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Kumar R, Kattimani B, Ojha PR, Khasage UJ. Quick Sequential Organ Failure Assessment Score, Lactate, and Neutrophil-Lymphocyte Ratio Help in Diagnosis and Mortality Prediction during Golden Hour of Sepsis in Emergency Department. J Emerg Trauma Shock 2023; 16:161-166. [PMID: 38292274 PMCID: PMC10824218 DOI: 10.4103/jets.jets_37_23] [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: 04/15/2023] [Revised: 06/21/2023] [Accepted: 07/06/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Sepsis is a life-threatening condition with a very narrow golden period in which confirmatory diagnosis may change the outcome dramatically. No confirmatory biomarker is available till date for early diagnosis of sepsis. This study aimed to evaluate the combined and independent role of quick sequential organ failure assessment (qSOFA) score, lactate, and neutrophil-lymphocyte ratio (NLR) in diagnosis and mortality prediction in early sepsis. Methods This was a hospital-based, single-center, prospective cohort study conducted in a tertiary care institute, Karnataka, India. Three hundred adult sepsis patients were recruited during 10-month period, and demographic data, qSOFA score, lactate, NLR, and culture samples were collected in ED within 1 h of admission. Outcome groups (survivor and nonsurvivor) were statistically analyzed with relative frequencies (%), median, mean ± standard deviation with 95% confidence interval (CI), univariate, bivariate, and multivariate logistic regression analysis, and Receiver -operating characteristic curve (ROC) curve to test the predictive ability of initial levels of three biomarkers. Results Sepsis was more prevalent among middle-aged male patients. Male gender (odds ratio [OR], 6.9; 95% CI: 1.61-30.1), qSOFA (OR, 154; 95% CI: 15-1565), and lactate (OR, 1.36; 95% CI: 22-833) show 97% (area under the curve) predictive accuracy of the model for sepsis on bivariate and multivariate logistic regression analysis. A significant rise in NLR was a poor outcome indicator on univariate analysis (P = 0.773). Conclusion All three biomarkers are good outcome predictors whereas qSOFA and lactate have diagnostic significance in early sepsis. These markers can be used for patient triaging, minimizing culture report dependence for treatment and ultimately the outcome.
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Affiliation(s)
- Rakesh Kumar
- Department of Emergency Medicine, BLDE, Vijayapura, Karnataka, India
| | - Babu Kattimani
- Department of Emergency Medicine, BLDE, Vijayapura, Karnataka, India
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Oi Y, Mori K, Yamagata H, Nogaki A, Takeda T, Watanabe C, Sakaguchi Y, Ogawa F, Abe T, Imaki S, Takeuchi I. Peripheral venous lactate levels substitute arterial lactate levels in the emergency department. Int J Emerg Med 2022; 15:7. [PMID: 35090392 PMCID: PMC8903598 DOI: 10.1186/s12245-022-00410-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 01/06/2022] [Indexed: 12/02/2022] Open
Abstract
Background Arterial lactate (AL) level is an important predictor of patient prognosis. AL and peripheral venous lactate (PVL) in blood gas analysis have a low concordance rate, and PVL cannot be used as a substitute for AL. However, if the AL range can be predicted from PVL, PVL may be an alternative method for predicting patient prognosis, and the risk of arterial puncture complications with AL may be reduced. This could be a safe and rapid test method. Methods This was a retrospective observational study of 125 cases in which blood gas analysis was performed on both arterial and venous blood with an infectious disease in an emergency department. Spearman’s rank correlation coefficient (r) and Bland–Altman analyses were performed. Sensitivity, specificity, and area under the curve (AUC) were calculated for PVL to predict AL < 2 mmol/L or < 4 mmol/L. Results The median [interquartile range] AL and PVL were 1.82 [1.25–2.46] vs. 2.08 [1.57–3.28], respectively, r was 0.93 (p < 0.0001), and a strong correlation was observed; however, Bland–Altman analysis showed disagreement. When AL < 2 mmol/L was used as the outcome, AUC was 0.970, the PVL cutoff value was 2.55 mmol/L, sensitivity was 85.71%, and specificity was 96.05%. If PVL < 2 mmol/L was the outcome, the sensitivity for AL < 2mmol/L was 100%, and for PVL levels ≥ 3 mmol/L, the specificity was 100%. When AL < 4 mmol/L was used as the outcome, AUC was 0.967, the PVL cutoff value was 3.4 mmol/L, sensitivity was 100%, and specificity was 85.84%. When PVL < 3.5 mmol/L was the outcome, the sensitivity for AL < 4 mmol/L was 100%, and for PVL levels ≥ 4 mmol/L, the specificity was 93.81%. Conclusions This study revealed that PVL and AL levels in the same critically ill patients did not perfectly agree with each other but were strongly correlated. Furthermore, the high accuracy for predicting AL ranges from PVL levels explains why PVL levels could be used as a substitute for AL level ranges. Supplementary Information The online version contains supplementary material available at 10.1186/s12245-022-00410-y.
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Affiliation(s)
- Yasufumi Oi
- Emergency Care Department, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan. .,Emergency and Critical Care Medical Center, Yokohama Municipal Citizen's Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan. .,Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
| | - Kosuke Mori
- Emergency and Critical Care Medical Center, Yokohama Municipal Citizen's Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Hidehiro Yamagata
- Emergency and Critical Care Medical Center, Yokohama Municipal Citizen's Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Ayako Nogaki
- Emergency and Critical Care Medical Center, Yokohama Municipal Citizen's Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Tomoaki Takeda
- Emergency and Critical Care Medical Center, Yokohama Municipal Citizen's Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Chikara Watanabe
- Emergency and Critical Care Medical Center, Yokohama Municipal Citizen's Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Yusuke Sakaguchi
- Emergency and Critical Care Medical Center, Yokohama Municipal Citizen's Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Fumihiro Ogawa
- Emergency Care Department, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Takeru Abe
- Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Shouhei Imaki
- Emergency and Critical Care Medical Center, Yokohama Municipal Citizen's Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Ichiro Takeuchi
- Emergency Care Department, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Department of Emergency Medicine, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
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Qu Z, Zhu Y, Wang M, Li W, Zhu B, Jiang L, Xi X. Prognosis and Risk Factors of Sepsis Patients in Chinese ICUs: A Retrospective Analysis of a Cohort Database. Shock 2021; 56:921-926. [PMID: 33843790 PMCID: PMC8579969 DOI: 10.1097/shk.0000000000001784] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/16/2021] [Accepted: 03/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sepsis-3 proposed a new definition of septic shock that excluded patients without hyperlactacidemia. The data from China might help to elucidate the prognosis of this special patient group. OBJECTIVE To study the clinical prognosis and factors affecting patients with sepsis based on data from Chinese intensive care units (ICUs). METHODS We conducted a retrospective, multicentre observational study in a larger Chinese cohort from January 1, 2014 to August 31, 2015. The patients were divided into four groups according to the presence or absence of hypotension/vasopressor delivery and hyperlactacidemia after fluid resuscitation. Descriptive statistics for the clinical characteristics were presented. The differences between groups were assessed. A survival curve was then plotted using the Kaplan-Meier method. Finally, to better understand the risk factors for the 28-day hospital mortality rates, Cox regression analysis was performed. RESULTS In total, 1,194 patients with sepsis were included: 282 with hypotension and hyperlactacidemia, 250 with hypotension but without hyperlactacidemia, 161 with hyperlactacidemia but without hypotension, and 501 without hypotension and hyperlactacidemia. The 28-day mortality rates of the four groups were 48.2%, 43.2%, 26.1%, and 24.8%, respectively. Age, the Acute Physiology And Chronic Health Evaluation (APACHE) II score, hyperlactacidemia, hypotension, intra-abdominal infection, and cancer increased the risk of the 28-day mortality, while soft tissue infection and coming from the operating room were associated with a decreased risk of mortality. CONCLUSIONS Patients with hypotension but without hyperlactacidemia in the ICU also show a high 28-day mortality, and some clinical factors may affect their prognosis and must be treated carefully in the future.
