1
|
Ward CL, Olafson SN, Cohen RB, Kaplan MJ, Bloom A, Parsikia A, Moran BJ, Leung PS. Combination of Lactate and Base Deficit Levels at Admission to Predict Mortality in Blunt Trauma Patients. Cureus 2023; 15:e40097. [PMID: 37425498 PMCID: PMC10328425 DOI: 10.7759/cureus.40097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 07/11/2023] Open
Abstract
INTRODUCTION Elevated lactate levels are associated with increased mortality in both trauma and non-trauma patients. The relation between base deficit (BD) and mortality is less clear. Traumatologists debate the utility of elevated lactate (EL) versus BD in predicting mortality. We hypothesized that EL (2mmol/L to 5mmol/L) and BD (≤-2mmol/L) in combination could predict mortality in blunt trauma patients. Methods: This is a retrospective analysis of the trauma registry from 2012 to 2021 at a level 1 trauma center. Blunt trauma patients with admission lactate and BD values were included in the analysis. Exclusion criteria were age <18, penetrating trauma, unknown mortality, and unknown lactate or BD. Logistics regression of the total 5153 charts showed 93% of the patients presented with lactate levels <5mmol/L, therefore patients with lactate >5mmol/L were excluded as outliers. The primary outcome was mortality. RESULTS A total of 4794 patients (151 non-survivors) were included in the analysis. Non-survivors had higher rates of EL + BD (35.8% vs. 14.4%, p <0.001). When comparing survivors and non-survivors, EL + BD (OR 5.69), age >65 (5.17), injury severity score (ISS) >25 (8.87), Glasgow coma scale <8 (8.51), systolic blood pressure (SBP) <90 (4.2), and ICU admission (2.61) were significant predictors of mortality. Other than GCS <8 and ISS >25, EL + BD had the highest odds of predicting mortality. CONCLUSION Elevated lactate + BD on admission in combination represents a 5.6-fold increase in mortality in blunt trauma patients and can be used to predict a patient's outcome on admission. This combination variable provides an additional early data point to identify patients at elevated risk of mortality at the moment of admission.
Collapse
Affiliation(s)
- Candace L Ward
- Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Samantha N Olafson
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Ryan B Cohen
- General Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Mark J Kaplan
- Trauma and Acute Care Surgery, Einstein Healthcare Network, Philadelphia, USA
| | - Alexi Bloom
- Trauma and Acute Care Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Afshin Parsikia
- General Surgery, Einstein Healthcare Network, Philadelphia, USA
| | - Benjamin J Moran
- Trauma and Acute Care Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Pak S Leung
- Trauma and Acute Care Surgery, Einstein Medical Center Philadelphia, Philadelphia, USA
| |
Collapse
|
2
|
Cao Y, Yao S, Shang J, Ping F, Tan Q, Tian Z, Huang W, Li Y. The combination of lactate level, lactate clearance and APACHE II score better predicts short-term outcomes in critically Ill patients: a retrospective cohort study. BMC Anesthesiol 2022; 22:382. [PMID: 36482299 PMCID: PMC9733168 DOI: 10.1186/s12871-022-01878-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/11/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The mortality rate is high in critically ill patients due to the difficulty of diagnosis and treatment. Thus, it is very important to explore the predictive value of different indicators related to prognosis in critically ill patients. METHODS This was a retrospective cohort study of patients in the intensive care unit (ICU) of the Sixth People's Hospital in Shanghai, China. A total of 1465 ICU patients had lactate values > 2.1 mmol/L at least once within 24 h of ICU admission, and arterial blood gas was monitored more than twice during the ICU stay. RESULTS The predictive value of lactate clearance at 24 h was not high, and the sensitivity and specificity were lower. The predictive value of the lactate level at baseline and the APACHE II score was higher than that of lactate clearance at 24 h in critically ill patients. The predictive value of the lactate level at baseline combined with the APACHE II score was higher than that of the lactate level at baseline or the APACHE II score alone. In addition, the predictive value of lactate clearance at 24 h combined with the APACHE II score was also significantly higher than that of lactate clearance at 24 h or the APACHE II score alone. In particular, the area under the ROC curve reached 0.900, the predictive value was markedly higher than that of the ROC alone, and the sensitivity and specificity were better when these three indicators were combined. CONCLUSIONS The combination of lactate level, lactate clearance and APACHE II score better predicts short-term outcomes in critically ill patients.
