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Age-adjusted and Expanded Lactate Thresholds as Predictors of All-Cause Mortality in the Emergency Department.

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.

SUBMITTER: Cannon CM

PROVIDER: S-EPMC7514398 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Age-adjusted and Expanded Lactate Thresholds as Predictors of All-Cause Mortality in the Emergency Department.

Cannon Chad M CM Miller Ross T RT Grow Krista L KL Purcell Seth S Nazir Niaman N

The western journal of emergency medicine 20200820 5

<h4>Introduction</h4>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.<h4>Methods</h4>This was a retrospective cohort study in an urban, tertiary-care teaching hospital. A to ...[more]

PMID: 32970582

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Project description:The LACE index has been shown to predict hospital readmissions and death with variable accuracy. A LACE index ≥ 10 is considered as high risk in the existing literature. We aimed to derive age-specific LACE index thresholds in the prediction of mortality and frequent readmissions. Analysis of prospectively collected data of consecutive alive-discharge episodes between 01/04/2017 and 31/03/2019 to a single hospital was conducted. The derivation of LACE index thresholds for predicting all-cause mortality within 6 months of hospital discharge or frequent readmissions (≥ 2 times within 28 days) was examined by receiver operating characteristics (ROC) in 32270 patients (14878 men, 17392 women) aged 18-107 year (mean = 64.0 years, SD = 20.5). For all patients with a LACE index ≥ 10, the area under the curve (AUC) for predicting mortality was 80.5% (95% CI 79.7-81.3) and for frequent readmissions was 84.0% (83.0-85.1). Two-graph ROC plots showed that the LACE index threshold where sensitivity equates specificity was 9.5 (95% intermediate range = 5.6-13.5) for predicting mortality and 10.3 (95% intermediate range = 6.6-13.6) for frequent readmissions. These thresholds were lowest among youngest individuals and rose progressively with age for mortality prediction: 18-49 years = 5.0, 50-59 years = 6.5, 60-69 years = 8.0, 70-79 years = 9.8 and ≥ 80 years = 11.6, and similarly for frequent readmissions: 18-49 years = 5.1, 50-59 years = 7.5, 60-69 years = 9.1, 70-79 years = 10.6 and ≥ 80 years = 12.0. Positive and negative likelihood ratios (LRs) ranged 1.5-3.3 and 0.4-0.6 for predicting mortality, and 2.5-4.4 and 0.3-0.6 for frequent readmissions, respectively, with stronger evidence in younger than in older individuals (LRs further from unity). In conclusion, the LACE index predicts mortality and frequent readmissions at lower thresholds and stronger in younger than in older individuals. Age should be taken into account when using the LACE index for identifying patients at high risk.

Project description:PURPOSE:Sepsis is a common acute life-threatening condition that emergency physicians routinely face. Diagnostic options within the Emergency Department (ED) are limited due to lack of infrastructure, consequently limiting the use of invasive hemodynamic monitoring or imaging tests. The mortality rate due to sepsis can be assessed via multiple scoring systems, for example, mortality in emergency department sepsis (MEDS) score and sepsis patient evaluation in the emergency department (SPEED) score, both of which quantify the variation of mortality rates according to clinical findings, laboratory data, or therapeutic interventions. This study aims to improve the management processes of sepsis patients by comparing SPEED score and MEDS score for predicting the 28-day mortality in cases of emergency sepsis. METHODS:The study is a cross-sectional, prospective study including 61 sepsis patients in ED in Suez Canal University Hospital, Egypt, from August 2017 to June 2018. Patients were selected by two steps: (1) suspected septic patients presenting with at least one of the following abnormal clinical findings: (a) body temperature higher than 38 °C or lower than 36 °C, (b) heart rate higher than 90 beats/min, (c) hyperventilation evidenced by respiratory rate higher than 20 breaths/min or PaCO2 lower than 32 mmHg, and (d) white blood cell count higher than 12,000/?L or lower than 4000/?L; (2) confirmed septic patients with at least a 2-point increase from the baseline total sequential organ failure assessment (SOFA) score following infection. Other inclusion criteria included adult patients with an age ?18 years regardless of gender and those who had either systemic inflammatory response syndrome or suspected/confirmed infection. Patients were shortly follow-up for the 28-day mortality. Each patient was subject to SPEED score and MEDS score and then the results were compared to detect which of them was more effective in predicting outcome. The receiver operating characteristic curves were also done for MEDS and SPEED scores. RESULTS:Among the 61 patients, 41 died with the mortality rate of 67.2%. The mortality rate increased with a higher SPEED and MEDS scores. Both SPEED and MEDS scores revealed significant difference between the survivors and nonsurvivors (p = 0.004 and p < 0.001, respectively), indicating that both the two systems are effective in predicting the 28-day mortality of sepsis patients. Thereafter, the receiver operating characteristic curves were plotted, which showed that SPEED was better than the MEDS score when applied to the complete study population with an area under the curve being 0.87 (0.788-0.963) as compared with 0.75 (0.634-0.876) for MEDS. Logistic regression analysis revealed that the best fitting predictor of 28-day mortality for sepsis patients was the SPEED scoring system. For every one unit increase in SPEED score, the odds of 28-day mortality increased by 37%. CONCLUSION:SPEED score is more useful and accurate than MEDS score in predicting the 28-day mortality among sepsis patients. Therefore SPEED rather than MEDS should be more widely used in the ED for sepsis patients.

Dataset Information

Age-adjusted and Expanded Lactate Thresholds as Predictors of All-Cause Mortality in the Emergency Department.

Publications

Age-adjusted and Expanded Lactate Thresholds as Predictors of All-Cause Mortality in the Emergency Department.

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