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Affiliation(s)
- Zeyu Qu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Yibing Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Xicheng District, Beijing, China
- Department of Statistics, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meiping Wang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Xicheng District, Beijing, China
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Fengtai District, Beijing, China
| | - Wen Li
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Bo Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Li Jiang
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Xicheng District, Beijing, China
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China
| | - Xiuming Xi
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Xicheng District, Beijing, China
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4
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Utility of the Lactate/Albumin Ratio as a Predictor for Mortality in Necrotizing Fasciitis Patients. Emerg Med Int 2021; 2021:3530298. [PMID: 34691782 PMCID: PMC8528631 DOI: 10.1155/2021/3530298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/07/2021] [Indexed: 12/14/2022] Open
Abstract
Background The lactate/albumin (L/A) ratio has been proposed as a prognostic marker because the ratio is associated with multiple organ failure and mortality in critically ill patients. We aimed to investigate the clinical utility of the L/A ratio as a good prognostic indicator of mortality in a cohort of necrotizing fasciitis patients. Method This retrospective study was conducted in two tertiary hospitals in Taiwan between 2015 and 2020. We reviewed adult patients with measured serum lactate and albumin on the emergency department (ED) arrival to evaluate the prognostic performance of the lactate and lactate/albumin (L/A) ratio for outcome prediction. Result Of the 262 NF patients, 20 (7.63%) died in the hospital. The area under the receiver operating characteristic curve (AUROC) value of the L/A ratio (0.76, 95% confidence interval [CI] 0.69–0.81, P < 0.01) was higher than lactate alone (0.71, 95% CI 0.65–0.74 P < 0.01) for predicting in-hospital mortality. The optimal cutoff of the L/A ratio was 1.61. The AUROC value of the L/A ratio was better than lactate alone regardless of normal lactate level. The cutoff of L/A ratio and hypoalbuminemia showed further discriminative value for in-hospital mortality even in patients with normal lactate levels. Conclusion The prognostic performance of the L/A ratio was superior to a single measurement of lactate for predicting in-hospital mortality and intensive care unit (ICU) lengths in necrotizing fasciitis patients. Aggressive intervention and intensive care were necessary for high-risk NF patients upon ED arrival.
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5
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Hu H, Li L, Zhang Y, Sha T, Huang Q, Guo X, An S, Chen Z, Zeng Z. A Prediction Model for Assessing Prognosis in Critically Ill Patients with Sepsis-associated Acute Kidney Injury. Shock 2021; 56:564-572. [PMID: 33847475 DOI: 10.1097/shk.0000000000001768] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sepsis-associated acute kidney injury (SA-AKI) is a common problem in critically ill patients and is associated with high morbidity and mortality. Early prediction of the survival of hospitalized patients with SA-AKI is necessary, but a reliable and valid prediction model is still lacking. METHODS We conducted a retrospective cohort analysis based on a training cohort of 2,066 patients enrolled from the Multiparameter Intelligent Monitoring in Intensive Care Database III (MIMIC III) and a validation cohort of 102 patients treated at Nanfang Hospital of Southern Medical University. Least absolute shrinkage and selection operator (LASSO) regression and multivariate Cox regression analysis were used to identify predictors for survival. Areas under the ROC curves (AUC), the concordance index (C-index), and calibration curves were used to evaluate the efficiency of the prediction model (SAKI) in both cohorts. RESULTS The overall mortality of SA-AKI was approximately 18%. Age, admission type, liver disease, metastatic cancer, lactate, BUN/SCr, admission creatinine, positive culture, and AKI stage were independently associated with survival and combined in the SAKI model. The C-index in the training and validation cohorts was 0.73 and 0.72. The AUC in the training cohort was 0.77, 0.72, and 0.70 for the 7-day, 14-day, and 28-day probability of in-hospital survival, respectively, while in the external validation cohort, it was 0.83, 0.73, and 0.67. SAPSII and SOFA scores showed poorer performance. Calibration curves demonstrated a good consistency. CONCLUSIONS Our SAKI model has predictive value for in-hospital mortality of SA-AKI in critically ill patients and outperforms generic scores.
