Helpful Only When Elevated: Initial Serum Lactate in Stable Emergency Department Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration

Shannon M. Fernando, Douglas P. Barnaby, Christophe L. Herry, E. John Gallagher, Nathan I. Shapiro, Andrew J.E. Seely

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Background: Early emergency department (ED) identification of septic patients at risk of deterioration is critical. Lactate is associated with 28-day mortality in admitted patients, but little evidence exists on its use in predicting short-term deterioration. Objective: Our aim was to determine the role of initial serum lactate for prediction of short-term deterioration in stable ED patients with suspected sepsis. Methods: We conducted a prospective cohort study of adult ED sepsis patients. Venous lactate was obtained within 2 h of ED arrival. Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission > 24 h, intubation, vasoactive medications for > 1 h, or noninvasive positive pressure ventilation for > 1 h) within 72 h. Patients meeting any endpoint within 1 h of arrival were excluded. Results: Nine hundred and eighty-five patients were enrolled, of whom 84 (8.5%) met the primary outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97% (95% confidence interval [CI] 94-100%), but a sensitivity of 27% (95% CI 18-37%) for predicting deterioration, with positive and negative likelihood ratios of 10.7 (95% CI 6.3-18.3) and 0.8 (95% CI 0.7-0.9), respectively. A lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67% (95% CI 55-76%) and specificity of 66% (95% CI 63-69%), with corresponding positive and negative likelihood ratios of 2.0 (95% CI 1.7-2.3) and 0.5 (95% CI 0.4-0.7). Conclusions: High ED lactate is predictive of subsequent deterioration from sepsis within 72 h, and may be useful in determining disposition, but low lactate is not effective in screening stable patients at risk of deterioration.

Original languageEnglish (US)
JournalJournal of Emergency Medicine
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Hospital Emergency Service
Lactic Acid
Sepsis
Confidence Intervals
Serum
Positive-Pressure Respiration
Critical Care
Intubation
Cohort Studies
Prospective Studies
Mortality

Keywords

  • Critical care
  • Emergency department
  • Intensive care unit
  • Lactate
  • Risk-stratification
  • Sepsis

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Helpful Only When Elevated : Initial Serum Lactate in Stable Emergency Department Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration. / Fernando, Shannon M.; Barnaby, Douglas P.; Herry, Christophe L.; Gallagher, E. John; Shapiro, Nathan I.; Seely, Andrew J.E.

In: Journal of Emergency Medicine, 01.01.2018.

Research output: Contribution to journalArticle

@article{32afe4dfc14a42d9b08df192f5288d5a,
title = "Helpful Only When Elevated: Initial Serum Lactate in Stable Emergency Department Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration",
abstract = "Background: Early emergency department (ED) identification of septic patients at risk of deterioration is critical. Lactate is associated with 28-day mortality in admitted patients, but little evidence exists on its use in predicting short-term deterioration. Objective: Our aim was to determine the role of initial serum lactate for prediction of short-term deterioration in stable ED patients with suspected sepsis. Methods: We conducted a prospective cohort study of adult ED sepsis patients. Venous lactate was obtained within 2 h of ED arrival. Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission > 24 h, intubation, vasoactive medications for > 1 h, or noninvasive positive pressure ventilation for > 1 h) within 72 h. Patients meeting any endpoint within 1 h of arrival were excluded. Results: Nine hundred and eighty-five patients were enrolled, of whom 84 (8.5{\%}) met the primary outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97{\%} (95{\%} confidence interval [CI] 94-100{\%}), but a sensitivity of 27{\%} (95{\%} CI 18-37{\%}) for predicting deterioration, with positive and negative likelihood ratios of 10.7 (95{\%} CI 6.3-18.3) and 0.8 (95{\%} CI 0.7-0.9), respectively. A lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67{\%} (95{\%} CI 55-76{\%}) and specificity of 66{\%} (95{\%} CI 63-69{\%}), with corresponding positive and negative likelihood ratios of 2.0 (95{\%} CI 1.7-2.3) and 0.5 (95{\%} CI 0.4-0.7). Conclusions: High ED lactate is predictive of subsequent deterioration from sepsis within 72 h, and may be useful in determining disposition, but low lactate is not effective in screening stable patients at risk of deterioration.",
keywords = "Critical care, Emergency department, Intensive care unit, Lactate, Risk-stratification, Sepsis",
author = "Fernando, {Shannon M.} and Barnaby, {Douglas P.} and Herry, {Christophe L.} and Gallagher, {E. John} and Shapiro, {Nathan I.} and Seely, {Andrew J.E.}",
year = "2018",
month = "1",
day = "1",
doi = "10.1016/j.jemermed.2018.01.040",
language = "English (US)",
journal = "Journal of Emergency Medicine",
issn = "0736-4679",
publisher = "Elsevier USA",

