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Li S, You T, Liu M, Hao Y, Li X, Wang Z, Huang F, Wang J. Dynamic changes in lactate levels within the first 24 hours in septic patients as a prognostic indicator: A retrospective cohort study utilizing latent class growth analysis. BIOMOLECULES & BIOMEDICINE 2023; 23:1118-1124. [PMID: 37485959 PMCID: PMC10655878 DOI: 10.17305/bb.2023.9259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/05/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023]
Abstract
Elevated lactate levels are common in sepsis patients. This study aimed to assess the effect of dynamic changes in lactate levels within the first 24 hours following admission on patient prognosis. We extracted data from the Medical Information Mart for Intensive Care (MIMIC)-IV database and classified patients using latent class growth analysis (LCGA). This analysis classified sepsis patients into different groups based on dynamic changes in lactate levels during the initial 24 hours post-admission, dividing this time frame into four periods (0-3 h, 3-6 h, 6-12 h, and 12-24 h). The highest lactate level recorded in each period was then used for patient classification. We subsequently compared the baseline characteristics and outcomes between these different groups. Our study encompassed 7,830 patients, whom LCGA successfully divided into two classes: class 1 (steady lactate class) and class 2 (increasing lactate class). Class 2 demonstrated a worse clinical status at baseline, as indicated by vital signs, disease severity scores, and laboratory results. Importantly, class 2 also had a significantly higher 28-day mortality rate than class 1 (55.6% vs 13.5%, P < 0.001). In conclusion, LCGA effectively categorized sepsis patients into two distinct groups based on their dynamic changes in lactate levels during the first 24 hours post-admission. This methodology has potential utility in clinical practice for managing sepsis patients.
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Affiliation(s)
- Shifeng Li
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Tao You
- Department of Hematopathology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Meili Liu
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yan Hao
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xinyue Li
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhiyang Wang
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Fang Huang
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jun Wang
- Department of Intensive Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Guy C, Holmes NE, Kishore K, Marhoon N, Serpa-Neto A. Decompensated metabolic acidosis in the emergency department: Epidemiology, sodium bicarbonate therapy, and clinical outcomes. CRIT CARE RESUSC 2023; 25:71-77. [PMID: 37876600 PMCID: PMC10581257 DOI: 10.1016/j.ccrj.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objective This article aims to describe the epidemiology of decompensated metabolic acidosis, the characteristics of sodium bicarbonate (SB) administration and outcomes in emergency department (ED) patients. Design This is a retrospective cohort study. Setting ED of a tertiary referral hospital in Melbourne, Australia. Participants Adult patients presenting to the ED between 1 July 2011 and 20 September 2020 with decompensated metabolic acidosis diagnosed on arterial blood gas (ABG). Main outcome measures We compared characteristics between those treated with or without SB. We studied SB administration characteristics, change in laboratory variables, factors associated with use and dose, and clinical outcomes. Results Among 753,613 ED patients, 314 had decompensated metabolic acidosis on ABG, with 17.8% receiving SB. Patients in the SB group had lower median pH, CO2, bicarbonate, and base excess (BE) levels compared with the No SB group (P < 0.01). The median number of SB doses in the SB group was one treatment. This was given at a median total dose of 100 mmol and at a median of 2.8 h after the diagnostic blood gas results. Only 42% of patients in the SB group had a subsequent blood gas measured. In such patients, there was no significant change in pH, bicarbonate, or BE. SB therapy was not independently associated with mortality. Conclusions ABG-confirmed decompensated metabolic acidosis was rare but associated with a high mortality. SB administration occurred in a minority of patients and in more acidaemic patients. However, SB dose was stereotypical and not tailored to acidosis severity. Assessment of SB effect was infrequent and showed no correction of acidosis. Systematic studies of titrated SB therapy are required to inform current practice.