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Affiliation(s)
- Hongbin Hu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lulan Li
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuan Zhang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tong Sha
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiaobing Huang
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Shock and Microcirculation, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Xiaohua Guo
- Department of Pathophysiology, Guangdong Provincial Key Laboratory of Shock and Microcirculation, School of Basic Medical Sciences, Southern Medical University, Guangzhou, China
| | - Shengli An
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Weinberger J, Klompas M, Rhee C. What Is the Utility of Measuring Lactate Levels in Patients with Sepsis and Septic Shock? Semin Respir Crit Care Med 2021; 42:650-661. [PMID: 34544182 DOI: 10.1055/s-0041-1733915] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Elevations in blood lactate concentrations have been studied in sepsis and other disease states for decades and are well known to be associated with increased mortality. Many studies have also demonstrated the prognostic accuracy of serial lactate levels, and some have suggested that lactate clearance may be a useful therapeutic target for resuscitation. Lactate measurements have therefore gained an increasingly prominent role in sepsis definitions, screening protocols, management guidelines, and quality measures over the past two decades. The heavy emphasis on lactate monitoring, however, has also generated controversy and concerns. Lactate is not specific to infection and its frequent use for sepsis screening and diagnosis may therefore trigger unnecessary broad-spectrum antibiotic use in some patients. Because hyperlactatemia does not always reflect fluid-responsive hypoperfusion, titrating resuscitation to lactate clearance can also lead to unnecessary fluid and volume overload. More broadly, there is a lack of high-quality evidence demonstrating that initial and serial lactate monitoring leads to better patient-centered outcomes. Indeed, a recent randomized controlled trial comparing resuscitation strategies based on lactate clearance versus normalizing capillary refill time showed no benefit and potential harm with lactate-guided therapy. In this article, we review the basic pathobiology of lactate metabolism and delineate why the traditional paradigm that hyperlactatemia reflects tissue hypoxia is overly simplistic and incomplete. We then review the evidence behind the diagnostic, prognostic, and therapeutic uses of lactate monitoring and place this in the context of evolving sepsis diagnosis and management guidelines.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Yoo MS, Zhu S, Lu Y, Greene JD, Hammer HL, Iberti CT, Nemazie S, Ananias MP, McCarthy CM, O’Malley RM, Young KL, Reed KO, Martinez RA, Cheung K, Liu VX. Association of Positive Fluid Balance at Discharge After Sepsis Management With 30-Day Readmission. JAMA Netw Open 2021; 4:e216105. [PMID: 34086036 PMCID: PMC8178709 DOI: 10.1001/jamanetworkopen.2021.6105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Although early fluid administration has been shown to lower sepsis mortality, positive fluid balance has been associated with adverse outcomes. Little is known about associations in non-intensive care unit settings, with growing concern about readmission from excess fluid accumulation in patients with sepsis. OBJECTIVE To evaluate whether positive fluid balance among non-critically ill patients with sepsis was associated with increased readmission risk, including readmission for heart failure. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study was conducted between January 1, 2012, and December 31, 2017, among 57 032 non-critically ill adults hospitalized for sepsis at 21 hospitals across Northern California. Kaiser Permanente Northern California is an integrated health care system with a community-based population of more than 4.4 million members. Statistical analysis was performed from January 1 to December 31, 2019. EXPOSURES Intake and output net fluid balance (I/O) measured daily and cumulatively at discharge (positive vs negative). MAIN OUTCOMES AND MEASURES The primary outcome was 30-day readmission. The secondary outcomes were readmission stratified by category and mortality after living discharge. RESULTS The cohort included 57 032 patients who were hospitalized for sepsis (28 779 women [50.5%]; mean [SD] age, 73.7 [15.5] years). Compared with patients with positive I/O (40 940 [71.8%]), those with negative I/O (16 092 [28.2%]) were older, with increased comorbidity, acute illness severity, preexisting heart failure or chronic kidney disease, diuretic use, and decreased fluid administration volume. During 30-day follow-up, 8719 patients (15.3%) were readmitted and 3639 patients (6.4%) died. There was no difference in readmission between patients with positive vs negative I/O (HR, 1.00; 95% CI, 0.95-1.05). No association was detected between readmission and I/O using continuous, splined, and quadratic function transformations. Positive I/O was associated with decreased heart failure-related readmission (HR, 0.80 [95% CI, 0.71-0.91]) and increased 30-day mortality (HR, 1.23 [95% CI, 1.15-1.31]). CONCLUSIONS AND RELEVANCE In this large observational study of non-critically ill patients hospitalized with sepsis, there was no association between positive fluid balance at the time of discharge and readmission. However, these findings may have been limited by variable recording and documentation of fluid intake and output; additional studies are needed to examine the association of fluid status with outcomes in patients with sepsis to reduce readmission risk.
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Affiliation(s)
- Michael S. Yoo
- The Permanente Medical Group, Oakland, California
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Shiyun Zhu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Yun Lu
- Division of Research, Kaiser Permanente, Oakland, California
| | - John D. Greene
- Division of Research, Kaiser Permanente, Oakland, California
| | - Helen L. Hammer
- The Permanente Medical Group, Oakland, California
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Colin T. Iberti
- The Permanente Medical Group, Oakland, California
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Siamack Nemazie
- The Permanente Medical Group, Oakland, California
- Department of Nephrology, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Martin P. Ananias
- The Permanente Medical Group, Oakland, California
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Caitlin M. McCarthy
- The Permanente Medical Group, Oakland, California
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Robert M. O’Malley
- The Permanente Medical Group, Oakland, California
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Karlyn L. Young
- The Permanente Medical Group, Oakland, California
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Karolin O. Reed
- The Permanente Medical Group, Oakland, California
- Department of Hospital Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Robert A. Martinez
- The Permanente Medical Group, Oakland, California
- Department of Adult and Family Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Kawai Cheung
- The Permanente Medical Group, Oakland, California
- Department of Adult and Family Medicine, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Vincent X. Liu
- The Permanente Medical Group, Oakland, California
- Division of Research, Kaiser Permanente, Oakland, California
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Wu PH, Wu KH, Hsiao CT, Wu SR, Chang CP. Utility of modified Laboratory Risk Indicator for Necrotizing Fasciitis (MLRINEC) score in distinguishing necrotizing from non-necrotizing soft tissue infections. World J Emerg Surg 2021; 16:26. [PMID: 34039397 PMCID: PMC8157441 DOI: 10.1186/s13017-021-00373-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background We conducted this study to promote a modified Laboratory Risk Indicator for Necrotizing Fasciitis (MLRINEC) score and evaluate the utility in distinguishing necrotizing fasciitis (NF) from other soft-tissue infections. Method A retrospective cohort study of hospitalized patients with NF diagnosed by surgical finding was conducted in two tertiary hospital in southern Taiwan between January 2015 and January 2020. Another group was matched by controls with non-necrotizing soft tissue infections based on time, demographics, and immune status. Data such as infectious location, comorbidities, and laboratory findings were recorded and compared. Logistics regression were used to determine the association with NF after adjustment for confounders and MLRINEC score was developed by then. Receiver operating curve (ROC) and the area under the curve (AUC) were used to evaluate its discriminating ability. Result A total of 303 patients were included; 101 in NF group and 202 in non-NF group. We added serum lactate and comorbid liver disease to the original LRINEC score and re-defined the cut-off values for 3 variables to develop the MLRINEC score. The cut-off value for MLRINEC score was 12 points with corresponding sensitivity of 91.8% and a specificity of 88.4%, and the area under ROC (AUC) was 0.893 (95% CI, 0.723 to 0.948; p < 0.01). Conclusion MLRINEC score shows a high sensitivity and specificity in distinguishing NF from non-necrotizing soft-tissue infections. Patients with a MLRINEC score > 12 points should be highly suspected of presence of necrotizing fasciitis.
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Affiliation(s)
- Po-Han Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan (R.O.C.)
| | - Kai-Hsiang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan (R.O.C.)
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan (R.O.C.).,Department of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shu-Ruei Wu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan (R.O.C.).
