Prehospital Point-Of-Care Lactate Increases the Prognostic Accuracy of National Early Warning Score 2 for Early Risk Stratification of Mortality: Results of a Multicenter, Observational Study

Modified Rapid Emergency Medicine Score-Lactate (mREMS-L) performance to screen non-anticipated 30-day-related-mortality in emergency department

BACKGROUND

The aim of this study was to compare the ability to predict 30-day in-hospital mortality of lactate versus the modified Rapid Emergency Medicine Score (mREMS) versus the arithmetic sum of the mREMS plus the numerical value of lactate (mREMS-L).

METHODS

A prospective, multicentric, emergency department delivery, pragmatic study was conducted. To determine the predictive capacity of the scales, lactate was measured and the mREMS and mREMS-L were calculated in adult patients (aged>18 years) transferred with high priority by ambulance to the emergency department in five hospitals of Castilla y Leon between 1 January 2020 and 31 December 2021. The area under the receiver operating characteristic (ROC) curve of each of the scales was calculated in terms of mortality for 30 days.

RESULTS

A total of 5371 participants were included, and the in-hospital mortality rate at 30 days was of 11.4% (615 cases). The best cut-off point determined in the mREMS was 7.0 points (sensitivity of 67% and specificity of 84%), and for lactate, the cut-off point was 1.4 mmol/L (sensitivity of 88% and specificity of 67%). Finally, the combined mREMS-L showed a cut-off point of 7.9 (sensitivity of 83% and a specificity of 83%). The area under the ROC curve of the mREMS, lactate and mREMS-L for 30-day mortality was 0.851, 0.853, and 0.903, respectively (p < 0.001 in all cases).

CONCLUSIONS

The new score generated, mREMS-L, obtained better statistical results than its components (mREMS and lactate) separately.

The accuracy of the National Early Warning Score 2 in predicting early death in prehospital and emergency department settings: a systematic review and meta-analysis

Background

Many studies have explored the accuracy of the National Early Warning Score 2 (NEWS2) in predicting mortality in prehospital and emergency settings, but their findings are inconsistent. Whether NEWS2 is reliable for the pre-examination and triage of patients in prehospital settings and emergency departments remains debatable. Hence, this study aimed to evaluate the accuracy of NEWS2 in predicting mortality in prehospital settings and emergency departments.

Methods

We searched PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wan Fang Data, Vip Database and SinoMed from the inception of each database to January 2023. The inclusion criteria: (I) patients in the prehospital settings or emergency departments; (II) the NEWS2 for predicting 2-day mortality, 30-day mortality, and in-hospital mortality; (III) sufficient data, such as sensitivity, specificity, overall survival, and deaths, were provided for the study; (IV) the type of study was accuracy prediction study. Two authors independently extracted data, including authors, year of publication, country of origin, study design, sample size, threshold cutoff values of NEWS2, and mortality. The PROBAST was used to assess the risk of bias in the included studies.

Results

Thirty studies with 185,835 participants were included. Among the 30 included studies, 13 have a high risk of bias, and 17 have a low risk of bias. The pooled sensitivity, specificity and AUC of 2-day mortality (early mortality), 30-day mortality and in-hospital mortality were 0.81 vs. 0.76 vs. 0.72 (95% CI: 0.61, 0.80), 0.81 vs. 0.69 vs. 0.78 (95% CI: 0.49, 0.93) and 0.88 vs. 0.80 vs. 0.78 (95% CI: 0.74, 0.82), respectively.

Conclusions

NEWS2 has excellent sensitivity and specificity in predicting early mortality in patients in the prehospitals setting and emergency departments. Nonetheless, it has poor performance in predicting in-hospital mortality and 30-day mortality. Our findings underpin the use of NEWS2 as a pre-examination and triage tool to predict early death in the prehospital settings and emergency departments. To improve the predictive accuracy, it should be used to monitor patients continuously rather than at a single point-in-time.

Prevalence and clinical significance of point of care elevated lactate at emergency admission in older patients: a prospective study

OBJECTIVE

Patients who are over 65 years old represent up to 24% of emergency department (ED) admissions. They are at increased risk of under-triage due to impaired physiological responses. The primary objective of this study was to assess the prevalence of elevated lactate by point of care testing (POCT) in this population. The secondary objective was to assess the additional value of lactate level in predicting an early poor outcome, as compared to and combined with common clinical scores and triage scales.

METHODS

This monocentric prospective study recruited ED patients who were over 65 years old between July 19th 2019 and June 17th 2020. Patients consulting for seizures or needing immediate assessment were excluded. POCT lactates were considered elevated if ≥ 2.5 mmol/L. A poor outcome was defined based on certain complications or therapeutic decisions.

RESULTS

In total, 602 patients were included; 163 (27.1%) had elevated lactate and 44 (7.3%) had a poor outcome. There was no association between poor outcome and lactate level. Modified Early Warning Score (MEWS) was significantly associated with poor outcome, alongside National Early Warning Score (NEWS). Logistic regression also associated lactate level combined with MEWS and poor outcome.

CONCLUSION

The prevalence of elevated lactate was 27.1%. Lactate level alone or combined with different triage scales or clinical scores such as MEWS, NEWS and qSOFA was not associated with prediction of a poor outcome. MEWS alone performed best in predicting poor outcome. The usefulness of POCT lactate measurement at triage is questionable in the population of 65 and above.

The predictive value of serum lactate to forecast injury severity in trauma-patients increases taking age into account

BACKGROUND

Two-tier trauma team activation (TTA)-protocols often fail to safely identify severely injured patients. A possible amendment to existing triage scores could be the measurement of serum lactate. The aim of this study was to determine the ability of the combination of serum lactate and age to predict severe injuries (ISS > 15).