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Affiliation(s)
- Christopher Guy
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Natasha E. Holmes
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and the University of Melbourne, Heidelberg, Victoria, Australia
- Department of Critical Care, School of Medicine, The University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Kartik Kishore
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and the University of Melbourne, Heidelberg, Victoria, Australia
| | - Nada Marhoon
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and the University of Melbourne, Heidelberg, Victoria, Australia
| | - Ary Serpa-Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and the University of Melbourne, Heidelberg, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Vetter P, Niggli C, Hambrecht J, Niggli P, Vomela J, Chaloupka R, Pape HC, Mica L. The Role of Lactate for Sepsis in Polytrauma Patients, a Time related Analysis using the IBM Watson Trauma Pathway Explorer ®. JOURNAL OF SURGERY AND RESEARCH 2022; 5:618-624. [PMID: 36777916 PMCID: PMC9912541 DOI: 10.26502/jsr.10020268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The Watson Trauma Pathway Explorer ® is an outcome prediction tool invented by the University Hospital of Zurich in collaboration with IBM®, representing an artificial intelligence application to predict the most adverse outcome scenarios in polytrauma patients: Systemic Inflammatory Respiratory Syndrome (SIRS), sepsis within 21 days and death within 72 h. The hypothesis was how lactate values woud be associated with the incidence of sepsis. Data from 3653 patients in an internal database, with ongoing implementation, served for analysis. Patients were split in two groups according to sepsis presence, and lactate values were measured at formerly defined time points from admission until 21 days after admission for both groups. Differences between groups were analyzed; time points with lactate as independent predictor for sepsis were identified. The predictive quality of lactate at 2 and 12 h after admission was evaluated. Threshold values between groups at all timepoints were calculated. Lactate levels differed from less than 2 h after admission until the end of the observation period (21 d). Lactate represented an independent predictor for sepsis from 12 to 48 h and 14 d to 21 d after admission relative to ISS levels. AUROC was poor at 2 and 12 h after admission with a slight improvement at the 12 h mark. Lactate levels decreased over time at a range of 2 [mmol/L] for 6-8 h after admission. These insights may allow for time-dependent referencing of lactate levels and anticipation of subsequent sepsis, although further parameters must be considered for a higher predictability.
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Affiliation(s)
- Philipp Vetter
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Cédric Niggli
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Jan Hambrecht
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Philipp Niggli
- Department of Mathematics, ETH Zurich, 8092 Zurich, Switzerland
| | - Jindrich Vomela
- Division of Medical Sciences in Sportsmedicine, Faculty of Sports Studies, Masaryks University, 62500 Brno, Czech Republic
| | - Richard Chaloupka
- Department of Orthopedic Surgery, Masaryks University, 62500 Brno, Czech Republic
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Ladislav Mica
- Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
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Caramello V, De Salve AV, Macciotta A, Boccuzzi A. Reply to "Usefulness of the PIRO system to predict mortality in patients with severe infection in the emergency department". Med Intensiva 2022; 46:661-662. [PMID: 36344016 DOI: 10.1016/j.medine.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/18/2021] [Indexed: 06/16/2023]
Affiliation(s)
- V Caramello
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, regione Gonzole 10, 10043 Orbassano, Turin, Italy.
| | - A V De Salve
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - A Macciotta
- Department of Clinical and Biological Science, University of Turin, Orbassano (TO), Italy
| | - A Boccuzzi
- Emergency Department and High Dependency Unit MECAU, AOU San Luigi Gonzaga, regione Gonzole 10, 10043 Orbassano, Turin, Italy
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Gill A, Ackermann K, Hughes C, Lam V, Li L. Does lactate enhance the prognostic accuracy of the quick Sequential Organ Failure Assessment for adult patients with sepsis? A systematic review. BMJ Open 2022; 12:e060455. [PMID: 36270756 PMCID: PMC9594532 DOI: 10.1136/bmjopen-2021-060455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To investigate whether adding lactate to the quick Sequential (sepsis-related) Organ Failure Assessment (qSOFA) improves the prediction of mortality in adult hospital patients, compared with qSOFA alone. DESIGN Systematic review in accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies guidelines. DATA SOURCES Embase, Medline, PubMed, SCOPUS, Web of Science, CINAHL and Open Grey databases were searched in November 2020. ELIGIBILITY CRITERIA Original research studies published after 2016 comparing qSOFA in combination with lactate (LqSOFA) with qSOFA alone in adult patients with sepsis in hospital. The language was restricted to English. DATA EXTRACTION AND SYNTHESIS Title and abstract screening, full-text screening, data extraction and quality assessment (using Quality Assessment of Diagnostic Accuracy Studies-2) were conducted independently by two reviewers. Extracted data were collected into tables and diagnostic test accuracy was compared between the two tests. RESULTS We identified 1621 studies, of which 11 met our inclusion criteria. Overall, there was a low risk of bias across all studies. The area under the receiver operating characteristic (AUROC) curve for qSOFA was improved by the addition of lactate in 9 of the 10 studies reporting it. Sensitivity was increased in three of seven studies that reported it. Specificity was increased in four of seven studies that reported it. Of the six studies set exclusively within the emergency department, five published AUROCs, all of which reported an increase following the addition of lactate. Sensitivity and specificity results varied throughout the included studies. Due to insufficient data and heterogeneity of studies, a meta-analysis was not performed. CONCLUSIONS LqSOFA is an effective tool for identifying mortality risk both in adult inpatients with sepsis and those in the emergency department. LqSOFA increases AUROC over qSOFA alone, particularly within the emergency department. However, further original research is required to provide a stronger base of evidence in lactate measurement timing, as well as prospective trials to strengthen evidence and reduce bias. PROSPERO REGISTRATION NUMBER CRD42020207648.
