Assessment of Concurrent Hyperglycemia and Lactate Elevation with Hospital Outcomes in Emergency Department Sepsis Patients
Mentor:Dr. Ryan Arnold, Attending, Department of Emergency Medicine, Cooper University Hospital
Background: There is an association between hyperglycemia and hyperlactatemia with increased mortality in emergency department (ED) patients with severe sepsis (lactate>4.0). The association of hyperglycemia (glucose>200mg/dL) with elevated serum lactate in lower severity ED-sepsis patients may identify patients at increased risk for clinical deterioration. Objective: To determine whether concurrent glucose and lactate elevation were predictive of adverse hospital outcomes in the ED PRE-SHOCK sepsis patients. Sub-analysis of hyperglycemia on hospital outcome in diabetic and non-diabetic ED PRE-SHOCK patients. Methods: Retrospective analysis of a prospectively maintained registry of sepsis patients with lactate and glucose measurements. History of diabetes was included. The PRE-SHOCK population (adult ED-sepsis patients with elevated lactate (2.0–3.9mM) or transient hypotension (sBP<90mmHg) receiving IV-antibiotics and admitted to medical floor). Exclusions include overt shock in the ED, pregnancy, or acute trauma. We defined a primary patient-centered outcome of increased organ failure (sequential organ failure assessment [SOFA] score increase >1 point, mechanical ventilation or vasopressor utilization) within 72-hours of admission or in-hospital mortality. Secondary outcomes included ventilator-free days, ICU utilization, and hospital/ICU stay length. Results: We identified 248 PRE-SHOCK patients. The primary outcome was met in 54% of cohort and 44% were transferred to ICU from a medical floor. Patients meeting outcome of increased organ failure had greater Shock Indexes (1.02 vs.0.93,p=0.042) and HR (115 vs.105,p<0.001) with no difference in initial lactate, age, MAP or exposure to hypotension (sBP<100 mmHg). Outcome patients had similar initial levels of organ dysfunction, but higher SOFA scores at 24, 48, and 72-hours, higher ICU transfer rates (60 vs.24%,p<0.001) and increased ICU/hospital length of stays. The PRE-SHOCK population has high incidences of clinical deterioration, progressive organ failure, and ICU transfers. No significant difference was found between non-diabetic(3vs.5%) and diabetic(11vs.15%) hyperglycemic PRE-SHOCK patient outcomes. Aggressive glucose control in PRE-SHOCK patients does not necessarily prevent adverse hospital outcomes.