Collapse
Affiliation(s)
- Yongmei Cao
- grid.412538.90000 0004 0527 0050Department of Critical Care Medicine, School of Medicine, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, China
| | - Sijia Yao
- grid.412528.80000 0004 1798 5117Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Xuhui District, No. 600, Yishan Road, Shanghai, 200233 China
| | - Jiawei Shang
- grid.412528.80000 0004 1798 5117Department of Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Xuhui District, No. 600, Yishan Road, Shanghai, 200233 China
| | - Feng Ping
- grid.412528.80000 0004 1798 5117Department of Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Xuhui District, No. 600, Yishan Road, Shanghai, 200233 China
| | - Qin Tan
- grid.412528.80000 0004 1798 5117Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Xuhui District, No. 600, Yishan Road, Shanghai, 200233 China
| | - Zijun Tian
- grid.412528.80000 0004 1798 5117Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Xuhui District, No. 600, Yishan Road, Shanghai, 200233 China
| | - Weifeng Huang
- grid.412528.80000 0004 1798 5117Department of Critical Care Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Xuhui District, No. 600, Yishan Road, Shanghai, 200233 China
| | - Yingchuan Li
- grid.412538.90000 0004 0527 0050Department of Critical Care Medicine, School of Medicine, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, China
| |
Collapse
|
3
|
Michael M, Kumle B, Kümpers P, Bernhard M. [Management of Critically Ill Non-traumatic Patients in the Emergency Department]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:466-477. [PMID: 35896385 DOI: 10.1055/a-1545-2422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
AbstractResuscitation room management of non-traumatic critically ill patients in the emergency department comprises approximately 1.5% of all emergency department visits. Critically ill patients
are usually brought to the hospital by emergency medical services, where they are first examined, given initial treatment, stabilized and then transported for further in-hospital treatment.
Resuscitation room management plays a key role at the interface of the out-of-hospital and in-hospital treatment chains. While the structured care of traumatological patients has been
established at a very high level for decades, the care of non-traumatic critically ill patients within the framework of resuscitation room care has only come into focus in recent years and
is only now being implemented in some places with professional concepts. Emergency departments at all levels of care are equipped to provide structured care for non-traumatologic shock room
patients. To professionalize non-traumatic resuscitation room management, the creation of uniform standards from alerting criteria, to equipment and staffing, as well as the establishment of
a uniform resuscitation room management algorithm is required. The (PRE_E-)AUD2IT-algorithm provides a structure for the non-traumatic care of critically ill patients in the
resuscitation room and includes preparation, resource retrieval, handover, initial care, diagnostics, differential diagnoses and the interpretation of examination findings. This overview
focuses on the management of critically ill non-traumatic patients in respect to the resuscitation room care concept.
Collapse
|
4
|
Michael M, Bax S, Finke M, Hoffmann M, Kornstädt S, Kümpers P, Kumle B, Laaf T, Reindl M, Schunk D, Pin M, Bernhard M. Aktuelle Ist-Analyse zur Situation des nichttraumatologischen Schockraummanagements in Deutschland. Notf Rett Med 2022. [DOI: 10.1007/s10049-020-00827-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Zusammenfassung
Einleitung
In Notaufnahmen kommen bundesweit nichttraumatologische kritisch kranke Patienten zur Aufnahme. Zur Struktur, Organisation und Ausstattung des nichttraumatologischen Schockraummanagements ist bisher wenig bekannt. Mittels einer Umfrage sollte daher der Ist-Zustand analysiert werden.