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Affiliation(s)
- Angus Gill
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Khalia Ackermann
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Clifford Hughes
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Vincent Lam
- Macquarie Medical School, Macquarie University, Sydney, New South Wales, Australia
| | - Ling Li
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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6
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Caramello V, De Salve A, Macciotta A, Boccuzzi A. Reply to “Usefulness of the PIRO system to predict mortality in patients with severe infection in the emergency department”. Med Intensiva 2022. [DOI: 10.1016/j.medin.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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7
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Yan G, Wang D, Tang C, Ma G. The Association of Serum Lactate Level with the Occurrence of Contrast-Induced Acute Kidney Injury and Long-Term Prognosis in Patients Undergoing Emergency Percutaneous Coronary Intervention. Int J Gen Med 2021; 14:3087-3097. [PMID: 34234537 PMCID: PMC8257073 DOI: 10.2147/ijgm.s316036] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 12/12/2022] Open
Abstract
Objective The association of lactate and contrast-induced acute kidney injury (CI-AKI) has not been well established. This prospective study was planned to identify the effects of lactate level on the occurrence of CI-AKI and long-term prognosis with acute myocardial infarction (AMI) patients undergoing emergency percutaneous coronary intervention (PCI). Methods A total of 280 patients with AMI who underwent emergency PCI were selected from March 2018 to March 2019. A receiver operating characteristic (ROC) curve was used to analyze the optimal cut-off value of lactate on predicting CI-AKI after PCI. A multivariable logistic regression model was used to explore the significant predictors that might affect the occurrence of CI-AKI after univariate analysis. The primary endpoints were clinical outcomes including events: a combined endpoint of major adverse cardiovascular events, re-hospitalization due to heart failure, and worsening renal function. The Cox regression model was further used to analyze the predictors of the long-term prognosis after PCI. Results Among the 280 patients, 64 patients (22.9%) developed CI-AKI after emergency PCI procedure. Multivariable logistic regression analysis revealed that baseline lactate level was the independent risk factor for the development of CI-AKI (OR, 3.657; 95% CI, 2.237–5.978; p<0.001). The area under the ROC curve for predicting CI-AKI of lactate was 0.786, and the optimum cut-off point of lactate was 3.02 mmol/L, with sensitivity of 65.6% and specificity of 85.2%. The incidence of primary endpoints in the high lactate group (lactate ≥3.02mmol/L) was significantly increased compared with the control group [26.3% (42/160) vs 15.8% (19/120), χ2=4.430, p=0.035]. Cox regression analysis also confirmed high lactate was an independent predictor for primary endpoint outcomes at 1-year follow-up (HR, 1.916; 95% CI, 1.118–3.285; p=0.018). Conclusion Our study demonstrates that baseline high lactate levels may be associated with an increased risk of CI-AKI and are the important predictors of long-term poor cardiorenal outcomes in AMI patients undergoing emergency PCI.
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Affiliation(s)
- Gaoliang Yan
- Department of Cardiology, Zhongda Hospital of Southeast University Medical School, Nanjing, Jiangsu, People's Republic of China
| | - Dong Wang
- Department of Cardiology, Zhongda Hospital of Southeast University Medical School, Nanjing, Jiangsu, People's Republic of China
| | - Chengchun Tang
- Department of Cardiology, Zhongda Hospital of Southeast University Medical School, Nanjing, Jiangsu, People's Republic of China
| | - Genshan Ma
- Department of Cardiology, Zhongda Hospital of Southeast University Medical School, Nanjing, Jiangsu, People's Republic of China
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8
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D'Onofrio V, Meersman A, Vijgen S, Cartuyvels R, Messiaen P, Gyssens IC. Risk Factors for Mortality, Intensive Care Unit Admission, and Bacteremia in Patients Suspected of Sepsis at the Emergency Department: A Prospective Cohort Study. Open Forum Infect Dis 2020; 8:ofaa594. [PMID: 33511231 PMCID: PMC7813192 DOI: 10.1093/ofid/ofaa594] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/03/2020] [Indexed: 12/31/2022] Open
Abstract
Background There is a clear need for a better assessment of independent risk factors for in-hospital mortality, intensive care unit admission, and bacteremia in patients presenting with suspected sepsis at the emergency department. Methods A prospective observational cohort study including 1690 patients was performed. Two multivariable logistic regression models were used to identify independent risk factors. Results Sequential organ failure assessment (SOFA) score of ≥2 and serum lactate of ≥2mmol/L were associated with all outcomes. Other independent risk factors were individual SOFA variables and systemic inflammatory response syndrome variables but varied per outcome. Mean arterial pressure <70 mmHg negatively impacted all outcomes. Conclusions These readily available measurements can help with early risk stratification and prediction of prognosis.
