SepsisPrognosis of emergency department patients with suspected infection and intermediate lactate levels: A systematic review
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.
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