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9
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Shimazui T, Nakada TA, Walley KR, Oshima T, Abe T, Ogura H, Shiraishi A, Kushimoto S, Saitoh D, Fujishima S, Mayumi T, Shiino Y, Tarui T, Hifumi T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Takuma K, Tsuruta R, Hagiwara A, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Fujimi S, Gando S. Significance of body temperature in elderly patients with sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:387. [PMID: 32605659 PMCID: PMC7329464 DOI: 10.1186/s13054-020-02976-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/12/2020] [Indexed: 01/05/2023]
Abstract
Background Elderly patients have a blunted host response, which may influence vital signs and clinical outcomes of sepsis. This study was aimed to investigate whether the associations between the vital signs and mortality are different in elderly and non-elderly patients with sepsis. Methods This was a retrospective observational study. A Japanese multicenter sepsis cohort (FORECAST, n = 1148) was used for the discovery analyses. Significant discovery results were tested for replication using two validation cohorts of sepsis (JAAMSR, Japan, n = 624; SPH, Canada, n = 1004). Patients were categorized into elderly and non-elderly groups (age ≥ 75 or < 75 years). We tested for association between vital signs (body temperature [BT], heart rate, mean arterial pressure, systolic blood pressure, and respiratory rate) and 90-day in-hospital mortality (primary outcome). Results In the discovery cohort, non-elderly patients with BT < 36.0 °C had significantly increased 90-day mortality (P = 0.025, adjusted hazard ratio 1.70, 95% CI 1.07–2.71). In the validation cohorts, non-elderly patients with BT < 36.0 °C had significantly increased mortality (JAAMSR, P = 0.0024, adjusted hazard ratio 2.05, 95% CI 1.29–3.26; SPH, P = 0.029, adjusted hazard ratio 1.36, 95% CI 1.03–1.80). These differences were not observed in elderly patients in the three cohorts. Associations between the other four vital signs and mortality were not different in elderly and non-elderly patients. The interaction of age and hypothermia/fever was significant (P < 0.05). Conclusions In septic patients, we found mortality in non-elderly sepsis patients was increased with hypothermia and decreased with fever. However, mortality in elderly patients was not associated with BT. These results illuminate the difference in the inflammatory response of the elderly compared to non-elderly sepsis patients.
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Affiliation(s)
- Takashi Shimazui
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan.
| | - Keith R Walley
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada
| | - Taku Oshima
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Acute and Critical Care Center, Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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10
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Edward U, Sawe HR, Mfinanga JA, Ottaru TA, Kiremeji M, Kitapondya DN, Kaale DA, Iyullu A, Bret N, Weber EJ. The utility of point of care serum lactate in predicting serious adverse outcomes among critically ill adult patients at urban emergency departments of tertiary hospitals in Tanzania. Trop Med Health 2019; 47:61. [PMID: 31889889 PMCID: PMC6935137 DOI: 10.1186/s41182-019-0186-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/21/2019] [Indexed: 12/27/2022] Open
Abstract
Background Elevated serum lactate levels have been shown in numerous studies to be associated with serious adverse events, including mortality. Point of care lactate level is increasingly available in resource-limited emergency department (ED) settings. However, little is known about the predictive ability of for serious adverse events. Aim of the study We aimed to describe the utility of serum lactate level as a predictor of 24-h serious adverse events among adult patients presenting at the Emergency Medicine Department (EMD) of Muhimbili National Hospital (MNH) and MUHAS Academic Medical Center (MAMC). Methods This was a prospective observational study involving adult patients presenting to the EMD-MNH and MAMC from 1 September 2018 and 31 October 2018. Eligible patients with at least one lactate level test drawn while in the ED were examined in terms of their demographics, relevant clinical characteristics, and any serious adverse event (SAE) within 24 h of arrival. The sensitivity and specificity of lactate level to predict outcomes of interest were determined using the best cut-off point constructed from AUROC to see how well lactate level could discriminate which patients would have adverse events in the next 24 h. Categorical and continuous variables were compared with the chi-square test and two-sample t test, respectively. Results We screened 2057 (20.9%) out of 9828 patients who presented during study period, and enrolled 387 (18.8%). The overall median age was 54 years (interquartile range 40–68 years) and 206 (53.2%) were male. Using local triaging system, a total of 322 (83.2%) was triaged as an emergency category. The mean lactate level was 3.2 ± 3.6 mmol/L, 65 (16.8%) patients developed at least one SAE, with 42 (11%) who required ICU/HDU, 37 (10%) needed ventilator support, 10 (3%) required inotropes, and 9 (2%) developed cardiac arrest. The overall 24-h mortality was 28 (7%). The AUC of serum lactate level for overall 24-h mortality was 0.801 (95%CI, 0.7–0.9, P ≤ 0.001). At the optimal cutoff value (3.8 mmol/L), lactate level had a sensitivity and specificity for 24-h mortality of 64% and 85%, respectively. Mortality of the high-lactate level group (33.8 mmol/L) was significantly higher than that of the low-lactate level group (< 3.8 mmol/L), 23.8% vs. 2.9%, respectively (95%CI 3.8–17.2, p < 0.001), with the relative risk of mortality in the high-lactate level group being 8.1 times higher compared to the low-lactate level group. Conclusion The utility of lactate level in predicting mortality was similar to that seen in high-resource settings. A serum lactate level of 33.8 mmol/L predicted 24-h serious adverse events in unselected patients seen in the high-acuity area of our ED. Incorporating serum lactate level in ED in lower- and middle-income countries (LMICs) can help identify patients at risk of developing serious adverse events.
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Affiliation(s)
- Uwezo Edward
- 1Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Hendry R Sawe
- 1Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania.,2Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Juma A Mfinanga
- 1Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania.,2Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Theresia A Ottaru
- 3Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Michael Kiremeji
- 1Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Deus N Kitapondya
- 1Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Dereck A Kaale
- 1Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Asha Iyullu
- 1Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Nicks Bret
- 4Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Ellen J Weber
- 5Department of Emergency Medicine, University of California, San Francisco, CA USA
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11
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Chang CP, Fann WC, Wu SR, Lin CN, Hsiao CT. Lactate on emergency department arrival as a predictor of in-hospital mortality in necrotizing fasciitis: a retrospective study. J Orthop Surg Res 2019; 14:73. [PMID: 30841912 PMCID: PMC6402084 DOI: 10.1186/s13018-019-1108-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 02/21/2019] [Indexed: 01/01/2023] Open
Abstract
Background Hyperlactatemia is known to be associated with adverse outcome in critical illness. In this study, we attempted to identify if hyperlactatemia on emergency department (ED) arrival is a reliable predictor for in-hospital mortality in necrotizing fasciitis (NF) patients. Method A prospective cohort study of hospitalized patients with NF was conducted in two tertiary teaching hospitals in Taiwan between March 2010 and March 2018. Blood samples were collected in the ED upon arrival, and the lactate levels were determined. Sequential organ failure assessment (SOFA) scores were calculated during the first 24 h after admission. All collected data were statistically analyzed. Result Of the 707 NF patients, 40 (5.66%) died in the hospital. The median (interquartile range) blood lactate level in all NF patients was 3.6 mmol/l (2.2–4.8). The blood lactate level upon ED arrival was significantly associated with mortality (odds ratio [OR] = 1.35; 95% confidence interval [CI], 1.30–1.46; P < 0.001), even after adjustment for age and SOFA score (OR = 1.27; P < 0.001). Multivariate regression analysis showed that a high blood lactate level (OR = 1.17; 95% CI, 1.07–1.29; P = 0.001) and a high SOFA score (OR = 1.15; 95% CI, 1.11–1.20; P < 0.001) were independent risk factors for in-hospital mortality in NF. Blood lactate achieved an area under-the-receiver-operating-characteristic curve (AUC) of 0.79 (P < 0.001) for predicting mortality that was similar to that of SOFA score (AUC = 0.82; P < 0.001). Blood lactate displayed a sensitivity of 62% and a specificity of 86% in predicting mortality at the optimal cutoff value of 5.80 mmol/l. Conclusion In necrotizing fasciitis patients, hyperlactatemia on ED arrival is independently associated with in-hospital mortality. NF patients with hyperlactatemia on ED arrival should be closely monitored for signs of deterioration and consider early and aggressive intervention to prevent mortality.
