.23; I2=42.4%) for rebleeding and 2.84 (95% CI: 2.14-3.77; I2=8.1%) for the need of packed red blood cell (pRBC) transfusion. Sensitivity and specificity for the mortality prediction were 72% (95% CI: 57-83%) and 75% (95% CI: 61-85%), respectively, with the area under the curve of 0.79 (95% CI: 0.72-0.85). In conclusion, the results showed that lactate level is a moderately accurate early prediction marker of most adverse clinical outcomes such as mortality, rebleeding, ICU admission and the need for pRBC transfusion in acute UGIB patients.

Predictors of 30-day mortality in patients diagnosed with hepatic encephalopathy on admission to the emergency department

BACKGROUND

The aim of this study is to compare the laboratory findings and disease severity scores of patients diagnosed with hepatic encephalopathy (HE) in the emergency department (ED) to predict 30-day mortality.

METHOD

The patients over 18 years old and diagnosed HE in the ED of a tertiary hospital were included in the study. Demographic and clinical characteristics, laboratory parameters, predisposing causes and outcomes of the patients included in the study were recorded in the data form. Severity of liver disease was assessed by Child Pugh Score (CPS), End-stage liver disease model (MELD), MELD-Na and MELD-Lactate scores.

RESULTS

Two hundred fifty-four patients diagnosed with HE were included in the study. 59.1% of the patients were male. The mean age of the patients was 65.2 ± 12.6 years. The mortality rate of the patients was 47.2%. When the receiver operating characteristic (ROC) analysis, which determines the predictive properties of laboratory parameters and disease severity scores, was examined, the area under curve value of the MELD-Lactate score (0.858 95% CI 0.812-0.904, P  < 0.001) was the highest. Binary logistic regression analysis for the estimation of patients' 30-day mortality showed that CPS and MELD-Lactate scores and blood ammonia and B-type natriuretic peptide levels were independent predictors of mortality.

CONCLUSION

According to the study data, MELD-Lactate and BNP levels in patients diagnosed with HE in the ED may help the clinician in the prediction of 30-day mortality in the early period.

Age, blood tests and comorbidities and AIMS65 risk scores outperform Glasgow-Blatchford and pre-endoscopic Rockall score in patients with upper gastrointestinal bleeding

BACKGROUND

Upper gastrointestinal (GI) bleeding is a life-threatening condition with high mortality rates.

AIM

To compare the performance of pre-endoscopic risk scores in predicting the following primary outcomes: In-hospital mortality, intervention (endoscopic or surgical) and length of admission (≥ 7 d).

METHODS

We performed a retrospective analysis of 363 patients presenting with upper GI bleeding from December 2020 to January 2021. We calculated and compared the area under the receiver operating characteristics curves (AUROCs) of Glasgow-Blatchford score (GBS), pre-endoscopic Rockall score (PERS), albumin, international normalized ratio, altered mental status, systolic blood pressure, age older than 65 (AIMS65) and age, blood tests and comorbidities (ABC), including their optimal cut-off in variceal and non-variceal upper GI bleeding cohorts. We subsequently analyzed through a logistic binary regression model, if addition of lactate increased the score performance.

RESULTS

All scores had discriminative ability in predicting in-hospital mortality irrespective of study group. AIMS65 score had the best performance in the variceal bleeding group (AUROC = 0.772; P < 0.001), and ABC score (AUROC = 0.775; P < 0.001) in the non-variceal bleeding group. However, ABC score, at a cut-off value of 5.5, was the best predictor (AUROC = 0.770, P = 0.001) of in-hospital mortality in both populations. PERS score was a good predictor for endoscopic treatment (AUC = 0.604; P = 0.046) in the variceal population, while GBS score, (AUROC = 0.722; P = 0.024), outperformed the other scores in predicting surgical intervention. Addition of lactate to AIMS65 score, increases by 5-fold the probability of in-hospital mortality (P < 0.05) and by 12-fold if added to GBS score (P < 0.003). No score proved to be a good predictor for length of admission.

CONCLUSION

ABC score is the most accurate in predicting in-hospital mortality in both mixed and non-variceal bleeding population. PERS and GBS should be used to determine need for endoscopic and surgical intervention, respectively. Lactate can be used as an additional tool to risk scores for predicting in-hospital mortality.