Methodik
Durch die Arbeitsgruppe „Schockraum“ der Deutschen Gesellschaft Interdisziplinäre Notfall- und Akutmedizin (DGINA) wurde mittels E‑Mail den 420 ärztlichen Leiter*Innen des DGINA-Mitgliederregisters eine Onlineumfrage zugesendet. Zwei Wochen nach initialem Anschreiben erfolgte eine Erinnerung. Die Ergebnisse wurden in einer anonymisierten Datenbank extrahiert und ausgewertet.
Ergebnisse
Insgesamt lag die Rücklaufquote mit 131 verwertbaren Antworten bei 31 %. Die Umfrage erfasste Krankenhäuser der Basis- (24 %), erweiterten (39 %) und umfassenden Notfallversorgung (37 %). Korrespondierend zur Versorgungsstufe stiegen die jährlichen Patientenkontakte (21.000 vs. 31.000 vs. 39.000), die Monitorplätze in den Notaufnahmen (9 ± 4 vs. 13 ± 6 vs. 18 ± 10), die Betten der assoziierten Notaufnahmestationen (4 ± 5 vs. 10 ± 17 vs. 13 ± 12), die verfügbaren Schockräume (1 ± 1 vs. 2 ± 1 vs. 3 ± 1) und deren Größe (31 ± 16 vs. 35 ± 9 vs. 38 ± 14 m2) an. Hinsichtlich verschiedener Ausstattungsmerkmale (z. B. Röntgenlafette: 58 vs. 65 vs. 78 %, Computertomographie im Schockraum: 6 vs. 12 vs. 27 %) zeigten sich deutliche Unterschiede in Abhängigkeit von der Versorgungsstufe. Während Kühlungssysteme in 30 % in allen Versorgungsstufen vorgehalten wurden, fanden sich andere Ausstattungsmerkmale (z. B. Videolaryngoskopie: 65 vs. 80 vs. 86 %, Bronchoskopie: 29 vs. 22 vs. 45 %) und spezielle Notfallprozeduren (z. B. REBOA [„resuscitative endovascular balloon occlusion of the aorta“]: 3 vs. 5 vs. 12 %, ACCD [„automated chest compression device“]: 26 vs. 57 vs. 61 %) häufiger in höheren Versorgungsstufen.
Schlussfolgerung
Die vorliegenden Ergebnisse zeigen erstmals den Ist-Zustand der nichttraumatologischen Schockraumversorgung in verschiedenen Versorgungsstufen in Deutschland. Empfehlungen zu Ausstattungsmerkmalen für das nichttraumatologische Schockraummanagement müssen zukünftig formuliert werden.
Collapse
|
5
|
„C-Probleme“ des nichttraumatologischen Schockraummanagements. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00936-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungIm Rahmen des nichttraumatologischen Schockraummanagements zur Versorgung kritisch kranker Patienten werden akute Störungen der Vitalfunktionen rasch detektiert und behandelt. Beim „primary survey“ (Erstversorgung) dient das etablierte ABCDE-Schema der strukturierten Untersuchung aller relevanten Vitalparameter. Akute Störungen werden hierbei unmittelbar detektiert und therapiert. „C-Probleme“ stellen den größten Anteil der ABCDE-Störungen bei nichttraumatologischen Schockraumpatienten dar und zeichnen sich durch eine hämodynamische Instabilität infolge hypovolämischer, obstruktiver, distributiver oder kardiogener Schockformen aus. Abhängig von den lokalen Versorgungsstrukturen umfasst die nichttraumatologische Schockraumversorgung hierbei auch die Stabilisierung von Patienten mit akutem Koronarsyndrom oder nach prähospitaler Reanimation (Cardiac Arrest Center).