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Affiliation(s)
- Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan, Republic of China
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan, Republic of China.,Department of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shu-Ruei Wu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chun-Nan Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan, Republic of China
| | - Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan, Republic of China. .,Department of Medicine, Chang Gung University, Taoyuan, Taiwan.
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12
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Ramya I, Mitra S, D'Sa S, Sathyendra S, Zachariah A, Kumar CV, Carey RAB, Verghese GM. Outcomes and factors influencing outcomes of critically ill HIV-positive patients in a tertiary care center in South India. J Family Med Prim Care 2019; 8:97-101. [PMID: 30911487 PMCID: PMC6396590 DOI: 10.4103/jfmpc.jfmpc_156_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The incidence of (Human immune deficiency) HIV in India has fallen by 58% since the onset of the HIV epidemic. As of 2016 there are 2.1 million people living in India with HIV and only 49% of the adults with HIV are on ART (1). The HIV infected individuals may require intensive care due to various reasons. This study attempts to look at the outcomes of these patients admitted in the intensive care unit and the predictors of these outcomes.
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Affiliation(s)
- I Ramya
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shubankar Mitra
- Department of Accident and Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shilpa D'Sa
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sowmya Sathyendra
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anand Zachariah
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - C Vignesh Kumar
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - George M Verghese
- Department of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India
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13
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Abstract
BACKGROUND In septic patients, it is uncertain whether isolated hyperlactatemia (lactate ≥4 mmol/L without refractory hypotension) can be used to diagnose septic shock and whether mortality rate differs from that of isolated refractory hypotension (refractory to 1000 mL or greater fluid bolus). AIMS To compare baseline characteristics, treatments, and outcomes of participants enrolled into the Australian Resuscitation in Sepsis Evaluation (ARISE) trial according to the presence of isolated hyperlactatemia or isolated refractory hypotension. PATIENTS Cohort of 1,332 ARISE participants with sepsis and either isolated hyperlactatemia or isolated refractory hypotension. METHODS We performed a secondary analysis of the ARISE data, constructing a propensity score model to discriminate between hyperlactatemia and isolated refractory hypotension. We analyzed 90-day all-cause mortality using a generalized linear model and inverse propensity score weighting. We modeled length of intensive care unit (ICU) and hospital stay using time to event analyses incorporating mortality as a competing risk. RESULTS There were 478 participants (35.9%) with isolated hyperlactatemia and 854 (64.1%) with isolated refractory hypotension. They had similar median (interquartile range) ages (66.2 [54.2, 76.3] years vs. 65.2 [50.9, 75.5] years) and similar sources of infection. However, isolated hyperlactatemia participants had higher mean (standard deviation) baseline APACHE II scores (isolated hyperlactatemia 16.2 [6.4]) vs. 14.5 [6.4] for isolated refractory hypotension; P < 0.001). Isolated hyperlactatemia participants had a 1.7 times higher risk of 90-day mortality (propensity-weighted risk ratio; 95% confidence intervals [CI] 1.2, 2.5, P = 0.003). They were less likely to be discharged alive from ICU and hospital (propensity weighted sub-hazard ratio 0.77 (95% CI 0.64, 0.92; P < 0.005) and 0.79 (95% CI 0.66, 0.95; P = 0.01), respectively). CONCLUSIONS ARISE trial participants with isolated hyperlactatemia had worse adjusted 90-day mortality than those with isolated refractory hypotension. In septic patients, isolated hyperlactatemia may define greater illness severity and worse outcomes than isolated refractory hypotension.
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14
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Swenson KE, Dziura JD, Aydin A, Reynolds J, Wira CR. Evaluation of a novel 5-group classification system of sepsis by vasopressor use and initial serum lactate in the emergency department. Intern Emerg Med 2018; 13:257-268. [PMID: 28132131 DOI: 10.1007/s11739-017-1607-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 01/07/2017] [Indexed: 01/13/2023]
Abstract
Prognostication in sepsis is limited by disease heterogeneity, and measures to risk-stratify patients in the proximal phases of care lack simplicity and accuracy. Hyperlactatemia and vasopressor dependence are easily identifiable risk factors for poor outcomes. This study compares incidence and hospital outcomes in sepsis based on initial serum lactate level and vasopressor use in the emergency department (ED). In a retrospective analysis of a prospectively identified dual-center ED registry, patients with sepsis were categorized by ED vasopressor use and initial serum lactate level. Vasopressor-dependent patients were categorized as dysoxic shock (lactate >4.0 mmol/L) and vasoplegic shock (≤4.0 mmol/L). Patients not requiring vasopressors were categorized as cryptic shock major (lactate >4.0 mmol/L), cryptic shock minor (>2.0 and ≤4.0 mmol/L), and sepsis without lactate elevation (≤2.0 mmol/L). Of 446 patients included, 4.9% (n = 22) presented in dysoxic shock, 11.7% (n = 52) in vasoplegic shock, 12.1% (n = 54) in cryptic shock major, 30.9% (n = 138) in cryptic shock minor, and 40.4% (n = 180) in sepsis without lactate elevation. Group mortality rates at 28 days were 50.0, 21.1, 18.5, 12.3, and 7.2%, respectively. After adjusting for potential confounders, odds ratios for mortality at 28 days were 15.1 for dysoxic shock, 3.6 for vasoplegic shock, 3.8 for cryptic shock major, and 1.9 for cryptic shock minor, when compared to sepsis without lactate elevation. Lactate elevation is associated with increased mortality in both vasopressor dependent and normotensive infected patients presenting to the emergency department (ED). Cryptic shock mortality (normotension + lactate >4 mmol/L) is equivalent to vasoplegic shock mortality (vasopressor requirement + lactate <4 mmol/L) in our population. The odds of normotensive, infected patients decompensating is three to fourfold higher with hyperlactemia. The proposed Sepsis-3 definitions exclude an entire group of high-risk ED patients. A simple classification in the ED by vasopressor requirement and initial lactate level may identify high-risk subgroups of sepsis. This study may inform prognostication and triage decisions in the proximal phases of care.