Predictive Role of Admission Venous Lactate Level in Patients with Upper Gastrointestinal Bleeding: A Prospective Observational Study

Upper gastrointestinal bleeding (UGIB) is one of the most common emergencies. Risk stratification is essential in patients with this potentially life-threatening condition. The aim of this prospective study was to evaluate the usefulness of the admission venous lactate level in predicting clinical outcomes in patients with UGIB. All consecutive adult patients hospitalized due to UGIB were included in the study. The clinical data included the demographic characteristics of the observed population, etiology of UGIB, need for surgical intervention and intensive care, bleeding recurrence, and mortality rates. Venous lactate was measured in all patients on admission. Logistic regression analyses were used to calculate the odds ratios (OR) of lactate levels for all outcomes. The receiver operating characteristic (ROC) curve was used to determine the accuracy of lactate levels in measuring clinical outcomes, while Youden index was used to calculate the best cut-off points. A total of 221 patients were included in the study (151M; 70F). There were 24 cases of UGIB recurrence (10.8%), 19 patients (8.6%) required surgery, and 37 individuals (16.7%) required intensive care. Mortality rate was 11.3% (25 cases). The logistic regression analysis showed statistically significant association between admission venous lactate and all clinical outcomes: mortality (OR = 1.39, 95%CI: 1.22–1.58, p < 0.001), recurrence of bleeding (OR = 1.16, 95%CI: 1.06; 1.28, p = 0.002), surgical intervention (OR = 1.17, 95%CI: 1.06–1.3, p = 0.002) and intensive care (OR = 1.33, 95%CI: 1.19–1.5, p < 0.001). The ROC curve analysis showed a high predictive value of lactate levels for all outcomes, especially mortality: cut-off point 4.3 (AUC = 0.82, 95%CI: 0.72–0.92, p < 0.001) and intensive care: cut-off point 4.2 (AUC = 0.76, 95%CI: 0.66–0.85, p < 0.001). Admission venous lactate level may be a useful predictive factor of clinical outcomes in patients with UGIB.

Laboratory Tests in the Patient with Abdominal Pain

Abdominal pain is one of the most common presenting complaints to the emergency department (ED). More often than not, some degree of laboratory testing is used to narrow the differential diagnosis based on the patient's history and examination. Ordering practices are often guided by evidence, habit, consulting services, and institutional/regional culture. This review highlights relevant laboratory studies that may be ordered in the ED, as well as commentary on indications and diagnostic value of these tests.

Combination of Model for End-Stage Liver Disease and Lactate Predicts Death in Patients Treated With Salvage Transjugular Intrahepatic Portosystemic Shunt for Refractory Variceal Bleeding

BACKGROUND AND AIMS

Data about the prognosis of salvage transjugular intrahepatic portosystemic shunt (TIPS) using covered stents for refractory variceal bleeding caused by portal hypertension are scarce. We aimed to assess survival and to identify predictors of mortality in these patients.

APPROACH AND RESULTS

One hundred sixty-four patients with cirrhosis from five centers treated with salvage TIPS between 2007 and 2017 were retrospectively divided into a derivation cohort (83 patients) and a validation cohort (81 patients). Comparisons were performed using the Mann-Whitney and Fischer's exact test. Six-week overall survival (OS) was correlated with variables on the day of the TIPS using Kaplan-Meier curves with log-rank test and univariate/multivariate analyses using the Cox model. Eighty-three patients were included in the derivation cohort (male, 78%; age, 55 years, alcohol-associated cirrhosis, 88%; Model for End-Stage Liver Disease [MELD], 19 [15-27]; arterial lactate, 3.7 mmol/L [2.0-8.3]). Six-week OS rate was 58%. At multivariate analysis, the MELD score (OR, 1.064; 95% CI, 1.005-1.126; P = 0.028) and arterial lactate (OR, 1.063; 95% CI, 1.013-1.114; P = 0.032) were associated with 6-week OS. Six-week OS rates were 100% in patients with arterial lactate ≤2.5 mmol/L and MELD score ≤ 15 and 5% in patients with lactate ≥12 mmol/L and/or MELD score ≥ 30. The 81 patients of the validation cohort had similar MELD and arterial lactate level but lower creatinine level (94 vs 106 µmol/L, P = 0.008); 6-week OS was 67%. Six-week OS rates were 86% in patients with arterial lactate ≤2.5 mmol/L and MELD score ≤ 15 and 10% for patients with lactate ≥12 mmol/L and/or MELD score ≥ 30. In the overall cohort, rebleeding rate was 15.8% at 6 weeks, and the acute-on-chronic liver failure grade (OR, 1.699; 95% CI, 1.056-1.663; P = 0.040) was independently associated with rebleeding.

CONCLUSIONS

After salvage TIPS, 6-week mortality remains high and can be predicted by MELD score and lactate. Survival rate at 6 weeks was >85% in patients with arterial lactate ≤2.5 mmol/L and MELD score ≤ 15, while mortality was >90% for lactate ≥12 mmol/L and/or MELD score ≥ 30.

Prognostic utility of lactate concentrations and kinetics to predict adverse events associated with acute drug overdose

OBJECTIVE

Clinical research on drug intoxication is necessary for appropriate action in emergency departments (EDs). However, currently, there are no evident biomarkers for predicting adverse events (AEs) in patients with drug intoxication. We aimed to evaluate the prognostic value of serum lactate concentrations and lactate kinetics for AEs such as cardiogenic or respiratory failure in patients admitted to the ED with acute drug overdose.

METHODS

We conducted a single-center retrospective study by reviewing the prospective suicide registry of patients visiting the ED. The primary outcome was composite AEs at any point during the ED visit or hospital stay.