Collapse
|
6
|
Saint-Pierre LM, Hopper K, Epstein SE. Retrospective evaluation of the prognostic utility of plasma lactate concentration and serial lactate measurements in dogs and cats presented to the emergency room (January 2012 - December 2016): 4863 cases. J Vet Emerg Crit Care (San Antonio) 2021; 32:42-49. [PMID: 34343401 DOI: 10.1111/vec.13106] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 03/24/2020] [Accepted: 03/29/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the prognostic significance of plasma lactate concentration, plasma lactate clearance, and delta lactate in dogs and cats presented to an emergency room (ER). DESIGN Retrospective study. SETTING University teaching hospital. ANIMALS A total of 8,321 animals with a plasma lactate concentration measured with 4,863 presenting to the ER and 1,529 dogs and 444 cats having a measurement within 4 hours of admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma lactate concentration of dogs and cats presented to a university teaching hospital was retrospectively evaluated. Of dogs and cats with a plasma lactate concentration measured within 4 hours of admission to the ER, hyperlactatemia was common, and the prevalence of hyperlactatemia for dogs 78% (361/462) and cats 67% (78/116) was highest when evaluated within the first 30 minutes following admission. The distribution of patient's plasma lactate concentration was significantly higher in non-survivors compared to survivors at all time points evaluated (P < 0.001). Both lactate clearance (P = 0.010) and delta lactate (P = 0.013) were significantly different between survivors and nonsurvivors. A delta lactate > 4.5 mmol/L was 100% (95% CI: 95 to 100%) specific for nonsurvival in patients with hyperlactatemia measured within 1 hour of admission to the ER. The most common cause of hyperlactatemia was shock in dogs (24%) and urinary tract diseases in cats (22%). Shock was associated with the highest mortality rate in both dogs (61%) and cats (77%). Hyperlactatemia was significantly associated with increased mortality for dogs with shock (P = 0.001), respiratory diseases (P = 0.022), diabetes mellitus (P = 0.018), and liver dysfunction (P = 0.006). CONCLUSIONS Hyperlactatemia was associated with mortality in both dogs and cats when measured at any time point in the 4 hours following admission to the ER. Serial lactate measurement may also be a valuable tool to guide clinical management decisions.
Collapse
Affiliation(s)
- Laurence M Saint-Pierre
- Veterinary Medical Teaching Hospital, University of California Davis, Davis, California, USA
| | - Kate Hopper
- Department of Surgical and Radiological Sciences, University of California Davis, Davis, California, USA
| | - Steven E Epstein
- Department of Surgical and Radiological Sciences, University of California Davis, Davis, California, USA
| |
Collapse
|
7
|
Michael M, Kleophas A, Keitel V, Flügen G, Bernhard M. [Acute Abdominal Pain in the Emergency Department]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:448-458. [PMID: 34187077 DOI: 10.1055/a-1191-1374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Abdominal pain is a common leading symptom in emergency medicine. This symptom complex includes a variety of different causes, ranging from intra-abdominal to extra-abdominal and retroperitoneal pathologies, which can affect all age groups. Abdominal complaints can include diseases ranging from trivialities to life-threatening emergencies. The acute abdominal condition is an interdisciplinary emergency in which interdisciplinary teamwork is mandatory. A rapid initial assessment and risk stratification is necessary in order to detect critically ill patients with an acute need for intervention at an early stage and to provide them with a suitable emergency therapy. A structured approach can identify the most important differential diagnoses.
