SYSTEMATIC REVIEW SNAPSHOT
TAKE-HOME MESSAGE Patients with a suspected infection in the emergency department (ED) who have intermediate lactate level elevations (2.0 to 3.9 mmol/L) carry a moderate to high risk of mortality, even without hypotension. What Is the Prognostic Value of Intermediate Lactate Level Elevations in Emergency Department Patients With Suspected Infection?
METHODS DATA SOURCES The authors conducted a systematic review with exploded Medical Subject Headings terms and key words involving sepsis, systemic inflammatory response syndrome, lactate, and outcome in a search strategy on 4 databases (MEDLINE, SCOPUS, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature Plus). STUDY SELECTION Two independent reviewers screened the titles and abstracts for eligibility (observational ED studies of adults [>17 years] with diagnosis of systemic inflammatory response syndrome, sepsis, or infectionrelated diagnosis with available lactate and hemodynamic data) and then abstracted study data, using a standardized collection form. DATA ANALYSIS The primary outcome of interest was 28-day mortality, as well as other accepted mortality data (ie, inhospital or 30-day mortality). In the setting of normotension, prognostic significance was reported as rate of progression to either shock or Sequential Organ Failure Assessment score greater than 1, if available. Simple descriptive statistics were used to report mortality rates with accompanying ranges; meta-analysis was not performed.
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no.
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2015
EBEM Commentators
Manpreet Singh, MD Department of Emergency Medicine Harbor-UCLA Medical Center Torrance, CA
Alex Koyfman, MD Department of Emergency Medicine UT Southwestern Medical Center/Parkland Memorial Hospital Dallas, TX
Results Pooled outcome data from prospective and retrospective studies including patients with suspected sepsis or systemic inflammatory response syndrome. Overall Mortality (inhospital, 28-day, or 30-day)
8 studies (N[11,062) 15%
Subgroup analysis* Mortality Progression to shock/SOFA score >1
6 studies (N[10,442) 15% 23% (132/568)
SOFA, Sequential Organ Failure Assessment. *Subgroup of patients with intermediate lactate level (2.0 to 3.9 mmol/L) but without hypotension.
Of the 306 potential publications, 287 were excluded and 20 articles were found to be appropriate for further review. Eight studies (5 prospective, 3 retrospective) for a total 11,062 patients met the final inclusion criteria. The mortality among these cohorts was approximately 15% (inhospital, 28-day, or 30-day mortality) and was essentially unchanged (15%) among patients with intermediate lactate level who did not have hypotension; however, the mortality reported in the individual studies was variable, ranging from 3.2% to 16.4%.
Commentary Lactate is one of the variables used to estimate the severity of disease
and prognosis of ED patients with suspected sepsis. It is a marker of tissue hypoxia and acidosis in anaerobic metabolism, which is the body’s mechanism for keeping up with the associated pathologic Lactate metabolic demands.1 should not be considered a sole product of inadequate blood perfusion, but rather a marker of strained cellular metabolism. Lactate measurement has been demonstrated to provide risk stratification, traditionally grouped into low, intermediate, and high strata with a curvilinear relationship to mortality.2 Patients with lactate levels greater than 4 mmol/L (high) and without hypotension Annals of Emergency Medicine 1
Systematic Review Snapshot
have a mortality rate not significantly different from that of patients requiring vasopressors, and therefore it is recommended that they receive early initiation of resuscitation.3 However, it is unclear whether patients with intermediate lactate results without hypotension warrant similar action. Although meta-analysis could not be performed, this systematic review indicates that for patients with suspected infection and intermediate lactate level elevation,
2 Annals of Emergency Medicine
aggressive monitoring or resuscitation should be considered, especially in light of evidence for improved lactate clearance with early fluid administration.4 Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this systematic review snapshot is: Puskarich MA, Illich BM, Jones AE. Prognosis of emergency department patients with suspected infection and intermediate lactate levels: a systematic review. J Crit Care. 2014;29:334-339.
1. Bakker J, Nijsten MW, Jansen TC. Clinical use of lactate monitoring in critically ill patients. Ann Intensive Care. 2013;3:12. 2. Jansen TC, van Bommel J, Bakker J. Blood lactate monitoring in critically ill patients: a systematic health technology assessment. Crit Care Med. 2009;37:2827-2839. 3. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;(39):165-228. 4. Liu V, Morehouse J, et al. Fluid volume, lactate values, and mortality in sepsis patients with intermediate lactate values. Ann Am Thorac Soc. 2013;10:466-473.
Michael Brown, MD, MSc, and Alan Jones, MD, serve as editors of the SRS series.
Volume
-,
no.