RESULTS

A total of 566 patients with acute drug overdose were enrolled in this study. Of these, 62 patients had AEs, whereas 363 patients did not, yielding an AE rate of 14.6%. The median 0 h lactate concentrations in the AE and non-AE groups were 2.7 [2.1-5.1] mmol/L and 2.1 [1.4-2.9] mmol/L, respectively (p < 0.001). The median 6 h lactate concentrations in the AE and non-AE groups were 2.0 [1.5-3.9] mmol/L and 1.3 [0.9-2.2] mmol/L, respectively (p < 0.001). The area under the curve of lactate at 0 h for predicting AEs was 0.705 (95% CI: 0.659-0.748). The optimal lactate cutoff point was 4.2 mmol/L (37.1% sensitivity, 92.8% specificity). Multivariable analysis using a stepwise backward method showed that the 0 h lactate concentration was associated with AEs in acute drug intoxication after adjusting for confounders (adjusted OR of 0 h lactate, 1.47; 95% CI, 1.23-1.77). However, the 6 h lactate concentrations, lactate clearance, and delta lactate levels did not predict the outcomes.

CONCLUSION

Lactate concentrations and kinetics in patients admitted to the ED with an acute drug overdose exhibited limited prognostic utility in predicting AEs and should be interpreted with caution when considered for clinical decision-making.

The usefulness of the percentage of immature granulocytes in predicting in-hospital mortality in patients with upper gastrointestinal bleeding

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is an important health problem with a potentially life threatening course. Measurement of immature granulocytes percentage (IG %), reflecting the fraction of circulating immature granulocyte (IG), is associated with increased mortality in patients with systemic inflammation, or distress. The aim of this study was to evaluate whether the IG% is an effective predictive marker for estimating the in-hospital mortality for patients with UGIB admitting to the emergency department (ED).

METHOD

This retrospective study included patients with UGIB who admitted to the ED, between 01.01.2019 and 31.12.2019. The patients were divided into two groups as discharged and dead. The IG% and other parameters were recorded. The primary end point of the study was in-hospital mortality. Logistic regression model was used to determine the factors affecting mortality.

RESULTS

This study included 149 patients, 94 of whom were men. The mean age of the patients was 64.5 ± 14.2. Twenty patients died during hospitalization and 129 were discharged. IG% was significantly higher in patients who died compared with patients who discharged. In the receiver operating characteristic (ROC) curves analysis to determine the in-hospital mortality, the cut-off value (>1%) for IG% level was found specificity (93.8%), sensitivity (100%), positive predictive value (PPV = 71.43%), negative predictive value (NPV = 100.00%) and area under curve (AUC = 0.98). Univariate logistic regression analysis showed that IG% was predicting in-hospital mortality (odds ratio, OR = 65.6, confidence interval, CI = 2.00-2152.6). CONCLUSıONS: High IG% levels may be used as a predictor of in-hospital mortality in patients with UGIB.

Immature Granulocyte Count and Percentage as New Predictors of Mortality in Patients with Upper Gastrointestinal Bleeding

Aims

Early identification of patients at risk of adverse outcomes may increase the survival rates in patients with upper gastrointestinal bleeding (UGIB), but this can be difficult to predict in emergencies. The aim of the study is to evaluate immature granulocyte (IG), which can be obtained from simple hemogram tests in patients with UGIB, in terms of clinical use and as a mortality marker.

Materials and methods

The patients diagnosed with UGIB between March 1, 2019, and September 30, 2019, were evaluated retrospectively. Demographic characteristics, causes of hemorrhage, clinical presentations, hemogram, and biochemistry values at ED admission and 30-day mortality status of the patients were examined. We divided the patients into groups according to their mortality status, and the groups were compared among themselves in terms of parameters.

Results

A total of 213 patients who met the inclusion criteria were included in the study. Of these patients, 139 (65.3%) were male and the mean age was 65.05 ± 16.7 years. Fifteen (7%) of them were in the nonsurvival group, while 198 (93%) were in the survival group. The efficacy of both the IG count (IGC) and IG% in predicting mortality was statistically significant (p = 0.002, p = 0.008, respectively). The sensitivity and specificity for the IGC were found as 60% and 84.4; for the IG%, they were found as 66.7% and 75.7%, respectively.

Conclusion

IGC and IG% are independent risk factors for the 30-day mortality status. These measurements are obtained from simple hemogram tests and may be useful for the evaluation of mortality in patients with UGIB.

How to cite this article

Bedel C, Korkut M, Avcı A, Uzun A. Immature Granulocyte Count and Percentage as New Predictors of Mortality in Patients with Upper Gastrointestinal Bleeding. Indian J Crit Care Med 2020;24(9):794-798.

Model for End-Stage Liver Disease-Lactate and Prediction of Inpatient Mortality in Patients With Chronic Liver Disease

BACKGROUND AND AIMS

Compared to other chronic diseases, patients with chronic liver disease (CLD) have significantly higher inpatient mortality; accurate models to predict inpatient mortality are lacking. Serum lactate (LA) may be elevated in patients with CLD due to both tissue hypoperfusion as well as decreased LA clearance. We hypothesized that a parsimonious model consisting of Model for End-Stage Liver Disease (MELD) and LA at admission may predict inpatient mortality in patients with CLD.