Collapse
|
8
|
Kreß JS, Rüppel M, Haake H, Vom Dahl J, Bergrath S. Short-term outcome and characteristics of critical care for nontrauma patients in the emergency department. Anaesthesist 2021; 71:30-37. [PMID: 33830277 DOI: 10.1007/s00101-021-00953-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/11/2021] [Accepted: 01/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency medical care for critically ill nontrauma patients (CINT) varies between different emergency departments (ED) and healthcare systems, while resuscitation of trauma patients is always performed within the ED. In many ED CINT are treated and stabilized while in many German smaller hospitals CINT are transferred directly to the intensive care unit (ICU) without performing critical care measures in the ED. Little is known about the resuscitation room management of CINT regarding patient characteristics and outcome although bigger hospitals perform ED resuscitation of CINT in routine care. Against this background we conducted this retrospective analysis of CINT treated by an ED resuscitation room concept in a German 756 bed teaching hospital. METHODS The collective of CINT treated within the ED resuscitation room (1 October 2018 to 31 March 2019) was analyzed after ethical approval. After each resuscitation room operation, the team leader filled out a standardized paper-based questionnaire and qualified the patient as a resuscitation room patient this way. Only patients who underwent invasive procedures and were admitted to ICU or died in the ED were included. Patient characteristics, performed critical care measures, short-term outcomes and the comparison of admission characteristics between survivors and non-survivors were evaluated. Additionally, the accordance of ED admission diagnoses and discharge diagnoses were analyzed. RESULTS Overall, 243 of 19,854 ED patients (1.22%) were treated in the resuscitation room. After exclusion of trauma patients, 193 (0.97%) CINT were included. Overall mortality was 29% (n = 56), 24‑h mortality was 13% (n = 25). Patient characteristics (vital signs, blood gas analysis) differed significantly between survivors and nonsurvivors except for respiratory rate and pain scale. An excerpt of conducted resuscitation room measures was as follows: arterial line n = 78 (40%); noninvasive ventilation n = 60 (31%); endotracheal intubation n = 56 (29%); cardiopulmonary resuscitation n = 19 (10%), central venous line n = 8 (4%). The number of conducted measures differed between survivors and nonsurvivors (median and interquartile range, IQR): 4 (IQR 2) vs. 4 (IQR 3) p = 0.0453. The length of ED stay was 148.2 ± 202.7 min until the patient was admitted to an ICU or died within the ED. ED admission diagnoses matched with hospital discharge diagnoses in 78%. CONCLUSION The observed mortality was high and was comparable to patient collectives with septic shock. Nonsurvivors showed significantly more impaired vital parameters and blood gas analysis parameters. Vital parameters together with blood gas analysis might enable ED risk stratification of CINT. Resuscitation room management enables immediate stabilization and diagnostic work-up of CINT even when no ICU bed is available. Furthermore, optimal allocation to specialized ICUs can probably be enabled more accurately after a first diagnostic work-up; however, although a first diagnostic work-up including laboratory tests and computed tomography in many cases was performed, ED admission and hospital discharge diagnoses matched only in 78%.
Collapse
Affiliation(s)
- Jessika Stefanie Kreß
- Kliniken Maria Hilf, Zentrum für klinische Akut- und Notfallmedizin, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany.,Lehrstuhl für Anästhesiologie, Medizinische Fakultät RWTH Aachen, Uniklinik RWTH Aachen, Aachen, Germany
| | - Marc Rüppel
- Kliniken Maria Hilf, Zentrum für klinische Akut- und Notfallmedizin, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany
| | - Hendrik Haake
- Klinik für Kardiologie, Elektrophysiologie und internistische Intensivmedizin, Kliniken Maria Hilf, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany
| | - Jürgen Vom Dahl
- Klinik für Kardiologie, Elektrophysiologie und internistische Intensivmedizin, Kliniken Maria Hilf, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany
| | - Sebastian Bergrath
- Kliniken Maria Hilf, Zentrum für klinische Akut- und Notfallmedizin, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany. .,Lehrstuhl für Anästhesiologie, Medizinische Fakultät RWTH Aachen, Uniklinik RWTH Aachen, Aachen, Germany.