METHODS

We conducted a retrospective cohort study in a single level one trauma center in a 20 months study-period and analyzed every trauma team activation (TTA) due to the mechanism of injury (MOI). Primary endpoint was the correlation between serum lactate (and age) and ISS and mortality. The validity of lactate (LAC) and lactate contingent on age (LAC + AGE) were assessed using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. We used a logistic regression model to predict the probability of an ISS > 15.

RESULTS

During the study period we included 325 patients, 75 met exclusion criteria. Mean age was 43 years (Min.: 11, Max.: 90, SD: 18.7) with a mean ISS of 8.4 (SD: 8.99). LAC showed a sensitivity of 0.82 with a specificity of 0.62 with an optimal cutoff at 1.72 mmol/l to predict an ISS > 15. The AUC of the ROC for LAC was 0.764 (95% CI: 0.67-0.85). The LAC + AGE model provided a significantly improved predictive value compared to LAC (0.765 vs. 0.828, p < 0.001).

CONCLUSIONS

The serum lactate concentration is able to predict injury severity. The prognostic value improves significantly taking the patients age into consideration. The combination of serum lactate and age could be a suitable Ad-on to existing two-tier triage protocols to minimize undertriage.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

An Analysis COVID-19 in Mexico: a Prediction of Severity

BACKGROUND

Coronavirus disease 2019 (COVID-19) causes a mild illness in most cases; forecasting COVID-19-associated mortality and the demand for hospital beds and ventilators are crucial for rationing countries' resources.

OBJECTIVE

To evaluate factors associated with the severity of COVID-19 in Mexico and to develop and validate a score to predict severity in patients with COVID-19 infection in Mexico.

DESIGN

Retrospective cohort.

PARTICIPANTS

We included 1,435,316 patients with COVID-19 included before the first vaccine application in Mexico; 725,289 (50.5%) were men; patient's mean age (standard deviation (SD)) was 43.9 (16.9) years; 21.7% of patients were considered severe COVID-19 because they were hospitalized, died or both.

MAIN MEASURES

We assessed demographic variables, smoking status, pregnancy, and comorbidities. Backward selection of variables was used to derive and validate a model to predict the severity of COVID-19.

KEY RESULTS

We developed a logistic regression model with 14 main variables, splines, and interactions that may predict the probability of COVID-19 severity (area under the curve for the validation cohort = 82.4%).

CONCLUSIONS

We developed a new model able to predict the severity of COVID-19 in Mexican patients. This model could be helpful in epidemiology and medical decisions.

Elevated serum lactate levels and age are associated with an increased risk for severe injury in trauma team activation due to trauma mechanism

BACKGROUND

The identification of risk factors for severe injury is crucial in trauma triage and trauma team activation (TTA) depends on a sufficient triage. The aim of this study was to determine whether or not elevated serum lactate levels and age are risk factors for severe injury in TTA due to trauma mechanism.

METHODS

We conducted a retrospective cohort study in a single level one trauma center between September 2019 and May 2021 and analysed every TTA due to trauma mechanism. Primary endpoint of interest was the association of serum lactate as well as age with injury severity assessed by the injury severity score (ISS).

RESULTS

During the study period, we included 250 patients. Mean age was 43.3 years (Min.: 11, Max.: 90, SD: 18.7) and the initial lactate level was 1.7 mmol/L (SD: 0.95) with a mean ISS of 8.4 (SD: 8.99). The adjusted odds ratio (OR) for age > 65 being associated with an ISS > 16 is 9.7 (p < 0.001; 95% CI 4.01-25.58) and for lactate > 2.2 mmol/L being associated with an ISS > 16 is 6.29 (p < 0.001; 95% CI 2.93-13.48). A lactate level of > 4 mmol/L results in a 36-fold higher risk of severe injury with an ISS > 16 (OR 36.06; 95% CI 4-324.29).

CONCLUSION

This study identifies age (> 65) and lactate (> 2.2 mmol/L) as independent risk factors for severe injury in a TTA due to trauma mechanism. Existing triage protocols might benefit from congruous amendments.

Can capillary lactate improve early warning scores in emergency department? An observational, prospective, multicentre study

AIMS

To determine the prognostic usefulness of the National Early Warning Score-2 (NEWS2) and quick Sepsis-related Organ Failure Assessment (qSOFA) scores, in isolation and combined with capillary lactate (CL), using the new NEWS2-L and qSOFA-L scores to predict the 30-day mortality risk.

METHODS

Prospective, multicentre and observational study in patients across four EDs. We collected sets of vital signs and CL and subsequently calculated NEWS2, qSOFA, NEWS2-L and qSOFA-L scores when patients arrived at the ED. The main outcome measure was all-cause mortality 30 days from the index event.

RESULTS

A total of 941 patients were included. Thirty-six patients (3.8%) died within 30 days of the index event. A high CL level has not been linked to a higher mortality. The NEWS2 presented AUROC of 0.72 (95% CI: 0.62-0.81), qSOFA of 0.66 (95% CI: 0.56-0.77) (P < .001 in both cases) and CL 0.55 (95% CI: 0.42-0.65; P = .229) to predict 30-day mortality. The addition of CL to the scores analysed does not improve the results of the scores used in isolation.

CONCLUSION

NEWS2 and qSOFA scores are a very useful tool for assessing the status of patients who come to the ED in general for all types of patients in triage categories II and III and for detecting the 30-day mortality risk. CL determined systematically in the ED does not seem to provide information on the prognosis of the patients.