Sharukh Lokhandwala1, Ari Moskowitz2, Rebecca Lawniczak3, Tyler Giberson4, Michael N Cocchi5, Michael W Donnino6. 1. Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA. 2. Department of Medicine, Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA. 3. Department of Emergency Medicine, Northern Westchester Hospital, Mt Kisco, NY. 4. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. 5. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, Milton, MA. 6. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine, Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA. Electronic address: mdonnino@bidmc.harvard.edu.
Abstract
PURPOSE: Occult hypoperfusion is associated with increased mortality in patients with sepsis. We sought to determine the practice patterns and outcomes of patients with sepsis-related occult hypoperfusion and introduce a potential method for risk stratification. MATERIALS AND METHODS: Single-center retrospective study of normotensive patients presenting to an urban tertiary care emergency department with lactate greater than or equal to 4 mmol/L and suspected infection. χ(2) Testing, Spearman, and Wilcoxon coefficients were used to compare binary, parametric, and nonparametric data, respectively. Patients were divided into 4 groups based on lactate clearance (<4 mmol/L) and the presence of respiratory distress while in the emergency department; outcomes were compared using χ(2) test and analysis of variance. RESULTS: Median initial lactate was 4.7 mmol/L (interquartile range, 4.2-6.4), and 34 (45.2%) of 73 exhibited respiratory distress. Hyperlactatemia resolved in 67.1% (49/73) of patients. Mortality was 23.3% (17/73), and 19.1% (14/73) required vasopressors. In patients with lactate clearance and without respiratory distress (n = 27), mortality was 0%, and none required vasopressors. In patients with persistent hyperlactatemia and/or respiratory distress (n = 46), 30.4% required vasopressors, and the mortality was 37.0% (P < .01 and P < .01, respectively). CONCLUSIONS: Patients defined as having occult hypoperfusion comprise a heterogeneous group with a varied degree of illness severity. Identifying those with low risk of clinical deterioration may be important for titration of care.
PURPOSE:Occult hypoperfusion is associated with increased mortality in patients with sepsis. We sought to determine the practice patterns and outcomes of patients with sepsis-related occult hypoperfusion and introduce a potential method for risk stratification. MATERIALS AND METHODS: Single-center retrospective study of normotensive patients presenting to an urban tertiary care emergency department with lactate greater than or equal to 4 mmol/L and suspected infection. χ(2) Testing, Spearman, and Wilcoxon coefficients were used to compare binary, parametric, and nonparametric data, respectively. Patients were divided into 4 groups based on lactate clearance (<4 mmol/L) and the presence of respiratory distress while in the emergency department; outcomes were compared using χ(2) test and analysis of variance. RESULTS: Median initial lactate was 4.7 mmol/L (interquartile range, 4.2-6.4), and 34 (45.2%) of 73 exhibited respiratory distress. Hyperlactatemia resolved in 67.1% (49/73) of patients. Mortality was 23.3% (17/73), and 19.1% (14/73) required vasopressors. In patients with lactate clearance and without respiratory distress (n = 27), mortality was 0%, and none required vasopressors. In patients with persistent hyperlactatemia and/or respiratory distress (n = 46), 30.4% required vasopressors, and the mortality was 37.0% (P < .01 and P < .01, respectively). CONCLUSIONS:Patients defined as having occult hypoperfusion comprise a heterogeneous group with a varied degree of illness severity. Identifying those with low risk of clinical deterioration may be important for titration of care.
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