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Affiliation(s)
- Valentino D'Onofrio
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Department of Infectious Diseases and Immunity, Jessa Hospital, Hasselt, Belgium.,Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Sara Vijgen
- Clinical Laboratory, Jessa Hospital, Hasselt, Belgium
| | | | - Peter Messiaen
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Department of Infectious Diseases and Immunity, Jessa Hospital, Hasselt, Belgium
| | - Inge C Gyssens
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
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9
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Basil-Kway V, Castillo-Reyther R, Domínguez-Salgado LA, Espinosa-Tanguma R, Medina Ú, Gordillo-Moscoso A. Early prognostic capacity of serum lactate for severe postpartum hemorrhage. Int J Gynaecol Obstet 2020; 153:483-488. [PMID: 33119891 DOI: 10.1002/ijgo.13446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/23/2020] [Accepted: 10/27/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate whether the concentration of serum lactate during the diagnosis of postpartum hemorrhage (bleeding ≥500 mL during labor or ≥1000 mL during cesarean delivery) predicts severe hemorrhage (SPPH; blood loss ≥1500 mL at end of labor or in the following 24 h). METHODS A prospective cohort pilot study was conducted of women with a vaginal or cesarean delivery from February 2018 to March 2019 who presented with bleeding ≥500 mL measured by the gravimetric method in a reference hospital in San Luis Potosi, Mexico. Venous blood samples were taken for analysis of serum lactate. A receiver operating characteristic curve determined the serum lactate threshold value for SPPH and χ2 test assessed the difference in serum lactate elevation between SPPH and non-SPPH groups. Lastly, the prognostic capacity between the thresholds was compared. RESULTS SPPH developed in 43.33% of the 30 women in the study group. The best prognostic threshold was 2.68 mmol/L of serum lactate (odds ratio [OR] 17.88, 95% confidence interval [CI] 2.7-16.8, P < 0.001); sensitivity was 0.85 (95% CI 0.55-0.98); specificity was 0.76 (95% CI 0.50-0.93). CONCLUSION Serum lactate may be a useful prognostic marker for SPPH, more studies are needed to validate these findings.
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Affiliation(s)
- Venance Basil-Kway
- Department of Clinical Epidemiology, School of Medicine, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Roberto Castillo-Reyther
- Department of Obstetrics and Gynecology, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosi, Mexico.,School of Medicine, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - L Andrés Domínguez-Salgado
- Department of Clinical Epidemiology, School of Medicine, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Ricardo Espinosa-Tanguma
- Department of Physiology, School of Medicine, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Úrsula Medina
- Department of Clinical Epidemiology, School of Medicine, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico.,Department of Pharmacology, School of Medicine, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Antonio Gordillo-Moscoso
- Department of Clinical Epidemiology, School of Medicine, Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
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10
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Martín-Rodríguez F, López-Izquierdo R, Medina-Lozano E, Ortega Rabbione G, Del Pozo Vegas C, Carbajosa Rodríguez V, Castro Villamor MÁ, Sánchez-Soberon I, Sanz-García A. Accuracy of prehospital point-of-care lactate in early in-hospital mortality. Eur J Clin Invest 2020; 50:e13341. [PMID: 32648960 DOI: 10.1111/eci.13341] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/21/2020] [Accepted: 07/05/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Emergency medical services (EMS) routinely face complex scenarios where decisions should be taken with limited clinical information. The development of fast, reliable and easy to perform warning biomarkers could help in such decision-making processes. The present study aims at characterizing the validity of point-of-care lactate (pLA) during prehospital tasks for predicting in-hospital mortality within two days after the EMS assistance. MATERIALS AND METHODS Prospective, multicentric, ambulance-based and controlled observational study without intervention, including six advanced life support and five hospitals. The pLA levels were recorded during EMS assistance of adult patients. The validity of pLA to determine the in-hospital mortality was assessed by the area under the curve (AUC) of the receiver operating curve (ROC). RESULTS A total of 2997 patients were considered in the study, with a median of 69 years (IQR 54-81) and 41.4% of women. The median pLA value was 2.7 mmol/L (1.9-3.8) in survivors and 5.7 mmol/L (4.4-7.6) in nonsurvivors. The global discrimination level of pLA reached an AUC of 0.867, being 1.9 mmol/L and 4 mmol/L the cut-off point for low and high mortality. The discrimination value of pLA was not affected by sex, age or pathology. CONCLUSIONS Our results highlight the clinical importance of prehospital pLA to determine the in-hospital risk of mortality. The incorporation of pLA into the EMS protocols could improve the early identification of risky patients, leading to a better care of such patients.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Clinical Simulation Center, School of Medicine, Valladolid University, Valladolid, Spain.,Emergency Medical Services-SACYL, Paseo Hospital Militar, Valladolid, Spain