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Affiliation(s)
- Kai E Swenson
- Department of Internal Medicine, Stanford School of Medicine, Stanford, USA
| | | | - Ani Aydin
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Suite 260, New Haven, USA
| | | | - Charles R Wira
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave., Suite 260, New Haven, USA.
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15
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Zaccone V, Tosoni A, Passaro G, Vallone CV, Impagnatiello M, Li Puma DD, De Cosmo S, Landolfi R, Mirijello A. Sepsis in Internal Medicine wards: current knowledge, uncertainties and new approaches for management optimization. Ann Med 2017; 49:582-592. [PMID: 28521523 DOI: 10.1080/07853890.2017.1332776] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Sepsis represents a global health problem in terms of morbidity, mortality, social and economic costs. Although usually managed in Intensive Care Units, sepsis showed an increased prevalence among Internal Medicine wards in the last decade. This is substantially due to the ageing of population and to multi-morbidity. These characteristics represent both a risk factor for sepsis and a relative contra-indication for the admission to Intensive Care Units. Although there is a lack of literature on the management of sepsis in Internal Medicine, the outcome of these patients seems to be gradually improving. This is due to Internists' increased adherence to guidelines and "bundles". The routine use of SOFA score helps physicians in the definition of septic patients, even if the optimal score has still to come. Point-of-care ultrasonography, lactates, procalcitonin and beta-d-glucan are of help for treatment optimization. The purpose of this narrative review is to focus on the management of sepsis in Internal Medicine departments, particularly on crucial concepts regarding diagnosis, risk assessment and treatment. Key Messages Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The prevalence of sepsis is constantly increasing, affecting more hospital patients than any other disease. At least half of patients affected by sepsis are admitted to Internal Medicine wards. Adherence to guidelines, routine use of clinical and lab scores and point-of-care ultrasonography are of help for early recognition of septic patients and treatment optimization.
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Affiliation(s)
- Vincenzo Zaccone
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | - Alberto Tosoni
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | - Giovanna Passaro
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | - Carla Vincenza Vallone
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | - Michele Impagnatiello
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | | | - Salvatore De Cosmo
- c Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza Hospital , San Giovanni Rotondo , Italy
| | - Raffaele Landolfi
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy
| | - Antonio Mirijello
- a Department of Medical Sciences , Gemelli Hospital, Catholic University of Rome , Rome , Italy.,c Department of Medical Sciences , IRCCS Casa Sollievo della Sofferenza Hospital , San Giovanni Rotondo , Italy
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16
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Moran JL, Santamaria J. Reconsidering lactate as a sepsis risk biomarker. PLoS One 2017; 12:e0185320. [PMID: 28972976 PMCID: PMC5626033 DOI: 10.1371/journal.pone.0185320] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 09/11/2017] [Indexed: 01/16/2023] Open
Abstract
Objectives There has been renewed interest in lactate as a risk biomarker in sepsis and septic shock. However, the ability of the odds ratio (OR) and change in the area under the receiver operator characteristic curve (AUC-ROC) to assess biomarker added-value has been questioned. Design, setting and participants A sepsis cohort was identified from the ICU database of an Australian tertiary referral hospital using APACHE III diagnostic codes. Demographic information, APACHE III scores, 24-hour post-admission patient lactate levels, and hospital mortality were accessed. Measurements and main results Hospital mortality was modelled using a base predictive logistic regression model and sequential addition of admission lactate, lactate clearance ([lactateadmission—lactatefinal]/lactateadmission), and area under the lactate-time curve (LTC). Added-value was assessed using lactate index OR; AUC-ROC difference (base-model versus lactate index addition); net (mortality) reclassification index (NRI; range -2 to +2); and net benefit (NB), the number of true positives per patient adjusted for the number of false positives. The data set comprised 717 patients with mean(SD) age and APACHE III score 61.1(16.5) years and 68.3(28.2) respectively; 59.2% were male. Admission lactate was 2.3(2.5) mmol/l; with lactate of ≥ 4 mmol/L (37% hospital mortality) in 17% and patients with lactate < 4 mmol/L having 18% hospital mortality. The admission base-model had an AUC-ROC = 0.81 with admission lactate OR = 1.127 (95%CI: 1.038, 1.224), AUC-ROC difference of 0.0032 (-0.0037, 0.01615; P = 0.61), and NRI 0.240(0.030, 0.464). The over-time model had an AUC-ROC = 0.86 with (i) clearance OR = 0.771, 95%CI: 0.578, 1.030; P = 0.08; AUC-ROC difference 0.001 (-0.003, 0.014; P = 0.78), and NRI 0.109(-0.193, 0.425) and (ii) LTC OR = 0.997, 95%CI: 0.989, 1.005, P = 0.49; AUC-ROC difference 0.004 (-0.002, 0.004; P = 0.34), and NRI 0.111(-0.222, 0.403). NB was not incremented by any lactate index. Conclusions Lactate added-value assessment is dependent upon the performance of the underlying predictive model and should incorporate risk reclassification and net benefit measures.
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Affiliation(s)
- John L. Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- * E-mail:
| | - John Santamaria
- Department of Critical Care Medicine, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
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17
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Nielsen ND, Martin-Loeches I, Wentowski C. The Effects of red Blood Cell Transfusion on Tissue Oxygenation and the Microcirculation in the Intensive Care Unit: A Systematic Review. Transfus Med Rev 2017; 31:205-222. [PMID: 28800876 DOI: 10.1016/j.tmrv.2017.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/12/2017] [Accepted: 07/11/2017] [Indexed: 01/15/2023]
Abstract
The transfusion of red blood cells (RBCs) is a common intervention in intensive care unit (ICU) patients, yet the benefits are far from clear in patients with moderate anemia (eg, hemoglobin (Hb) levels of 7-10 g/dL). Determining which of these patients benefit, and how to even define benefit, from transfusion is challenging. As the intended physiological benefit underpinning RBC transfusion is to improve tissue oxygenation, several studies utilizing a wide range of assessment techniques have attempted to study the effects of transfusion on tissue oxygenation and microcirculatory function. The objective of this systematic review was to determine whether RBC transfusion improves tissue oxygenation/microcirculatory indices in the ICU population, and to provide an introduction to the techniques used in these studies. Eligible studies published between January 1996 and February 2017 were identified from searches of PubMed, Embase, Cinahl, ScienceDirect, Web of Science, and The Cochrane Library. Seventeen studies met inclusion criteria, though there was significant heterogeneity in study design, patient population, assessment techniques and outcomes reported. Overall, the majority of studies (11 of 17) concluded that transfusion did not generally improve tissue oxygenation or microcirculation. Inter-individual effects were highly variable, however, and closer review of sub-groups available in 9 studies revealed that patients with abnormal tissue oxygenation or microcirculatory indices prior to transfusion had improvement in these indices with transfusion, irrespective of assessment method. This finding suggests a new strategy for future trials in the ICU: utilizing tissue oxygenation/microcirculatory parameters to determine the need for transfusion rather than largely arbitrary hemoglobin concentrations.
