Prognostic accuracy of using lactate in addition to the quick Sequential Organ Failure Assessment score and the National Early Warning Score for emergency department patients with suspected infection

Abstract

BackgroundThe aim of this study was to determine whether: (1) the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and National Early Warning Score (NEWS) clinical prediction tools alone, (2) modified versions of these prediction tools that integrate lactate into their scores, or (3) use of the two tools in tandem with lactate better predicts in-hospital 28-day mortality among adult EDpatients with suspected infection.MethodsFrom 1 January through 31 December 2018, this retrospective cohort study enrolled consecutive adult patients with suspected infection evaluated at two EDs in France. Patients were included if blood cultures were obtained and non-prophylactic antibiotics were administered in the ED. qSOFA, NEWS criteria and lactate measurements were recorded when patients were clinically suspected of having an infection. Two composite scores (lactate qSOFA (LqSOFA) and lactate NEWS (LNEWS)) integrating lactate were created. Diagnostic test performances for predicting in-hospital mortality within 28days were assessed for qSOFA≥2, LqSOFA≥2, qSOFA≥2 or lactate≥2 mmol/L, and for NEWS≥7, LNEWS≥7, and NEWS≥7 or lactate≥2 mmol/L.Results1003 patients were included, 130 (13%) of whom had died by day 28. Sensitivities for 28-day mortality were 50% (95%CI41% to 59%) for qSOFA≥2,69% (95% CI60% to 77%) for LqSOFA≥2,77% (95% CI69% to 84%) for qSOFA or lactate≥2 mmol/L; and 69% (95% CI60% to 77%) for NEWS≥7, 80% (95% CI72% to 86%) for LNEWS≥7, 87% (95% CI80% to 92%) for NEWS≥7 or lactate≥2 mmol/L.ConclusionLactate used in tandem with qSOFA or NEWS yielded higher sensitivities in predicting in-hospital 28-day mortality, as compared with integration of lactate into these prediction tools or usage of the tools independently.

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

“…deterioration in patients with different clinical beyond cases of sepsis, in which its use is evident. [26][27][28][29][30] Hence, different studies reported its use in association with other scores: associated to ViEWS, it improves the prognosis of mortality in critical and major trauma patients 16,17 ; when associated to Modified Early Warning Score (MEWS) it improves accuracy with respect to admission to the ICU 29 ; when used with NEWS2, it detects the risk of 2-day in-hospital mortality in the ED setting. 22,31 Although its effectiveness is questionable when it is used indiscriminately among general patients in emergency services, contradictory results are reported between different authors.…”

“…The use of lactate in combination with different EWSs is not new. Since 2013 when Jo et al 21 combined it with ViEWS, numerous studies have tested it in different populations, demonstrating that the use of biomarkers, and specifically lactate, is very useful for identifying clinical deterioration in patients with different clinical conditions beyond cases of sepsis, in which its use is evident 26–30 . Hence, different studies reported its use in association with other scores: associated to ViEWS, it improves the prognosis of mortality in critical and major trauma patients 16,17 ; when associated to Modified Early Warning Score (MEWS) it improves accuracy with respect to admission to the ICU 29 ; when used with NEWS2, it detects the risk of 2‐day in‐hospital mortality in the ED setting 22,31 .…”

Accelerating Detection and Intervention for Sepsis in Skilled Nursing Facilities Using a Sepsis Pathway

“…Similar to hospital settings, providing timely sepsis-related data to physicians is crucial to timely assessment and further confirmation of sepsis 7. Lactate is part of the battery of tests performed in hospital settings to monitor the progress of sepsis 20. However, obtaining lactate levels can be challenging in facilities that do not have access to laboratories nearby and in resource-limited settings.…”

“…7 Lactate is part of the battery of tests performed in hospital settings to monitor the progress of sepsis. 20 However, obtaining lactate levels can be challenging in facilities that do not have access to laboratories nearby and in resource-limited The modified sepsis care pathway also encouraged nurses and CNAs to be vigilant about the results of any laboratory tests and to communicate with the physicians. Increased communication facilitated the timely and effective diagnosis of sepsis in the implementation phase.…”