| | - Raúl López-Izquierdo
- Advanced Clinical Simulation Center, School of Medicine, Valladolid University, Valladolid, Spain.,Emergency Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Elena Medina-Lozano
- Advanced Clinical Simulation Center, School of Medicine, Valladolid University, Valladolid, Spain
| | - Guillermo Ortega Rabbione
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa (IIS-IP), Madrid, Spain.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), CABA, Argentina
| | | | | | | | | | - Ancor Sanz-García
- Data Analysis Unit, Health Research Institute, Hospital de la Princesa (IIS-IP), Madrid, Spain
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11
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Almutary A, Althunayyan S, Alenazi K, Alqahtani A, Alotaibi B, Ahmed M, Osman IS, Kakpuri A, Alanazi A, Arafat M, Al-Mutairi A, Bashraheel F, Almazroua F. National Early Warning Score (NEWS) as Prognostic Triage Tool for Septic Patients. Infect Drug Resist 2020; 13:3843-3851. [PMID: 33149629 PMCID: PMC7602891 DOI: 10.2147/idr.s275390] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/26/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose We assessed the National Early Warning Score (NEWS) in emergency triage for predicting sepsis-related outcomes. Methods A retrospective chart review of all cases enrolled in the sepsis management protocol for a one-year duration. The protocol utilized the NEWS as a screening tool for sepsis in the triage area. Primary outcomes of interest were hyperlactatemia, admission to ICU and intrahospital mortality. Sensitivity, specificity, and area under the curve (AUC) were calculated for a given NEWS. Results A total of 444 patients were reviewed from July 2018 to June 2019, with a mean age of 58.7 years. A NEWS ≥5 was more than 88% sensitive in predicting hyperlactatemia, ICU admission, and/or mortality. Specificity, on the other hand, was as low as 12%. The AUC for the NEWS was 0.667 for predicting hyperlactatemia and 0.602 for predicting ICU admission or mortality. Conclusion The NEWS was a sensitive screening tool for predicting sepsis-related outcomes. However, it was not specific, and further studies are recommended to assess the integration of other factors to improve specificity.
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Affiliation(s)
| | - Saqer Althunayyan
- Department of Accident and Trauma, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Khaled Alenazi
- Internal Medicine Department, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Badar Alotaibi
- Emergency Department, Riyadh Care Hospital, Riyadh, Saudi Arabia
| | - Marwa Ahmed
- Pharmaceutical Care Services Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Isam S Osman
- Vascular Surgery Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Adil Kakpuri
- Quality Management and Patient Safety Administration, King Saud Medical City, Riyadh, Saudia Arabia
| | - Abdulaziz Alanazi
- Nursing Administration, King Saud Medical City, Riyadh, Saudia Arabia
| | - Mohammed Arafat
- Emergency Medicine Department, King Saud University Medical City, Riyadh, Saudi Arabia
| | | | - Fatma Bashraheel
- College of Medicine, Alma'arefa University, Riyadh, Saudi Arabia
| | - Faisal Almazroua
- Emergency Department, King Saud Medical City, Riyadh, Saudi Arabia
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12
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Jones N, Tridente A, Dempsey-Hibbert NC. Immature platelet indices alongside procalcitonin for sensitive and specific identification of bacteremia in the intensive care unit. Platelets 2020; 32:941-949. [PMID: 32897796 DOI: 10.1080/09537104.2020.1809646] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Hematological markers that can be rapidly analyzed and regularly monitored during a patient's stay on ICU, and that can identify bacterial causes of sepsis are being extensively sought. The significance of platelets in early immunological responses provides justification for assessing their usefulness in the identification of bacteremia amongst sepsis patients. In this preliminary study, the full blood count, including the platelet count by impedance (PLT-I), Immature Platelet Fraction (IPF%) and absolute immature platelet count (AIPC), were analyzed in eighty-two sepsis patients daily over the first 5 days stay on ICU. C-Reactive Protein (CRP), procalcitonin (PCT), and lactate were also analyzed daily. Blood cultures confirmed or excluded the presence of bacteremia. PCT provided the earliest indicator of bacteremia, with significant differences between the two cohorts on day 1. The change in IPF% and AIPC from day 1 to day 2 (Δ IPF% and Δ AIPC) provided the most accurate indication; A combination of Δ IPF% and day 2 PCT, provided a positive predictive value and negative predictive value of 100% and 96.10%, respectively. These data provide strong justification for larger multi-center validation studies to confirm the usefulness of these platelet indices during the assessment of sepsis on the ICU.