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Affiliation(s)
- Nathan D Nielsen
- Section of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's University Hospital, Department of Clinical Medicine, Trinity College, Dublin, Ireland
| | - Catherine Wentowski
- Division of Pulmonary and Critical Care Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA
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18
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Kalantari A, Mallemat H, Weingart SD. Sepsis Definitions: The Search for Gold and What CMS Got Wrong. West J Emerg Med 2017; 18:951-956. [PMID: 28874949 PMCID: PMC5576633 DOI: 10.5811/westjem.2017.4.32795] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 03/31/2017] [Accepted: 04/25/2017] [Indexed: 12/29/2022] Open
Abstract
On October 1, 2015, the United States Centers for Medicare and Medicaid Services (CMS) issued a core measure addressing the care of septic patients. These core measures are controversial among healthcare providers. This article will address that there is no gold standard definition for sepsis, severe sepsis or septic shock and the CMS-assigned definitions for severe sepsis and septic shock are premature and inconsistent with evidence-based definitions.
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Affiliation(s)
- Annahieta Kalantari
- Aria Jefferson Health, Department of Emergency Medicine, Philadelphia, Pennsylvania.,Philadelphia College of Osteopathic Medicine, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Haney Mallemat
- Cooper Medical School of Rowan University, Department of Emergency Medicine, Department of Critical Care Medicine, Camden, New Jersey
| | - Scott D Weingart
- Stony Brook Medicine, Department of Emergency Medicine, Division of Emergency Critical Care, Stony Brook, New York
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19
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van den Nouland DPA, Brouwers MCGJ, Stassen PM. Prognostic value of plasma lactate levels in a retrospective cohort presenting at a university hospital emergency department. BMJ Open 2017; 7:e011450. [PMID: 28137926 PMCID: PMC5293863 DOI: 10.1136/bmjopen-2016-011450] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES The prognostic value of lactate in the setting of an emergency department (ED) has not been studied extensively. The goal of this study was to assess 28-day mortality in ED patients in whom lactate was elevated (≥4.0 mmol/L), <4.0 mmol/L or not determined and to study the impact of the underlying cause of hyperlactatemia, that is, type A (tissue hypoxia) or type B (non-hypoxia), on mortality. DESIGN Retrospective study. SETTING A secondary and tertiary referral centre in the Netherlands. MATERIALS AND METHODS All internal medicine patients with hyperlactatemia (≥4.0 mmol/L) at the ED between January 2011 and October 2014 were included in this study. Samples of patients with lactate levels <4.0 mmol/L and of patients in whom no lactate was measured were included as a reference. RESULTS In 1144 of 19 822 patients (5.8%), lactate was measured. Hyperlactatemia (n=197) was associated with a higher 28-day mortality than in those with lactate <4.0 mmol/L (40.6% vs 18.5%; p<0.001) and in those without lactate measurements (9.5%). Type A hyperlactatemia, present in 84% of those with hyperlactatemia, was associated with higher mortality than type B hyperlactatemia (45.8% vs 12.5%, p=0.001). CONCLUSIONS This study demonstrates that the prognostic value of lactate depends largely on the underlying cause and the population in whom lactate has been measured. Prospective studies are required to address the true added value of lactate at the ED.
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Affiliation(s)
- Danith P A van den Nouland
- Department of Internal Medicine, Section of Acute Medicine, Maastricht University Medical Centre+, Maastricht University, Maastricht, The Netherlands
| | - Martijn C G J Brouwers
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht University, Maastricht, The Netherlands
| | - Patricia M Stassen
- Section of Acute Medicine, Division of General Medicine, Department of Internal Medicine, Maastricht University Medical Centre+, School of CAPHRI, Maastricht University, Maastricht, The Netherlands
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20
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Abstract
Sepsis is a challenging, dynamic, pathophysiology requiring expertise in diagnosis and management. Controversy exists as to the most sensitive early indicators of sepsis and sepsis severity. Patients presenting to the emergency department often lack complete history or clinical data that would point to optimal management. Awareness of these potential knowledge gaps is important for the emergency provider managing the septic patient. Specific areas of management including the initiation and management of mechanical ventilation, the appropriate disposition of the patient, and consideration of transfer to higher levels of care are reviewed.
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Affiliation(s)
- Lars-Kristofer N Peterson
- Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA; Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Karin Chase
- Pulmonary and Critical Care Medicine Division, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA; Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA
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21
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Li Y, Zhang X, Lin P, Qiu H, Wei J, Cao Y, Pan S, Walline J, Qian C, Shan Z, Yu X. Effects of Shenfu Injection in the Treatment of Septic Shock Patients: A Multicenter, Controlled, Randomized, Open-Label Trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2016; 2016:2565169. [PMID: 27446222 PMCID: PMC4944053 DOI: 10.1155/2016/2565169] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/13/2016] [Accepted: 06/07/2016] [Indexed: 12/11/2022]
Abstract
The effect of Shenfu on biochemical parameters and survival during resuscitation in patients with septic shock was examined. This was a multicenter, controlled, randomized, open-label trial carried out in 210 patients with septic shock from seven medical centers in China. They were randomized to Shenfu or saline. The primary outcome was lactate clearance. The secondary outcomes were shock index normalization, dose of vasopressors, ICU stay, hospital stay, and mortality. A total of 199 patients completed the trial. Blood pressure, heart rate, and other routine lab tests showed no difference between the groups. Lactate levels and lactate clearance were similar between the two groups. Hospital and ICU stay were similar between the two groups. When considering all patients, the 7- and 28-day mortality were similar between the two groups, but when considering only patients with lactate levels ≥4.5 mmol/L, the Shenfu group showed a better 7-day survival than the control group (7 days: 83.3% versus 54.5%, P = 0.034; 28 days: 72.7% versus 47.6%, P = 0.092). Shenfu may improve the 7-day survival in patients with impaired lactate clearance (≥4.5 mmol/L), but the mechanism for this effect is unclear. Additional studies are necessary to characterize the hemodynamic changes after Shenfu infusion. This trial is registered with ChiCTR-TRC-11001369.