APPROACH AND RESULTS

We examined all patients with CLD in two large and diverse health care systems in Texas (North Texas [NTX] and Central Texas [CTX]) between 2010 and 2015. We developed (n = 3,588) and validated (n = 1,804) a model containing MELD and LA measured at the time of hospitalization. We further validated the model in a second cohort of 14 tertiary care hepatology centers that prospectively enrolled nonelective hospitalized patients with cirrhosis (n = 726). MELD-LA was an excellent predictor of inpatient mortality in development (concordance statistic [C-statistic] = 0.81, 95% confidence interval [CI] 0.79-0.82) and both validation cohorts (CTX cohort, C-statistic = 0.85, 95% CI 0.78-0.87; multicenter cohort C-statistic = 0.82, 95% CI 0.74-0.88). MELD-LA performed especially well in patients with specific cirrhosis diagnoses (C-statistic = 0.84, 95% CI 0.81-0.86) or sepsis (C-statistic = 0.80, 95% CI 0.78-0.82). For MELD score 25, inpatient mortality rates were 11.2% (LA = 1 mmol/L), 19.4% (LA = 3 mmol/L), 34.3% (LA = 5 mmol/L), and >50% (LA > 8 mmol/L). A linear increase (P < 0.01) was seen in MELD-LA and increasing number of organ failures. Overall, use of MELD-LA improved the risk prediction in 23.5% of patients compared to MELD alone.

CONCLUSIONS

MELD-LA (bswh.md/meldla) is an early and objective predictor of inpatient mortality and may serve as a model for risk assessment and guide therapeutic options.

Is Immature Granulocyte Count a Potential Prognostic Marker for Upper Gastrointestinal Tract Bleeding? A New Road to Explore

How to cite this article: Prabu NR, Patil VP. Is Immature Granulocyte Count a Potential Prognostic Marker for Upper Gastrointestinal Tract Bleeding? A New Road to Explore. Indian J Crit Care Med 2020;24(9):750-752.

Lactate Level Predicts Mortality in Patients with Upper Gastrointestinal Bleeding

Background and Objectives

The aim of this study was to show whether the level of lactate in venous blood compared with the Glasgow-Blatchford Bleeding Score (GBS), in patients diagnosed with upper gastrointestinal system (UGI) bleeding in the emergency department, will help to predict the need for transfusion and prognosis.

Materials and Methods

Patients with UGI bleeding who were admitted to the emergency department were included in the study. The parameters age, gender, referral complaints, comorbidities, lactate levels in venous blood, GBS, endoscopy findings, length of hospital stay, transfusion amount, and outcome of patients were recorded in the data collection form.

Results

A total of 139 patients were included in the study. The most common complaints were melena (38.1%) and hematemesis (32.4%). The most frequent endoscopic diagnosis was duodenal ulcer (40.3%). The cutoff value of the venous blood lactate level for the prediction of the need for red blood cell transfusion was 1.58 mmol/L, and the cutoff value for GBS was 9.5. While 124 patients were discharged, 15 patients died. The mean value of venous lactate in survived patients was 2.37 mmol/L and 4.80 in dead patients. This difference was statistically significant (p = 0.044). The cutoff value of lactate for the prediction of mortality was 2.32 mmol/L, and the cutoff value for GBS was 13.5.

Conclusions

The venous blood lactate value of a patient who was admitted to the emergency department with UGI bleeding might be helpful in predicting the transfusion needs of the patient and predicting the mortality.

CLINICAL UTILITY OF RISK SCORES IN VARICEAL BLEEDING

BACKGROUND

Variceal bleeding remains important cause of upper gastrointestinal bleed. Various risk scores are used in risk stratification for non-variceal bleed. Their utility in variceal bleeding patients is not clear. This study aims to compare probability of these scores in predicting various outcomes in same population.

OBJECTIVE

This study aims to compare probability of these scores in predicting various outcomes in same population. To study characteristics and validate AIMS65, Rockall, Glasgow Blatchford score(GBS), Progetto Nazionale Emorragia Digestiva (PNED) score in variceal Upper Gastrointestinal Bleed (UGIB) patients for predicting various outcomes in our population.

METHODS

Three hundred subjects with UGIB were screened prospectively. Of these 141 patients with variceal bleeding were assessed with clinical, blood investigations and endoscopy and risk scores were calculated and compared to non-variceal cases. All cases were followed up for 30 days for mortality, rebleeding, requirement of blood transfusion and need of radiological or surgical intervention.