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Affiliation(s)
- Nathan Jones
- Haematology Department, Warrington District General Hospital, Warrington, UK
| | - Ascanio Tridente
- Intensive Care Unit, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
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Cannon CM, Miller RT, Grow KL, Purcell S, Nazir N. Age-adjusted and Expanded Lactate Thresholds as Predictors of All-Cause Mortality in the Emergency Department. West J Emerg Med 2020; 21:1249-1257. [PMID: 32970582 PMCID: PMC7514398 DOI: 10.5811/westjem.2020.5.46811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION While numerous studies have found emergency department (ED) lactate levels to be associated with increased in-hospital mortality, little information is available on the role age plays in this association. This study investigates whether age is a necessary variable to consider when using lactate levels as a marker of prognosis and a guide for management decisions in the ED. METHODS This was a retrospective cohort study in an urban, tertiary-care teaching hospital. A total of 13,506 lactate levels were obtained over a 4.5-year period. All adult patients who had a lactate level obtained by the treating provider in the ED were screened for inclusion. The main outcome measure was in-hospital mortality using age-adjusted cohorts and expanded lactate thresholds with secondary outcomes comparing mortality based on the primary clinical impression. RESULTS Of the 8796 patients in this analysis, there were 474 (5.4%) deaths. Mortality rates increased with both increasing lactate levels and increasing age. For all ages, mortality rates increased from 2.8% in the less than 2.0 millimoles per liter (mmol/L) lactate level, to 5.6% in the 2.0-2.9 mmol/L lactate level, to 8.0% in the 3.0-3.9 mmol/L lactate level, to 13.9% in the 4.0-4.9 mmol/L lactate level, to 13.7% in the 5.0-5.9 mmol/L lactate level, and to 39.1% in the 6.0 mmol/L or greater lactate level (p <0.0001). Survivors, regardless of age, had a mean lactate level <2.0 whereas non-survivors had mean lactate levels of 6.5, 4.5, and 3.7 mmol/L for age cohorts 18-39, 40-64, and ≥ 65 years, respectively. CONCLUSION Our findings suggest that although lactate levels can be used as a prognostic tool to risk stratify ED patients, the traditional lactate level thresholds may need to be adjusted to account for varying risk based on age and clinical impressions.
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Affiliation(s)
- Chad M. Cannon
- University of Kansas Medical Center, Department of Emergency Medicine, Kansas City, Kansas
| | - Ross T. Miller
- University of Kansas Medical Center, Department of Emergency Medicine, Kansas City, Kansas
| | - Krista L. Grow
- University of Kansas Medical Center, Department of Emergency Medicine, Kansas City, Kansas
| | - Seth Purcell
- University of Kansas Medical Center, Department of Emergency Medicine, Kansas City, Kansas
| | - Niaman Nazir
- University of Kansas Medical Center, Department of Preventative Medicine and Public Health, Kansas City, Kansas
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Lo VCK, Su H, Lam YM, Willis K, Pullar V, Kowgier M, Hubner RP, Tsang JLY. Management of Patients With Sepsis in Canadian Community Emergency Departments: A Retrospective Multicenter Observational Study. Health Serv Res Manag Epidemiol 2020; 7:2333392820920082. [PMID: 32341942 PMCID: PMC7175053 DOI: 10.1177/2333392820920082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/01/2020] [Accepted: 03/02/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Sepsis is a life-threatening syndrome and a leading cause of morbidity and mortality representing significant financial burden on the health-care system. Early identification and intervention is crucial to maximizing positive outcomes. We studied a quality improvement initiative with the aim of reviewing the initial management of patients with sepsis in Canadian community emergency departments, to identify areas for improving the delivery of sepsis care. We present a retrospective, multicenter, observational study during 2011 to 2015 in the community setting. METHODS We collected data on baseline characteristics, clinical management metrics (triage-to-physician-assessment time, triage-to-lactate-drawn time, triage-to-antibiotic time, and volume of fluids administered within the first 6 hours of triage), and outcomes (intensive care unit [ICU] admission, in-hospital mortality) from a regional database. RESULTS A total of 2056 patients were analyzed. The median triage-to-physician-assessment time was 50 minutes (interquartile range [IQR]: 25-104), triage-to-lactate-drawn time was 50 minutes (IQR: 63-94), and triage-to-antibiotics time was 129 minutes (IQR: 70-221). The median total amount of fluid administered within 6 hours of triage was 2.0 L (IQR: 1.5-3.0). The ICU admission rate was 36% and in-hospital mortality was 25%. We also observed a higher ICU admission rate (51% vs 24%) and in-hospital mortality (44% vs 14%) in those with higher lactate concentration (≥4 vs ≤2 mmol/L), independent of other sepsis-related parameters. CONCLUSION Time-to-physician-assessment, time-to-lactate-drawn, time-to-antibiotics, and fluid resuscitation in community emergency departments could be improved. Future quality improvement interventions are required to optimize management of patients with sepsis. Elevated lactate concentration was also independently associated with ICU admission rate and in-hospital mortality rate.