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Affiliation(s)
- Yi Li
- Emergency Department, Peking Union Medical College Hospital, Beijing 100730, China
| | - Xinchao Zhang
- Emergency Department, Beijing Hospital of the Ministry of Health, Beijing 100005, China
| | - Peihong Lin
- Emergency Department, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Haibo Qiu
- Emergency Department, Zhongda Hospital, Dongnan University, Nanjing 210009, China
| | - Jie Wei
- Emergency Department, Hubei Provincial Hospital, Wuhan 430000, China
| | - Yu Cao
- Emergency Department, The First Affiliated Hospital of Huaxi Medical College of Sichuan University, Chengdu 610044, China
| | - Shuming Pan
- Emergency Department, Xinhua Hospital, Shanghai Jiao Tong University, Shanghai 200093, China
| | - Joseph Walline
- Emergency Department, Saint Louis University, Saint Louis, MO 63130, USA
| | - Chuanyun Qian
- Emergency Department, The First Affiliated Hospital of Kunming Medical University, Kunming 650034, China
| | - Zhigang Shan
- Emergency Department, PLA 263 Hospital, Beijing 101199, China
| | - XueZhong Yu
- Emergency Department, Peking Union Medical College Hospital, Beijing 100730, China
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22
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Motzkus CA, Luckmann R. Does Infection Site Matter? A Systematic Review of Infection Site Mortality in Sepsis. J Intensive Care Med 2016; 32:473-479. [PMID: 26880006 DOI: 10.1177/0885066615627778] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Sepsis treatment protocols emphasize source control with empiric antibiotics and fluid resuscitation. Previous reviews have examined the impact of infection site and specific pathogens on mortality from sepsis; however, no recent review has addressed the infection site. This review focuses on the impact of infection site on hospital mortality among patients with sepsis. METHODS The PubMed database was searched for articles from 2001 to 2014. Studies were eligible if they included (1) one or more statistical models with hospital mortality as the outcome and considered infection site for inclusion in the model and (2) adult patients with sepsis, severe sepsis, or septic shock. Data abstracted included stage of sepsis, infection site, and raw and adjusted effect estimates. Nineteen studies were included. Infection sites most studied included respiratory (n = 19), abdominal (n = 19), genitourinary (n = 18), and skin and soft tissue infections (n = 11). Several studies found a statistically significant lower mortality risk for genitourinary infections on hospital mortality when compared to respiratory infections. CONCLUSION Based on studies included in this review, the impact of infection site in patients with sepsis on hospital mortality could not be reliably estimated. Misclassification among infections and disease states remains a serious possibility in studies on this topic.
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Affiliation(s)
- Christine A Motzkus
- 1 Clinical and Population Health Research Program, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.,2 Department of Family Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Roger Luckmann
- 1 Clinical and Population Health Research Program, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.,2 Department of Family Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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23
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Jia L, Wang H, Gao Y, Liu H, Yu K. High incidence of adverse events during intra-hospital transport of critically ill patients and new related risk factors: a prospective, multicenter study in China. Crit Care 2016; 20:12. [PMID: 26781179 PMCID: PMC4717618 DOI: 10.1186/s13054-016-1183-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 01/06/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The aim of the present study was to investigate the incidence of adverse events (AEs) during intra-hospital transport (IHT) of critically ill patients and evaluate the risk factors associated with these events. METHODS This prospective multicenter observational study was performed in 34 intensive care units in China during 20 consecutive days from 5 November to 25 November 2012. All consecutive patients who required IHT for diagnostic testing or therapeutic procedures during the study period were included. All AEs that occurred during IHT were recorded. The incidence of AEs was defined as the rate of transports with at least one AE. The statistical analysis included a description of demographic and clinical characteristics of the cohort as well as identification of risk factors for AEs during IHT by univariate and multivariate logistic regression analyses. RESULTS In total, 441 IHTs of 369 critically ill patients were analyzed. The overall incidence of AEs was 79.8% (352 IHTs). The proportion of equipment- and staff-related adverse events was 7.9% (35 IHTs). The rate of patient-related adverse events (P-AEs) was 79.4% (349 IHTs). The rates of vital sign-related P-AEs and arterial blood gas analysis-related P-AEs were 57.1% (252 IHTs) and 46.9% (207 IHTs), respectively. The incidence of critical P-AEs was 33.1% (146 IHTs). The rates of vital sign-related critical P-AEs and arterial blood gas analysis-related critical P-AEs were 22.9% (101 IHTs) and 15.0% (66 IHTs), respectively. All data collected in our study were considered potential risk factors. In the multivariate analysis, predictive factors for P-AEs were pH, partial pressure of carbon dioxide in arterial blood, lactate level, glucose level, and heart rate before IHT. Furthermore, the Acute Physiology and Chronic Health Evaluation II score, partial pressure of oxygen in arterial blood, lactate level, glucose level, heart rate, respiratory rate, pulse oximetry, and sedation before transport were independent influential factors for critical P-AEs during IHT. CONCLUSIONS The incidence of P-AEs during IHT of critically ill patients was high. Risk factors for P-AEs during IHT were identified. Strategies are needed to reduce their frequency. TRIAL REGISTRATION Chinese Clinical Trial Register identifier ChiCTR-OCS-12002661. Registered 5 November 2012.
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Affiliation(s)
- Liu Jia
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.
| | - Hongliang Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.
| | - Yang Gao
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.
| | - Haitao Liu
- Department of Critical Care Medicine, the Third Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.
| | - Kaijiang Yu
- Department of Critical Care Medicine, the Third Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.
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24
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Suetrong B, Walley KR. Lactic Acidosis in Sepsis: It's Not All Anaerobic: Implications for Diagnosis and Management. Chest 2016; 149:252-61. [PMID: 26378980 DOI: 10.1378/chest.15-1703] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/24/2015] [Accepted: 08/31/2015] [Indexed: 12/21/2022] Open
Abstract
Increased blood lactate concentration (hyperlactatemia) and lactic acidosis (hyperlactatemia and serum pH < 7.35) are common in patients with severe sepsis or septic shock and are associated with significant morbidity and mortality. In some patients, most of the lactate that is produced in shock states is due to inadequate oxygen delivery resulting in tissue hypoxia and causing anaerobic glycolysis. However, lactate formation during sepsis is not entirely related to tissue hypoxia or reversible by increasing oxygen delivery. In this review, we initially outline the metabolism of lactate and etiology of lactic acidosis; we then address the pathophysiology of lactic acidosis in sepsis. We discuss the clinical implications of serum lactate measurement in diagnosis, monitoring, and prognostication in acute and intensive care settings. Finally, we explore treatment of lactic acidosis and its impact on clinical outcome.
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Affiliation(s)
- Bandarn Suetrong
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Keith R Walley
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada.
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