RESULTS

Variceal bleeding (141) was more common than non variceal (134) and 25 had negative endoscopy. In variceal group, cirrhosis (85%) was most common etiology. Distribution of age and sex were similar in both groups. Presence of coffee coloured vomitus (P=0.002), painless bleed (P=0.001), edema (P=0.001), ascites (P=0.001), hemoglobin <7.5 gms (P<0.001), pH<7.35 (P<0.001), serum bicarbonate level <17.6 mmol/L (P<0.001), serum albumin<2.75 gms% (P<0.001), platelet count <1.2 lacs/µL (P<0.001), high INR 1.35 (P<0.001), BUN >25mmol/L (P<0.001), and ASA status (P<0.001), high lactate >2.85 mmol/L (P=0.001) were significant. However, no factor was found significant on multivariate analysis. Rockall was found to be significant in predicting mortality and rebleed. AIMS65 was also significant in predicting mortality. GBS was significant in predicting blood transfusion and need of intervention. PNED score was significant in all events except mortality.

CONCLUSION

All four scores had lower predictive potential in predicting events in variceal bleed. However, AIMS65 & Rockall score were significant in predicting mortality, while GBS in predicting need of transfusion and intervention. PNED score was significant in all events except mortality.

Comparison of risk scores in upper gastrointestinal bleeding in western India: A prospective analysis

AIM

To study the upper gastrointestinal bleeding (UGIB) characteristics and to validate the Rockall and Glasgow-Blatchford scores (GBS), Progetto Nazionale Emorragica Digestiva (PNED) and albumin, international normalized ratio (INR), mental status, systolic blood pressure, and age > 65 (AIMS65) risk scores in predicting outcomes in patients with UGIB.

METHODS

Three hundred subjects with hematemesis and/or melena were prospectively enrolled and followed up for 30 days. All patients were assessed by hematological investigations, imaging, and endoscopy and risk scores were calculated.

RESULTS

The mean age was 43.5 ± 17.2 years, and 207 (69%) were males. Hematemesis was the most common presentation (94%). Variceal bleeding was the most common etiology (47.7%). Thirty patients died (10%) and 50 had rebleeding (16.7%). On univariate analysis, serum albumin ≤ 2.7 gm% (p = 0.008), Glasgow Coma scale ≤ 13.9 (p = 0.001), serum bilirubin > 3 mg/dL (p = 0.004), serum bicarbonate ≤ 15.7 mEq/L (p = 0.001), systolic blood pressure < 90 mmHg (p = 0.004), and arterial pH ≤ 7.3 (p = 0.003) were found to be the predictors of mortality. No variable was found significant on multivariate analysis. All four scores were significant in predicting mortality, but Rockall (area under receiver operating characteristic [AUROC] 0.728) was better than others. Rebleeding was better predicted by PNED (modified) (AUROC 0.705). In predicting the need for transfusion and surgical or radiological intervention, GBS score > 0 was significant while score of < 2 classified patients into low risk for mortality with high negative predictive value.

CONCLUSION

Our study showed that the variceal bleeding was the commonest cause of UGIB. Rockall score was more significant in predicting mortality while PNED for rebleeding. Low risk for mortality, need for blood transfusion, or interventions were accurately predicted by GBS.

Lactic Acid Is an Independent Predictor of Mortality and Improves the Predictive Value of Existing Risk Scores in Patients Presenting With Acute Gastrointestinal Bleeding

Background

There are validated clinical risk scores for risk stratifying patients presenting with acute upper gastrointestinal bleed (GIB), including Glasgow-Blatchford score (GBS), Pre-endoscopic Rockall score (RS-PE) and post-endoscopic complete Rockall Score (RS-C), and AIMS65. Several studies have explored the predictive value of lactic acid (LA) in the context of GI bleeding, but the prognostic role of LA and its incremental value in combination with existing clinical risk scores is not well defined.

Methods

We conducted a retrospective analysis of consecutive patients presenting to the emergency department of a single large academic tertiary care center from January 2014 to December 2015 with a charted diagnosis of acute GIB, inclusive of both upper and lower sources. We evaluated the independent role of LA as well as three clinical risk scores for predicting in-hospital mortality in these patients.

Results

Out of 704 patients admitted with acute GI bleeding, 366 patients had LA measured on presentation to the emergency department. The mean LA level, GBS, RS-PE and RS-C were found to be significantly higher in non-survivors, while there was no difference in the mean AIMS65 score between survivors and non-survivors. A multivariate logistic regression analysis showed that LA level was an independent predictor of in-hospital mortality. The area under the curve (AUC) for the receiver operator characteristic for RS-C, RS-PE, and GBS were 0.742, 0.675, and 0.652, respectively. When integrating LA into the above risk scores, the AUC for RS-C, RS-PE, and GBS showed statistical significance improvements to 0.780 (P = 0.04), 0.774 (P = 0.012), and 0.706 (P = 003), respectively.

Conclusions

In unselected patients with GIB who presented to the emergency department, LA is an independent predictor of in-hospital mortality. Integration of LA into RS-C, RS-PE, and GBS risk scores improved their ability to predict in-hospital mortality. The modified LA-based RS-PE (L-Rockall pre-endoscopic) score demonstrated predictive value comparable to the post-endoscopic RS-C.

