Introduction:Screening for severe sepsis in adult emergency department (ED) patients may involve potential delays while waiting for laboratory testing, leading to postponed identification or over-utilization of resources. The systemic inflammatory response syndrome (SIRS) criteria are inaccurate at predicting clinical outcomes in sepsis. Shock index (SI), defined as heart rate / systolic blood pressure, has previously been shown to identify high risk septic patients. Our objective was to compare the ability of SI, individual vital signs, and the systemic inflammatory response syndrome (SIRS) criteria to predict the primary outcome of hyperlactatemia (serum lactate ≥ 4.0 mmol/L) as a surrogate for disease severity, and the secondary outcome of 28-day mortality.Methods:We performed a retrospective analysis of a cohort of adult ED patients at an academic community trauma center with 95,000 annual visits, from February 1st, 2007 to May 28th, 2008. Adult patients presenting to the ED with a suspected infection were screened for severe sepsis using a standardized institutional electronic order set, which included triage vital signs, basic laboratory tests and an initial serum lactate level. Test characteristics were calculated for two outcomes: hyperlactatemia (marker for morbidity) and 28-day mortality. We considered the following covariates in our analysis: heart rate >90 beats/min; mean arterial pressure < 65 mmHg; respiratory rate > 20 breaths/min; ≥ 2 SIRS with vital signs only; ≥2 SIRS including white blood cell count; SI ≥ 0.7; and SI ≥ 1.0. We report sensitivities, specificities, and positive and negative predictive values for the primary and secondary outcomes.Results:2524 patients (89.4%) had complete records and were included in the analysis. 290 (11.5%) patients presented with hyperlactatemia and 361 (14%) patients died within 28 days. Subjects with an abnormal SI of 0.7 or greater (15.8%) were three times more likely to present with hyperlactatemia than those with a normal SI (4.9%). The negative predictive value (NPV) of a SI ≥ 0.7 was 95%, identical to the NPV of SIRS.Conclusion:In this cohort, SI ≥ 0.7 performed as well as SIRS in NPV and was the most sensitive screening test for hyperlactatemia and 28-day mortality. SI ≥ 1.0 was the most specific predictor of both outcomes. Future research should focus on multi-site validation, with implications for early identification of at-risk patients and resource utilization.

Background Admission hyperglycemia has been reported as a mortality risk factor for septic nondiabetic patients; however, hyperglycemia’s known association with hyperlactatemia was not addressed in these analyses. Objectives The objective was to determine whether the association of hyperglycemia with mortality remains significant when adjusted for concurrent hyperlactatemia. Methods This was a post hoc, nested analysis of a retrospective cohort study performed at a single center. Providers had identified study subjects during their ED encounters; all data were collected from the electronic medical record (EMR). Nondiabetic adult ED patients hospitalized for suspected infection, two or more systemic inflammatory response syndrome (SIRS) criteria, and simultaneous lactate and glucose testing in the ED were enrolled. The setting was the ED of an urban teaching hospital from 2007 to 2009. To evaluate the association of hyperglycemia (glucose > 200 mg/dL) with hyperlactatemia (lactate ≥ 4.0 mmol/L), a logistic regression model was created. The outcome was a diagnosis of hyperlactatemia, and the primary variable of interest was hyperglycemia. A second model was created to determine if coexisting hyperlactatemia affects hyperglycemia’s association with mortality; the main outcome was 28-day mortality, and the primary risk variable was hyperglycemia with an interaction term for simultaneous hyperlactatemia. Both models were adjusted for demographics; comorbidities; presenting infectious source; and objective evidence of renal, respiratory, hematologic, or cardiovascular dysfunction. Results A total of 1,236 ED patients were included, and the median age was 77 years (interquartile range [IQR] = 60 to 87 years). A total of 115 (9.3%) subjects were hyperglycemic, 162 (13%) were hyperlactatemic, and 214 (17%) died within 28 days of their initial ED visits. After adjustment, hyperglycemia was significantly associated with simultaneous hyperlactatemia (odds ratio [OR] = 4.14, 95% confidence interval [CI] = 2.65 to 6.45). Hyperglycemia and concurrent hyperlactatemia were associated with increased mortality risk (OR = 3.96, 95% CI = 2.01 to 7.79), but hyperglycemia in the absence of simultaneous hyperlactatemia was not (OR = 0.78, 95% CI = 0.39 to 1.57). Conclusions In this cohort of septic adult nondiabetic patients, mortality risk did not increase with hyperglycemia unless associated with simultaneous hyperlactatemia. The previously reported association of hyperglycemia with mortality in nondiabetic sepsis may be due to the association of hyperglycemia with hyperlactatemia.

Objective To determine if metformin use affects the prevalence and prognostic value of hyperlactatemia to predict mortality in septic adult Emergency Department (ED) patients. Methods Single-center retrospective cohort study. ED providers identified study subjects; data was collected from the medical record. Patients Adult ED patients with suspected infection and 2 or more Systemic Inflammatory Response Syndrome Criteria. The outcome was 28-day mortality. The primary risk variable was serum lactate (< 2.0; 2.0–3.9; ≥4.0 mmol/L) categorized by metformin use; covariates-demographics, Predisposition, Infection, Response, Organ Dysfunction score, and metformin use contraindications. Setting Urban teaching hospital; 2/1/2007 to 10/31/2008. Results 1947 ED patients were enrolled; 192 (10%) were taking metformin; 305 (16%) died within 28-days. Metformin users had higher median lactate levels than non-users [2.2 mmol/L (IQR 1.6–3.2) vs. 1.9 mmol/L (IQR 1.3–2.8)] and a higher, though non-significant, prevalence of hyperlactatemia (lactate ≥ 4.0 mmol/L) (17% vs. 13%) (p=0.17). In multivariate analysis (reference group non-metformin users, lactate < 2.0 mmol/L), hyperlactatemia was associated with an increased adjusted 28-day mortality risk among non-metformin users (OR = 3.18, p < 0.01), but not among metformin users (OR = 0.54, p=0.33). Additionally, non-metformin users had a higher adjusted mortality risk than metformin users (OR = 2.49, p < 0.01). These differences remained significant when only diabetics were analyzed. Conclusions In this study of adult ED patients with suspected sepsis, metformin users had slightly higher median lactate levels and prevalence of hyperlactatemia. However, hyperlactatemia did not predict an increased mortality risk in patients taking metformin.