}

TY - JOUR

T1 - Helpful Only When Elevated

T2 - Initial Serum Lactate in Stable Emergency Department Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration

AU - Fernando, Shannon M.

AU - Barnaby, Douglas P.

AU - Herry, Christophe L.

AU - Gallagher, E. John

AU - Shapiro, Nathan I.

AU - Seely, Andrew J.E.

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background: Early emergency department (ED) identification of septic patients at risk of deterioration is critical. Lactate is associated with 28-day mortality in admitted patients, but little evidence exists on its use in predicting short-term deterioration. Objective: Our aim was to determine the role of initial serum lactate for prediction of short-term deterioration in stable ED patients with suspected sepsis. Methods: We conducted a prospective cohort study of adult ED sepsis patients. Venous lactate was obtained within 2 h of ED arrival. Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission > 24 h, intubation, vasoactive medications for > 1 h, or noninvasive positive pressure ventilation for > 1 h) within 72 h. Patients meeting any endpoint within 1 h of arrival were excluded. Results: Nine hundred and eighty-five patients were enrolled, of whom 84 (8.5%) met the primary outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97% (95% confidence interval [CI] 94-100%), but a sensitivity of 27% (95% CI 18-37%) for predicting deterioration, with positive and negative likelihood ratios of 10.7 (95% CI 6.3-18.3) and 0.8 (95% CI 0.7-0.9), respectively. A lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67% (95% CI 55-76%) and specificity of 66% (95% CI 63-69%), with corresponding positive and negative likelihood ratios of 2.0 (95% CI 1.7-2.3) and 0.5 (95% CI 0.4-0.7). Conclusions: High ED lactate is predictive of subsequent deterioration from sepsis within 72 h, and may be useful in determining disposition, but low lactate is not effective in screening stable patients at risk of deterioration.

AB - Background: Early emergency department (ED) identification of septic patients at risk of deterioration is critical. Lactate is associated with 28-day mortality in admitted patients, but little evidence exists on its use in predicting short-term deterioration. Objective: Our aim was to determine the role of initial serum lactate for prediction of short-term deterioration in stable ED patients with suspected sepsis. Methods: We conducted a prospective cohort study of adult ED sepsis patients. Venous lactate was obtained within 2 h of ED arrival. Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission > 24 h, intubation, vasoactive medications for > 1 h, or noninvasive positive pressure ventilation for > 1 h) within 72 h. Patients meeting any endpoint within 1 h of arrival were excluded. Results: Nine hundred and eighty-five patients were enrolled, of whom 84 (8.5%) met the primary outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97% (95% confidence interval [CI] 94-100%), but a sensitivity of 27% (95% CI 18-37%) for predicting deterioration, with positive and negative likelihood ratios of 10.7 (95% CI 6.3-18.3) and 0.8 (95% CI 0.7-0.9), respectively. A lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67% (95% CI 55-76%) and specificity of 66% (95% CI 63-69%), with corresponding positive and negative likelihood ratios of 2.0 (95% CI 1.7-2.3) and 0.5 (95% CI 0.4-0.7). Conclusions: High ED lactate is predictive of subsequent deterioration from sepsis within 72 h, and may be useful in determining disposition, but low lactate is not effective in screening stable patients at risk of deterioration.

KW - Critical care

KW - Emergency department

KW - Intensive care unit

KW - Lactate

KW - Risk-stratification

KW - Sepsis

UR - http://www.scopus.com/inward/record.url?scp=85043451514&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85043451514&partnerID=8YFLogxK

U2 - 10.1016/j.jemermed.2018.01.040

DO - 10.1016/j.jemermed.2018.01.040

M3 - Article

C2 - 29548723

AN - SCOPUS:85043451514

JO - Journal of Emergency Medicine

JF - Journal of Emergency Medicine

SN - 0736-4679

ER -