Early Risk Score for Predicting Hypotension in Normotensive Patients with Non-Variceal Upper Gastrointestinal Bleedin

Risk assessment for upper gastrointestinal bleeding (UGIB) is important; however, current scoring systems are insufficient. We aimed to develop and validate a prediction model for rapidly determining the occurrence of hypotension in non-variceal UGIB patients with normotension (systolic blood pressure ≥90 mmHg) at emergency department presentation. In this prospective observational cohort study, consecutive non-variceal UGIB patients between January 2012 and April 2017 were enrolled. We developed and validated a new prediction model through logistic regression, with the occurrence of hypotension <24 h as the primary outcome. Among 3363 UGIB patients, 1439 non-variceal UGIB patients were included. The risk factors for the occurrence of hypotension were lactate level, blood in nasogastric tube, and systolic blood pressure. The area under the curve (AUC) of the new scoring model (LBS—Lactate, Blood in nasogastric tube, Systolic blood pressure) in the development cohort was 0.74, higher than the value of 0.64 of the Glasgow–Blatchford score for predicting the occurrence of hypotension. The AUC of the LBS score in the validation cohort was 0.83. An LBS score of ≤2 had a negative predictive value of 99.5% and an LBS score of ≥7 had a specificity of 97.5% in the validation cohort. The new LBS score stratifies normotensive patients with non-variceal UGIB at risk for developing hypotension.

Comparison of the National Early Warning Score+Lactate score with the pre-endoscopic Rockall, Glasgow-Blatchford, and AIMS65 scores in patients with upper gastrointestinal bleeding

Objective

We compared the predictive value of the National Early Warning Score+Lactate (NEWS+L) score with those of other parameters such as the pre-endoscopic Rockall score (PERS), Glasgow-Blatchford score (GBS), and albumin, international normalized ratio, altered mental status, systolic blood pressure, age older than 65 years score (AIMS65) among patients with upper gastrointestinal bleeding (UGIB).

Methods

We conducted a retrospective study of patients with UGIB during 2 consecutive years. The primary outcome was the composite of in-hospital death, intensive care unit admission, and the need for ≥5 packs of red blood cell transfusion within 24 hours.

Results

Among 530 included patients, the composite outcome occurred in 59 patients (19 in-hospital deaths, 13 intensive care unit admissions, and 40 transfusions of ≥5 packs of red blood cells within 24 hours). The area under the receiver operating characteristic curve of the NEWS+L score for the composite outcome was 0.76 (95% confidence interval, 0.70 to 0.82), which demonstrated a significant difference compared to PERS (0.66, 0.59–0.73, P=0.004), but not to GBS (0.70, 0.64–0.77, P=0.141) and AIMS65 (0.76, 0.70–0.83, P=0.999). The sensitivities of NEWS+L scores of 3 (n=34, 6.4%), 4 (n=92, 17.4%), and 5 (n=171, 32.3%) were 100%, 98.3%, and 96.6%, respectively, while the sensitivity of an AIMS65 score of 0 (n=159, 30.0%) was 91.5%.

Conclusion

The NEWS+L score showed better discriminative performance than the PERS and comparable discriminative performance to the GBS and AIMS65. The NEWS+L score may be used to identify low-risk patients among patients with UGIB.

Prognostic Utility of Initial Lactate in Patients With Acute Drug Overdose: A Validation Cohort

STUDY OBJECTIVE

Previous studies have suggested that the initial emergency department (ED) lactate concentration may be an important prognostic indicator for inhospital mortality from acute drug poisoning. We conduct this cohort study to formally validate the prognostic utility of the initial lactate concentration in a larger, distinct patient population with acute drug overdose.

METHODS

This observational, prospective, cohort study was conducted during 5 years at 2 urban teaching hospitals. Consecutive adult ED patients with acute drug overdose had serum lactate levels tested as part of clinical care. The primary outcome was inpatient fatality. Receiver operating characteristics were plotted to determine optimal cut points, test characteristics, area under the curve, odds ratios, and 95% confidence intervals (CIs).

RESULTS

Of 3,739 patients screened, 1,406 were analyzed (56% women; mean age 43.1 years) and 24 died (1.7%). The difference in mean initial lactate concentration was 5.9 mmol/L (95% CI 3.4 to 8.1 mmol/L) higher in patients who died compared with survivors. The area under the curve for prediction of fatality was 0.85 (95% CI 0.73 to 0.95). The optimal lactate cut point for fatality was greater than or equal to 5.0 (odds ratio 34.2; 95% CI 13.7 to 84.2; 94.7% specificity). Drug classes for which lactate had the highest utility were salicylates, sympathomimetics, acetaminophen, and opioids (all area under the curve ≥0.97); lowest utility was for diuretics and angiotensin-converting enzyme inhibitors.

CONCLUSION

Initial lactate concentration is a useful biomarker for early clinical decisionmaking in ED patients with acute drug overdose. Studies of lactate-tailored management for these patient populations are warranted.

