Advertisement

Prognostic use of lactate to predict inpatient mortality in acute gastrointestinal hemorrhage

Published:February 19, 2014DOI:https://doi.org/10.1016/j.ajem.2014.02.010

      Abstract

      Background

      Gastrointestinal hemorrhage (GIH) is a common complaint seen in the emergency department (ED) and carries a small but significant mortality rate. The principal purpose of this investigation was to determine whether an ED venous lactate as part of initial laboratory studies is predictive of mortality in patients admitted to the hospital for GIH.

      Methods

      Retrospective cohort study for 6 years at an urban tertiary referral hospital included all ED patients with the charted diagnosis of acute GIH. Serum lactate was drawn at the bedside as part of patient care after arrival to the ED at the discretion of the clinical team. Clinical parameters and inpatient mortality were collected from the medical record. Optimal cut points for lactate were derived using receiver operating characteristics curves and imputed into a multivariable logistic regression model.

      Results

      Of the 2834 medical records that had GIH diagnoses, 1644 had an ED lactate recorded. A lactate greater than 4 mmol/L conferred a 6.4-fold increased odds of in-hospital mortality (94% specificity, P < .001). Controlling for age, initial hematocrit, and heart rate, every 1-point increase in lactate conferred a 1.4-fold increase in the odds of mortality.

      Conclusions

      Elevated initial lactate drawn in the ED can be associated with in-hospital mortality for ED patients with acute GIH. Prospective validation studies are warranted.
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Imperiale T.F.
        • Dominitz J.A.
        • Provenzale D.T.
        • Boes L.P.
        • Rose C.M.
        • Bowers J.C.
        • et al.
        Predicting poor outcome from acute upper gastrointestinal hemorrhage.
        Arch Intern Med. 2007; 167: 1291-1296
      1. Cagir B. Kate J. Lower gastrointestinal bleeding. Medscape, 2011
        • Fallam M.A.
        • Prakash C.
        • Edmundowicz S.
        Acute gastrointestinal bleeding.
        Med Clin North Am. 2000; 84: 1183-1208
        • Gilbert D.A.
        Epidemiology of upper gastrointestinal bleeding.
        Gastrointest Endosc. 1990; 36: 58-513
        • Johanson J.F.
        Curbing the costs of GI bleeding.
        Am J Gastroenterol. 1998; 93: 1384-1385
        • Quirk D.M.
        • Barry M.J.
        • Aserkogg B.
        Physician specialty and variations in the cost of treating patients with acute upper gastrointestinal bleeding.
        Gastroenterology. 1997; 113: 1443-1448
        • Cooper G.S.
        • Chak A.
        • Way L.E.
        • Hammer pJ
        • Harper D.L.
        • Rosenthal G.E.
        Endoscopic practice for upper gastrointestinal hemorrhage; differences between major teaching and community-based hospitals.
        Gastrointest Endosc. 1998; 48: 348-353
        • Rockall T.A.
        • Logan R.F.
        • Devlin H.B.
        • Northfield T.C.
        Risk assessment after acute upper gastrointestinal haemorrhage.
        Gut. 1996; 38: 316-321
        • Manini A.F.
        • Kumar A.
        • Olsen D.
        • Vlahov D.
        • Hoffman R.S.
        Utility of serum lactate to predict drug-overdose fatality.
        Clin Toxicol (Phila). 2010; 48: 730-736
        • Sobhian B.
        • Kröpfl A.
        • Hölzenbein T.
        • Khadem A.
        • Redl H.
        • Bahrami S.
        Increased circulating d-lactate levels predict risk of mortality after hemorrhage and surgical trauma in baboons.
        Shock. 2012; 37: 473-477
        • Hajjar A.
        • Nakamura R.E.
        • de Almeida J.P.
        • Fukushima J.T.
        • Hoff P.M.
        • Vincent J.L.
        • et al.
        Lactate and base deficit are predictors of mortality in critically ill patients with cancer.
        Clinics (San Paolo). 2011; 66: 2037-2042
        • Maarslet L.
        • Møller M.B.
        • Dall R.
        • Hjortholm K.
        • Raun H.
        Lactate levels predict mortality and need for peritoneal dialysis in children undergoing congenital heart surgery.
        Acta Anaesthesiol Scand. 2012; 56: 459-464
        • Neville A.L.
        • Nemtsev D.
        • Manasrah R.
        • Bricker S.D.
        • Putnam B.A.
        Mortality risk stratification in elderly trauma patients based on initial arterial lactate and base deficit levels.
        Am Surg. 2011; 77: 1337-1341
        • Nichol A.
        • Bailey M.
        • Egi M.
        • Pettila V.
        • French C.
        • Stachewski E.
        • et al.
        Dynamic lactate indices as predictors of outcome in critically ill patients.
        Crit Care. 2011; 15: R242
        • Jansen T.C.
        • van Bommel J.
        • Mulder pg
        • Rommes J.H.
        • Schieveld S.J.M.
        • Bakker J.
        The prognostic value of blood lactate levels relative to that of vital signs in the prehospital setting: a pilot study.
        Crit Care. 2008; 12: R160https://doi.org/10.1186/cc7159
        • Bakker J.
        • Gris P.
        • Coffernils M.
        • Kahn R.J.
        • Vincent J.L.
        Serial blood lactate levels can predict the development of multiple organ failure following septic shock.
        Am J Surg. 1996; 171: 221-226
        • Shapiro N.I.
        • Howell M.D.
        • Talmor D.
        • Nathanson L.A.
        • Lisbon A.
        • Wolfe R.E.
        • et al.
        Serum lactate as a predictor of mortality in emergency department patients with infection.
        Ann Emerg Med. 2005; 45: 524-528
        • Nguyen H.B.
        • Loomba M.
        • Yang J.J.
        • Jacobesen G.
        • Shah K.
        • Otero R.M.
        • et al.
        Early lactate clearance is associated with biomarkers of inflammation, coagulation, apoptosis, organ dysfunction and mortality in severe sepsis and septic shock.
        J Inflamm (Lond). 2010; 7: 6
        • Howell M.D.
        • Donnino M.
        • Clardy P.
        • Talmor D.
        • Shapiro N.I.
        Occult hypoperfusion and mortality in patients with suspected infection.
        Intensive Care Med. 2007; 33: 1892-1899
        • Bakker J.
        • Jansen T.C.
        Don't take vitals, take a lactate.
        Intensive Care Med. 2007; 33: 1863-1865
        • Wada T.
        • Hagiwara A.
        • Yahagi N.
        • et al.
        Lactate clearance is a predictor of sustained bleeding in emergency room patients with moderate upper gastrointestinal bleeding.
        Abstracted in Critical care. 2013; 17
        • Gilbert E.H.
        • Lowenstein S.R.
        • Koziol J.
        • Barta D.C.
        • Steiner J.
        Chart reviews in emergency medicine research: where are the methods?.
        Ann Emerg Med. 1996; 27: 305-308