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Affiliation(s)
- Victor C. K. Lo
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St Catharines, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Haitong Su
- Department of Anesthesiology, University of Toronto, Ontario, Canada
| | - Yuet Ming Lam
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | | | | | - Matthew Kowgier
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | | | - Jennifer L. Y. Tsang
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St Catharines, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Niagara Health, St Catharines, Ontario, Canada
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Branco M, Linhares P, Carvalho B, Santos P, Costa BM, Vaz R. Serum lactate levels are associated with glioma malignancy grade. Clin Neurol Neurosurg 2019; 186:105546. [PMID: 31605893 DOI: 10.1016/j.clineuro.2019.105546] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/29/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Recent studies have suggested that high grade gliomas are associated with elevated serum lactate concentrations. The aim of the present study is to assess these findings in a sample of patients. PATIENTS AND METHODS We reviewed the anesthetic charts of patients with low-grade and high-grade glioma who underwent resection surgery and collected serum lactate concentration before tumor resection, as well as other demographic and tumor-related data (age, gender, WHO grade, and size of the tumor). A statistical comparison between patients with normal (<2 mmol/L) and elevated (≥ 2 mmol/L) serum lactate was performed. RESULTS We included a total of 152 patients (mean age 49.07 years). 62.5% of patients (n = 95) had a high-grade glioma and 37.5% (n = 67) a low-grade glioma. The multivariate regression showed that high grade gliomas had significantly higher lactate concentration (p < 0.01). The OR for elevated pre-resection serum lactate increased from 4.94 to 14.33 after adjusting for age and pre-surgical corticosteroid use, and the AUC for the final regression model was 0.98. CONCLUSION This study reinforces the role of serum lactate as a potential biomarker of brain tumors malignancy, and its results encourage further research on this subject, in order to improve the understanding of this phenomenon and to assess its potential as prognostic and therapeutic monitoring tool.
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Affiliation(s)
- Mariana Branco
- Serviço de Neurologia, Centro Hospitalar de Entre Douro e Vouga, Portugal; Faculdade de Medicina da Universidade do Porto, Portugal.
| | - Paulo Linhares
- Faculdade de Medicina da Universidade do Porto, Portugal; Serviço de Neurocirurgia, Centro Hospitalar de São João, Portugal
| | - Bruno Carvalho
- Serviço de Neurocirurgia, Centro Hospitalar de São João, Portugal
| | - Patrícia Santos
- Serviço de Anestesiologia, Centro Hospitalar de São João, Portugal
| | - Bruno M Costa
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Portugal
| | - Rui Vaz
- Faculdade de Medicina da Universidade do Porto, Portugal; Serviço de Neurocirurgia, Centro Hospitalar de São João, Portugal
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Abstract
Introduction: Lactate devices offer the potential for paramedics to improve patient triage and escalation of care for specific presentations. There is also scope to improve existing prehospital tools by including lactate measurement. Method: A literature search was conducted using the Medline, CINAHL, Academic Search Premier, Sciencedirect and Scopus databases. Findings: Acquiring prehospital lactate measurement in trauma settings improved triage and recognition of the need for critical care. Within a medical setting, studies offered mixed results in relating prehospital lactate measurement to diagnosis, escalating treatments and mortality. The accuracy of prehospital lactate measurements acquired varies, which could impact decision making. Conclusion: Prehospital lactate thresholds could aid decision making, although the literature is limited and evidence varies. Lactate values of ≥4 mmol/litre in medical and ≥2.5 mmol/litre in trauma patients could signify that care should be escalated to an appropriate facility, and that resuscitative measures should be initiated, particularly with sepsis, as reflected by standardised lactate values that guide treatment in hospitals. Similarly, a lactate value of <2 mmol/litre could mean de-escalating care into the community, although further research is warranted on this.
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Althunayyan SM, Alsofayan YM, Khan AA. Shock index and modified shock index as triage screening tools for sepsis. J Infect Public Health 2019; 12:822-826. [PMID: 31113741 DOI: 10.1016/j.jiph.2019.05.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/25/2019] [Accepted: 05/05/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Fever is one of the common conditions encountered in the emergency department, which related to a spectrum of diseases severity. Identifying sepsis patients from uncomplicated febrile patients is challenging in the emergency triage areas and pre-hospital settings. OBJECTIVES Assess the triage shock index (SI) and modified shock index (MSI) in febrile patients as predictors for sepsis and sepsis-related outcomes. DESIGN A retrospective cohort study. SETTING Patients presented to the Emergency Department of King Khalid University Hospital. PATIENTS AND METHODS The analysis included all febrile adult patients triaged with a temperature of 38 °C or more from January 2016 to December 2017. Based on triage vital sign we calculate the SI with cut-off levels of ≥0.7 and ≥1 and MSI with cut-off levels of ≥1 and ≥1.3. We report the Relative Risk, Sensitivity, Specificity, Positive and Negative Predictive Values of the predictors. MAIN OUTCOME MEASURES Sepsis and sepsis-related outcomes such as hyperlactatemia, ICU admission, and 28 days mortality. SAMPLE SIZE 274 patients. RESULTS 274 patients met our inclusion/exclusion criteria. Of the 274 patients, 252 patient (92%) were septic, 62 patients (22%) had hyperlactatemia, 20 patients admitted to the ICU, and 5 patient died within 28 days. An MSI of ≥1 had a sensitivity of 90% for sepsis predication, 85% for ICU admission and 100% for 28 days mortality. MSI of ≥1.3 showed a specificity (59%-100%) for all the outcomes of interest. Non-significant statistical trends of greater accuracy of MSI over SI. CONCLUSION MSI and SI were found to be promising predictors in triaging febrile patients. However no single cut-off values of MSI or SI were found to have an optimal accuracy for prediction of sepsis and sepsis-related outcomes. Further studies are required to assess the incorporation of MSI in a multi-item scaling system for the prediction of sepsis and its related outcomes. LIMITATIONS Small single center study and the results may not be generalizable.