Elevated lactate level predicts intensive care unit admissions, endoscopies and transfusions in patients with acute gastrointestinal bleeding

Background and aims

Initial clinical management decision in patients with acute gastrointestinal bleeding (GIB) is often based on identifying high- and low-risk patients. Little is known about the role of lactate measurement in the triage of patients with acute GIB. We intended to assess if lactate on presentation is predictive of need for intervention in patients with acute GIB.

Patients and methods

We performed a single-center, retrospective, cross-sectional study including patients ≥18 years old presenting to emergency with acute GIB between January 2014 and December 2014. Intensive care unit (ICU) admission, inpatient endoscopy (upper endoscopy and/or colonoscopy), and packed red blood cell (PRBC) transfusion were assessed as outcomes. Analyses included univariate and multivariate logistic regression analyses.

Results

Of 1,237 patients with acute GIB, 468 (37.8%) had venous lactate on presentation. Of these patients, 165 (35.2%) had an elevated lactate level (>2.0 mmol/L). Patients with an elevated lactate level were more likely to be admitted to ICU than patients with a normal lactate level (adjusted odds ratio [AOR] 2.96, 95% confidence interval [CI] 1.74–5.01; p<0.001). Patients with an elevated lactate level were more likely to receive PRBC transfusion (AOR 3.65, 95% CI 1.76–7.55; p<0.001) and endoscopy (AOR 1.64, 95% CI 1.02–2.65; p=0.04) than patients with a normal lactate level.

Conclusion

Elevated lactate level predicts the need for ICU admissions, transfusions, and endoscopies in patients with acute GIB. Lactate measurement may be a useful adjunctive test in the triage of patients with acute GIB.

Usefulness of the Delta Neutrophil Index to Predict 30-Day Mortality in Patients with Upper Gastrointestinal Bleeding

PURPOSE

The delta neutrophil index (DNI), reflecting the fraction of circulating immature granulocytes, is associated with increased mortality in patients with systemic inflammation. It is rapidly and easily measured while performing a complete blood count. This study aimed to determine whether the DNI can predict short-term mortality in patients presenting to the emergency department (ED) with upper gastrointestinal hemorrhage (UGIH).

METHODS

We retrospectively identified consecutive patients (>18 years old) with UGIH admitted to the ED from January 1, 2015 to February 28, 2016. The diagnosis of UGIH was confirmed using clinical, laboratory, and endoscopic findings. The DNI was determined on each day of hospitalization. The outcome of interest was 30-day mortality.

RESULTS

Overall, 432 patients with UGIH met our inclusion criteria. The multivariate Cox regression model demonstrated that higher DNI values on days 0 (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.02-1.17; P = 0.012) and 1 (HR, 1.15; 95% CI, 1.06-1.24; P = 0.001) were strong independent predictors of short-term mortality. Further, a DNI >1% at ED admission was associated with an increased risk (HR, 40.9; 95% CI, 20.8-80.5; P < 0.001) of 30-day mortality. The optimal cut-off value for DNI on day 1 was 2.6%; this was associated with an increased hazard of 30-day mortality following UGIH (HR, 7.85; 95% CI, 3.59-17.15; P < 0.001).

CONCLUSION

The DNI can be measured rapidly and simply at ED admission without additional cost or time burden. Increased DNI values independently predict 30-day mortality in patients with UGIH.

Arterial lactate does not predict outcome better than existing risk scores in upper gastrointestinal bleeding

OBJECTIVE

Upper gastrointestinal bleeding (UGIB) is a frequent medical emergency and several scoring systems are developed to help risk-stratify patients. We aimed to investigate if elevated arterial lactate (AL) was associated with 30-day mortality, need for hospital-based intervention, or rebleeding. Furthermore, we compared the performance of AL with existing scoring systems and examined if incorporation of AL could improve their predictive ability.

MATERIALS AND METHODS

Retrospective cohort study of 331 consecutive patients admitted with UGIB during a one-year period. Multivariate analyses were performed to evaluate the association between AL and outcomes. Receiver operating characteristic curves were used to compare AL with existing scoring systems and to test if incorporation of AL could significantly increase their performance.

RESULTS

AL was significantly associated with mortality (p = .001), need for hospital-based intervention (p = .005), and rebleeding (p = .031). In predicting mortality and rebleeding, AL performed equally to existing scoring systems, however, inferior to all, in predicting need for intervention. Two of the scoring systems were marginally improved in predicting mortality if AL was included.

CONCLUSIONS

AL is associated with adverse outcomes in patients with UGIB, but has only similar or inferior ability to predict relevant clinical outcomes compared to existing scoring systems. Although AL could enhance performance of two scorings systems in predicting mortality, it does not have an apparent clinical significance. Thus, our data does not support routine measurement of AL in patients with UGIB.

