Sepsis
Prognosis of emergency department patients with suspected infection and intermediate lactate levels: A systematic review

https://doi.org/10.1016/j.jcrc.2013.12.017Get rights and content

Abstract

Purpose

Previous studies have shown a correlation between blood lactate greater than 4.0 mmol/L and mortality in patients with suspected infection in the emergency department (ED), but data are more limited regarding the prognosis of intermediate blood lactate (2.0-3.9 mmol/L), particularly in the absence of hemodynamic instability. We sought to quantify the prognostic significance of intermediate blood lactate levels in ED patients with suspected infection, emphasizing patients without hypotension.

Methods

A systematic review of 4 databases was conducted to identify studies using a comprehensive search strategy. All studies performed on adult ED patients with suspected infection and available data on hemodynamics, intermediate lactate levels, and mortality rates were included.

Results

We identified 20 potential publications, 8 of which were included. Intermediate lactate elevation was found in 11062 patients with suspected or confirmed infection, 1672 (15.1%) of whom died. Subgroup analysis of normotensive patients demonstrated a mortality of 1561 (14.9%) of 10 442, with rates from individual studies between 3.2% and 16.4%.

Conclusion

This systematic review found that among ED patients with suspected infection, intermediate lactate elevation is associated with a moderate to high risk of mortality, even among patients without hypotension. Physicians should consider close monitoring and aggressive treatment for such patients.

Section snippets

Purpose

In the United States, emergency departments (EDs) treat approximately 570 000 patients with sepsis yearly [1]. In addition, there are 200 000 US deaths attributed to sepsis annually [2], with estimated mortality rates ranging from 15% to 30% based on administrative databases [3]. Despite active research in the field, early administration of bundled care and quantitative resuscitation protocols remains the most consistently beneficial therapy for the treatment of severe sepsis available in the

Search strategy for identification of studies

We followed a written protocol that was designed in accordance with recommended guidelines and finalized prior to beginning the study [17]. A preliminary search strategy was developed using exploded Medical Subject Heading terms and keywords involving sepsis, systemic inflammatory response syndrome (SIRS), lactate, and outcome. This strategy was revised and improved upon by a medical librarian. We searched MEDLINE (1950–July 2013), SCOPUS (1996–July 2013), Cochrane Library (2005–July 2013), and

Study selection

Searching the databases identified 302 potential publications for review (Fig. 1). Reviewing reference lists and related articles found 5 other potential studies. After removing duplicates and screening titles and abstracts, 287 articles were excluded as irrelevant and 20 articles were found to be appropriate for further review. The 20 relevant articles were retrieved in full text. A single reviewer examined all of the references obtained. Twelve of these articles were excluded for failing to

Discussion

In this systematic review, we used standardized methodology to identify and report the prognostic value of intermediately elevated lactate values in ED patients with suspected infection but without hemodynamic instability and found an overall summary rate of 15%, indicating a nontrivial risk of either in-hospital or 28- to 30-day mortality. This is compared with mortality rates for other acute emergency care conditions such as myocardial infarction (~ 5%) [28], nonmassive pulmonary embolism

Conclusion

In this systematic review, we found that among ED patients with suspected infection, intermediate lactate elevation is associated with a moderate to high risk of mortality compared with many other acute care diseases, even among patients without hypotension. Physicians should be aware of the poor prognosis of this group of patients, should monitor them closely, and give consideration to more aggressive treatment in order to prevent further progression to shock or death.

Acknowledgments

Dr Jones has received salary support from the National Institute of General Medical Sciences (R01 GM103799). Dr Puskarich received salary support from a Career Development Grant from the Emergency Medicine Foundation.

References (36)

  • F. Paoletti et al.

    Central venous catheters: observations on the implantation technique and its complications

    Minerva Anestesiol

    (2005)
  • O. Traore et al.

    Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter-related bacteremia in intensive care units

    Crit Care Med

    (2005)
  • D. Talmor et al.

    The costs and cost-effectiveness of an integrated sepsis treatment protocol

    Crit Care Med

    (2008)
  • A.E. Jones et al.

    Cost effectiveness of an emergency department based early sepsis resuscitation protocol

    Crit Care Med

    (2011)
  • T.C. Jansen et al.

    Blood lactate monitoring in critically ill patients: a systematic health technology assessment

    Crit Care Med

    (2009)
  • M. Mikkelsen et al.

    Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock

    Crit Care Med

    (2009)
  • M. Puskarich et al.

    Prognostic value of incremental lactate elevations in emergency department patients with suspected infection

    Acad Emerg Med

    (2012)
  • E. Rivers et al.

    Early goal-directed therapy in the treatment of severe sepsis and septic shock

    N Engl J Med

    (2001)
  • Cited by (63)

    • Demystifying Lactate in the Emergency Department

      2020, Annals of Emergency Medicine
    View all citing articles on Scopus
    View full text