| |
Collapse
|
9
|
Bruno RR, Wernly B, Binneboessel S, Baldia P, Duse DA, Erkens R, Kelm M, Mamandipoor B, Osmani V, Jung C. Failure of Lactate Clearance Predicts the Outcome of Critically Ill Septic Patients. Diagnostics (Basel) 2020; 10:diagnostics10121105. [PMID: 33352862 PMCID: PMC7767189 DOI: 10.3390/diagnostics10121105] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose: Early lactate clearance is an important parameter for prognosis assessment and therapy control in sepsis. Patients with a lactate clearance >0% might differ from patients with an inferior clearance in terms of intensive care management and outcomes. This study analyzes a large collective with regards to baseline risk distribution and outcomes. Methods: In total, 3299 patients were included in this analysis, consisting of 1528 (46%) ≤0% and 1771 (54%) >0% patients. The primary endpoint was intensive care unit (ICU) mortality. Multilevel logistic regression analyses were used to compare both groups: A baseline model (model 1) with lactate clearance as a fixed effect and ICU as a random effect was installed. For model 2, patient characteristics (model 2) were included. For model 3, intensive care treatment (mechanical ventilation and vasopressors) was added to the model. Models 1 and 2 were used to evaluate the primary and secondary outcomes, respectively. Model 3 was only used to evaluate the primary outcomes. Adjusted odds ratios (aORs) with respective 95% confidence intervals (CI) were calculated. Results: The cohorts had no relevant differences regarding the gender, BMI, age, heart rate, body temperature, and baseline lactate. Neither the primary infection focuses nor the ethnic background differed between both groups. In both groups, the most common infection sites were of pulmonary origin, the urinary tract, and the gastrointestinal tract. Patients with lactate clearance >0% evidenced lower sepsis-related organ failure assessment (SOFA) scores (7 ± 6 versus 9 ± 6; p < 0.001) and creatinine (1.53 ± 1.49 versus 1.80 ± 1.67; p < 0.001). The ICU mortality differed significantly (14% versus 32%), and remained this way after multivariable adjustment for patient characteristics and intensive care treatment (aOR 0.43 95% CI 0.36–0.53; p < 0.001). In the additional sensitivity analysis, the lack of lactate clearance was associated with a worse prognosis in each subgroup. Conclusion: In this large collective of septic patients, the 6 h lactate clearance is an independent method for outcome prediction.
Collapse
Affiliation(s)
- Raphael Romano Bruno
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (R.R.B.); (S.B.); (P.B.); (D.A.D.); (R.E.); (M.K.)
| | - Bernhard Wernly
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria;
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Solna, 171 64 Stockholm, Sweden
| | - Stephan Binneboessel
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (R.R.B.); (S.B.); (P.B.); (D.A.D.); (R.E.); (M.K.)
| | - Philipp Baldia
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (R.R.B.); (S.B.); (P.B.); (D.A.D.); (R.E.); (M.K.)
| | - Dragos Andrei Duse
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (R.R.B.); (S.B.); (P.B.); (D.A.D.); (R.E.); (M.K.)
| | - Ralf Erkens
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (R.R.B.); (S.B.); (P.B.); (D.A.D.); (R.E.); (M.K.)
| | - Malte Kelm
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (R.R.B.); (S.B.); (P.B.); (D.A.D.); (R.E.); (M.K.)
- Cardiovascular Research Institute Düsseldorf (CARID), 40225 Düsseldorf, Germany
| | - Behrooz Mamandipoor
- Fondazione Bruno Kessler Research Institute, 38123 Trento, Italy; (B.M.); (V.O.)
| | - Venet Osmani
- Fondazione Bruno Kessler Research Institute, 38123 Trento, Italy; (B.M.); (V.O.)
| | - Christian Jung
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany; (R.R.B.); (S.B.); (P.B.); (D.A.D.); (R.E.); (M.K.)
- Correspondence:
| |
Collapse
|
10
|
Wilson W, Selvaraj DR, Ramya Kumar MV, Jain V, Umra S, Murty S. Arterial lactate as a prognostic tool to predict mortality and disposition in the emergency department: A prospective observational single-centre study. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920964177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Point-of-care tools are invaluable in the emergency department. Arterial lactate has been used for prognostication in subsets of population in the emergency department but not often for a heterogeneous population. Objectives: We aimed to study the use of arterial lactate as a prognostication and disposition tool in an undifferentiated population presenting to the emergency department. Methods: We conducted a prospective study among all consenting emergency department patients with age >18 years, who had an arterial blood gas performed as a part of routine care and had a lactate value ⩾2 mmol/L. We collected data on demographics, comorbidities and patient disposition from the emergency department and 28-day mortality as a follow-up telephonically. Results: We included 469 patients with a median age of 37 years. Sixteen provisional diagnoses were made in the emergency department, and pneumonia/lower respiratory tract infection was relatively higher (13.6%). The median lactate was 4.6 (interquartile range = 3.2–7) with 155 patients (33%) being transferred to intensive care unit and 62 deaths (13.2%) recorded at 28 days. Furthermore, we observed optimum values for lactates at 5 mmol/L predicted intensive care unit admissions and 6 mmol/L predicted mortality. A unit increase in arterial lactate in the emergency department significantly increased mortality by 66% (95% confidence interval = 1.45–1.88; p < 0.001) and had a 2.15 times (95% confidence interval = 1.63–2.83; p < 0.001) significantly higher chance of being transferred to the intensive care unit. Conclusion: Arterial lactate can be used as a prognostication tool for a heterogeneous population presenting to the emergency department. Clinical significance: Point-of-care investigations such as arterial lactate can help the emergency physician make quick decisions on the floor and guide prognostication and disposition.