-
:
-
2015
TAKE-HOME MESSAGE Patients with a suspected infection in the emergency department (ED) who have intermediate lactate level elevations (2.0 to 3.9 mmol/L) carry a moderate to high risk of mortality, even without hypotension. What Is the Prognostic Value of Intermediate Lactate Level Elevations in Emergency Department Patients With Suspected Infection?
METHODS DATA SOURCES The authors conducted a systematic review with exploded Medical Subject Headings terms and key words involving sepsis, systemic inflammatory response syndrome, lactate, and outcome in a search strategy on 4 databases (MEDLINE, SCOPUS, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature Plus). STUDY SELECTION Two independent reviewers screened the titles and abstracts for eligibility (observational ED studies of adults [>17 years] with diagnosis of systemic inflammatory response syndrome, sepsis, or infectionrelated diagnosis with available lactate and hemodynamic data) and then abstracted study data, using a standardized collection form. DATA ANALYSIS The primary outcome of interest was 28-day mortality, as well as other accepted mortality data (ie, inhospital or 30-day mortality). In the setting of normotension, prognostic significance was reported as rate of progression to either shock or Sequential Organ Failure Assessment score greater than 1, if available. Simple descriptive statistics were used to report mortality rates with accompanying ranges; meta-analysis was not performed.
Volume
-,
no.
-
:
-
2015
EBEM Commentators
Manpreet Singh, MD Department of Emergency Medicine Harbor-UCLA Medical Center Torrance, CA
Alex Koyfman, MD Department of Emergency Medicine UT Southwestern Medical Center/Parkland Memorial Hospital Dallas, TX
Results Pooled outcome data from prospective and retrospective studies including patients with suspected sepsis or systemic inflammatory response syndrome. Overall Mortality (inhospital, 28-day, or 30-day)
8 studies (N[11,062) 15%
Subgroup analysis* Mortality Progression to shock/SOFA score >1
6 studies (N[10,442) 15% 23% (132/568)
SOFA, Sequential Organ Failure Assessment. *Subgroup of patients with intermediate lactate level (2.0 to 3.9 mmol/L) but without hypotension.
Of the 306 potential publications, 287 were excluded and 20 articles were found to be appropriate for further review. Eight studies (5 prospective, 3 retrospective) for a total 11,062 patients met the final inclusion criteria. The mortality among these cohorts was approximately 15% (inhospital, 28-day, or 30-day mortality) and was essentially unchanged (15%) among patients with intermediate lactate level who did not have hypotension; however, the mortality reported in the individual studies was variable, ranging from 3.2% to 16.4%.
Commentary Lactate is one of the variables used to estimate the severity of disease
and prognosis of ED patients with suspected sepsis. It is a marker of tissue hypoxia and acidosis in anaerobic metabolism, which is the body’s mechanism for keeping up with the associated pathologic Lactate metabolic demands.1 should not be considered a sole product of inadequate blood perfusion, but rather a marker of strained cellular metabolism. Lactate measurement has been demonstrated to provide risk stratification, traditionally grouped into low, intermediate, and high strata with a curvilinear relationship to mortality.2 Patients with lactate levels greater than 4 mmol/L (high) and without hypotension Annals of Emergency Medicine 1
Systematic Review Snapshot
have a mortality rate not significantly different from that of patients requiring vasopressors, and therefore it is recommended that they receive early initiation of resuscitation.3 However, it is unclear whether patients with intermediate lactate results without hypotension warrant similar action. Although meta-analysis could not be performed, this systematic review indicates that for patients with suspected infection and intermediate lactate level elevation,
2 Annals of Emergency Medicine
aggressive monitoring or resuscitation should be considered, especially in light of evidence for improved lactate clearance with early fluid administration.4 Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this systematic review snapshot is: Puskarich MA, Illich BM, Jones AE. Prognosis of emergency department patients with suspected infection and intermediate lactate levels: a systematic review. J Crit Care. 2014;29:334-339.
1. Bakker J, Nijsten MW, Jansen TC. Clinical use of lactate monitoring in critically ill patients. Ann Intensive Care. 2013;3:12. 2. Jansen TC, van Bommel J, Bakker J. Blood lactate monitoring in critically ill patients: a systematic health technology assessment. Crit Care Med. 2009;37:2827-2839. 3. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;(39):165-228. 4. Liu V, Morehouse J, et al. Fluid volume, lactate values, and mortality in sepsis patients with intermediate lactate values. Ann Am Thorac Soc. 2013;10:466-473.
Michael Brown, MD, MSc, and Alan Jones, MD, serve as editors of the SRS series.
Volume
-,
no.
-
:
-
2015