Lactate Parameters Predict Clinical Outcomes in Patients with Nonvariceal Upper Gastrointestinal Bleeding

The predictive role of lactate in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) has been suggested. This study evaluated several lactate parameters in terms of predicting outcomes of bleeding patients and sought to establish a new scoring model by combining lactate parameters and the AIMS65 score. A total of 114 patients with NVUGIB who underwent serum lactate level testing at least twice and endoscopic hemostasis within 24 hours after admission were retrospectively analyzed. The associations between five lactate parameters and clinical outcomes were evaluated and the predictive power of lactate parameter combined AIMS65s (L-AIMS65s) and AIMS56 scoring was compared. The most common cause of bleeding was gastric ulcer (48.2%). Lactate clearance rate (LCR) was associated with 30-day rebleeding (odds ratio [OR], 0.931; 95% confidence interval [CI], 0.872-0.994; P = 0.033). Initial lactate (OR, 1.313; 95% CI, 1.050-1.643; P = 0.017), maximal lactate (OR, 1.277; 95% CI, 1.037-1.573; P = 0.021), and average lactate (OR, 1.535; 95% CI, 1.137-2.072; P = 0.005) levels were associated with 30-day mortality. Initial lactate (OR, 1.213; 95% CI, 1.027-1.432; P = 0.023), maximal lactate (OR, 1.271; 95% CI, 1.074-1.504; P = 0.005), and average lactate (OR, 1.501; 95% CI, 1.150-1.959; P = 0.003) levels were associated with admission over 7 days. Although L-AIMS65s showed the highest area under the curve for prediction of each outcome, differences between L-AIMS65s and AIMS65 did not reach statistical significance. In conclusion, lactate parameters have a prognostic role in patients with NVUGIB. However, they do not increase the predictive power of AIMS65 when combined.

Predicting the Occurrence of Hypotension in Stable Patients With Nonvariceal Upper Gastrointestinal Bleeding: Point-of-Care Lactate Testing

OBJECTIVES

It is difficult to assess risk in normotensive patients with upper gastrointestinal bleeding. The aim of this study was to evaluate whether the initial lactate value can predict the in-hospital occurrence of hypotension in stable patients with acute nonvariceal upper gastrointestinal bleeding.

DESIGN

Retrospective, observational, single-center study.

SETTING

Emergency department of a tertiary-care, university-affiliated hospital during a 5-year period.

PATIENTS

Medical records of 3,489 patients with acute upper gastrointestinal bleeding who were normotensive at presentation to the emergency department. We analyzed the ability of point-of-care testing of lactate at emergency department admission to predict hypotension development (defined as systolic blood pressure <90 mm Hg) within 24 hours after emergency department admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 1,003 patients with acute nonvariceal upper gastrointestinal bleeding, 157 patients experienced hypotension within 24 hours. Lactate was independently associated with hypotension development (odds ratio, 1.6; 95% CI, 1.4-1.7), and the risk of hypotension significantly increased as the lactate increased from 2.5-4.9 mmol/L (odds ratio, 2.2) to 5.0-7.4 mmol/L (odds ratio, 4.0) and to greater than or equal to 7.5 mmol/L (odds ratio, 39.2) (p<0.001). Lactate elevation (≥2.5 mmol/L) was associated with 90% specificity and an 84% negative predictive value for hypotension development. When the lactate levels were greater than 5.0 mmol/L, the specificity and negative predictive value increased to 98% and 87%, respectively.

CONCLUSIONS

Point-of-care testing of lactate can predict in-hospital occurrence of hypotension in stable patients with acute nonvariceal upper gastrointestinal bleeding. However, subsequently, prospective validate research will be required to clarify this.

Predictive Role of Admission Lactate Level in Critically Ill Patients with Acute Upper Gastrointestinal Bleeding

BACKGROUND

The predictive role of lactate in critically ill patients with acute upper gastrointestinal bleeding (UGIB) remains to be elucidated.

OBJECTIVE

The primary objective of this study was to assess the value of lactate level on admission to predict in-hospital death in patients with UGIB admitted to the intensive care unit (ICU). The secondary objective was to assess whether lactate level adds predictive value to the clinical Rockall score in these patients.

METHODS

This was a retrospective cohort study that included 133 patients with acute UGIB admitted to the ICU. Inclusion criteria were age > 18 years and presence of UGIB on admission to the ICU.

RESULTS

Mean age was 55.4 years old and 64.7% were male. The most common cause of gastrointestinal bleeding was peptic ulcer disease, followed by erosive esophagitis/gastritis. The in-hospital mortality was 22.6%. Median lactate level in survivors and nonsurvivors was 2.0 (interquartile range [IQR] 1.2-4.2 mmol/L) and 8.8 (IQR 3.4-13.3 mmol/L; p < 0.01), respectively. The receiver operating characteristic (ROC) area to predict in-hospital death for clinical Rockall score and lactate level (0.82) was significantly higher than the ROC area for the clinical Rockall score alone (0.69) (p < 0.01).

CONCLUSIONS

In patients admitted to the ICU with acute UGIB, lactate level on admission has a high sensitivity but low specificity for predicting in-hospital death. Lactate level adds to the predictive value of the clinical Rockall score. Given its high sensitivity, lactate level can be used in addition to other prediction tools to predict outcomes in patients with UGIB.