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Affiliation(s)
- Saqer M Althunayyan
- Department of Accident and Trauma, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, 9063 Prince Fahad bin Ibrahim, Street Al Malaz District 12642 - 3569 Riyadh, Saudi Arabia.
| | - Yousef M Alsofayan
- Department of Emergency Medicine, College of Medicine & University Medical City, King Saud University, Riyadh, Saudi Arabia.
| | - Anas A Khan
- Department of Emergency Medicine, College of Medicine & University Medical City, King Saud University, Riyadh, Saudi Arabia.
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Comment on: "Helpful Only When Elevated: Initial Serum Lactate in Stable Emergency Department Patients With Sepsis Is Specific, but Not Sensitive for Future Deterioration". J Emerg Med 2019; 56:228-229. [PMID: 30738564 DOI: 10.1016/j.jemermed.2018.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/09/2018] [Indexed: 11/21/2022]
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Peyrony O, Dumas G, Legay L, Principe A, Franchitti J, Simonetta M, Verrat A, Amami J, Milacic H, Bragança A, Gillet A, Resche-Rigon M, Fontaine JP, Azoulay E. Central venous oxygen saturation is not predictive of early complications in cancer patients presenting to the emergency department. Intern Emerg Med 2019; 14:281-289. [PMID: 30306323 DOI: 10.1007/s11739-018-1966-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/06/2018] [Indexed: 12/14/2022]
Abstract
Central venous oxygen saturation (ScvO2) is easily observable in oncology patients with long-term central venous catheters (CVC), and has been studied as a prognostic factor in patients with sepsis. We sought to investigate the association between ScvO2 and early complications in cancer patients presenting to the ED. We prospectively enrolled adult cancer patients with pre-existing CVC who presented to the ED. ScvO2 was measured on their CVC. The outcome was admission to the intensive care unit (ICU) or mortality by day 7. ScvO2 was first studied as a continuous variable (%) with a ROC analysis and as a categorical variable (cut-off at < 70%) with a multivariate analysis. A total of 210 cancer patients were enrolled. At baseline, ScvO2 showed no significant difference between patients who were admitted to the ICU or died before day 7, and patients who did not (67%; IQR 62-68% vs. 71%; IQR 65-78% respectively, P = 0.3). The ROC analysis showed the absence of discrimination accuracy for ScvO2 to predict the outcome (AUC = 0.56). By multivariate analysis, ScvO2 < 70% was not associated with the outcome (OR 1.67; 95% CI 0.64-4.36). Variables that were associated with ICU admission or death by day 7 included a shock-index (heart rate/systolic blood pressure) > 1 and a performance status > 2 (OR 4.76; 95% CI 1.81-12.52 and OR 6.23, 95% CI 2.40-16.17, respectively). This study does not support the use of ScvO2 to risk stratify cancer patients presenting to the ED.
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Affiliation(s)
- Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
| | - Guillaume Dumas
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Léa Legay
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Alessandra Principe
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jessica Franchitti
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Marie Simonetta
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Anne Verrat
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jihed Amami
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Hélène Milacic
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Adélia Bragança
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Ariane Gillet
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Matthieu Resche-Rigon
- Biostatistics and Medical Information Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS-INSERM-UMR1153), ECSTRRA Team, Paris, France
- Paris Diderot University, Paris, France
| | - Jean-Paul Fontaine
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Elie Azoulay
- Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS-INSERM-UMR1153), ECSTRRA Team, Paris, France
- Paris Diderot University, Paris, France
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Úbeda-Iglesias A, Alonso-Romero L, Esquinas-Rodríguez AM. Comments on "Helpful Only When Elevated: Initial Serum Lactate in Stable Emergency Department Patients With Sepsis Is Specific, but Not Sensitive for Future Deterioration". J Emerg Med 2019; 56:227-228. [PMID: 30738563 DOI: 10.1016/j.jemermed.2018.09.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 06/09/2023]
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