Collapse
Affiliation(s)
- William Wilson
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Dhiraj Ravindran Selvaraj
- Division of Clinical Research and Training, St. John’s Research Institute, Bengaluru, Karnataka, India
| | - MV Ramya Kumar
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vinayak Jain
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Simran Umra
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Karnataka, India
- Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shakuntala Murty
- Department of Emergency Medicine, St. John’s Medical College, Bengaluru, Karnataka, India
| |
Collapse
|
11
|
Bernhard M, Döll S, Kramer A, Weidhase L, Hartwig T, Petros S, Gries A. Elevated admission lactate levels in the emergency department are associated with increased 30-day mortality in non-trauma critically ill patients. Scand J Trauma Resusc Emerg Med 2020; 28:82. [PMID: 32807232 PMCID: PMC7433202 DOI: 10.1186/s13049-020-00777-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background Elevated blood lactate levels were reported as useful predictors of clinical outcome and mortality in critically ill patients. To identify higher-risk patients, this investigation evaluated the relationship between patient mortality and admission lactate levels during the management of non-trauma critically ill patients in the emergency department (ED). Methods In this prospective, single centre observational study in a German university ED, all adult patients who were admitted to the ED resuscitation room were evaluated between September 1, 2014 and August 31, 2015. Blood samples for blood gas analysis, including lactate levels, were obtained immediately at admission. Study endpoint was 30-day mortality. Results During the study period, 532 patients were admitted to the resuscitation room of the ED. The data of 523 patients (98.3%) were available. The overall 30-day mortality was 34.2%. Patients presenting to the resuscitation room with admission lactate levels < 2.0 mmol/l had a 30-day mortality of 22.7%, while admission lactate levels above 8.0 mmol/l were associated with higher mortality (8.0–9.9 mmol/l: OR: 2.83, 95%CI: 1.13–7.11, p = 0.03, and ≥ 10 mmol/l: OR: 7.56, 95%CI: 4.18–13.77, p < 0.001). Conclusion High lactate levels at admission are associated with an increased 24-h and 30-day mortality. These measurements may be used not only to predict mortality, but to help identify patients at risk for becoming critically ill. The breakpoint for mortality may be an ALL ≥8.0 mmol/l.
Collapse
Affiliation(s)
- Michael Bernhard
- Emergency Department, University Hospital of Düsseldorf, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Stephanie Döll
- Emergency Department, Helios Hospital Erfurt, Erfurt, Germany
| | - Andre Kramer
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Lorenz Weidhase
- Medical Intensive Care Unit, University Hospital of Leipzig, Leipzig, Germany
| | - Thomas Hartwig
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, University Hospital of Leipzig, Leipzig, Germany
| | - André Gries
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| |
Collapse
|
12
|
Abstract
The basis of all metabolic processes in the human body is the production and metabolism of carriers of energy. Lactate is the end-product of anaerobic glycolysis. Lactate can serve as a substrate for gluconeogenesis and as an oxidation substrate. Hyperlactatemia can be detected as the result of a multitude of acute events (e.g. shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine deficiency, liver failure and intoxication). Hyperlactatemia can be associated with increased mortality, therefore in emergency medicine the search for the cause of hyperlactatemia is just as important as an effective causal treatment. Repetitive measurements of lactate are components of several treatment algorithms as observation of the dynamic development of blood lactate concentrations can help to make a better assessment of the acute medical condition of the patient and to evaluate the effectiveness of the measures undertaken.
Collapse
|