Jon Gitz Holler

Lactate level, aetiology and mortality of adult patients in an emergency department: a cohort study

Background Increased lactate is associated with high mortality among patients with suspected infection or trauma in the emergency department (ED), but the association with patients with other aetiologies is less well described. The aim of this study was to describe the relation between lactate, aetiology and 7-day mortality in adult ED patients. Methods A retrospective cohort study of all adult patients who had a lactate measured within 4 h after arrival to the ED at Odense University Hospital between June 2012 and May 2013. The categorisation of suspected aetiology was based on discharge diagnoses. Results 5360 patients were included; 51.7% were men, and the median age was 67 years (IQR 50–79). 77.2% had low lactate (0–1.9 mmol/L), 16.2% intermediate lactate (2–3.9 mmol/L), and 6.6% high lactate (≥4 mmol/L). 7-day mortality was 2.9% (95% CI 2.4% to 3.5%) for patients with low lactate, 7.8% (95% CI 6.1% to 9.8%) for patients with intermediate lactate, and 23.9% (95% CI 19.6% to 28.8%) for patients with high lactate. The association between lactate level and mortality varied across different diagnostic groups. Based on Area Under the Curve in receiver operating characteristic analysis, lactate level showed to be useful in patients with infection (0.78, 95% CI 0.73 to 0.84), trauma (0.78, 95% CI 0.65 to 0.92), cardiac diseases (0.83, 95% CI 0.75 to 0.91) and gastrointestinal diseases (0.83, 95% CI 0.68 to 0.98). Lactate level was not useful in neurological (0.58, 95% CI 0.50 to 0.67) and respiratory disease (0.64, 95% CI 0.55 to 0.74), and of uncertain value in the remaining diagnostic groups. Conclusions Among adult ED patients, the prognostic value of lactate varies between diagnostic groups.

Nontraumatic Hypotension and Shock in the Emergency Department and the Prehospital setting, Prevalence, Etiology, and Mortality: A Systematic Review

Background Acute patients presenting with hypotension in the prehospital or emergency department (ED) setting are in need of focused management and knowledge of the epidemiology characteristics might help the clinician. The aim of this review was to address prevalence, etiology and mortality of nontraumatic hypotension (SBP ≤ 90 mmHg) with or without the presence of shock in the prehospital and ED setting. Methods We performed a systematic literature search up to August 2013, using Medline, Embase, Cinahl, Dare and The Cochrane Library. The analysis and eligibility criteria were documented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-guidelines) and The Cochrane Collaboration. No restrictions on language, publication date, or status were imposed. We used the Newcastle-Ottawa quality assessment scale (NOS-scale) and the Strengthening the Reporting of Observational studies in Epidemiology (STROBE-statement) to assess the quality. Results Six observational studies were considered eligible for analysis based on the evaluation of 11,880 identified papers. Prehospital prevalence of hypotension was 19.5/1000 emergency medicine service (EMS) contacts, and the prevalence of hypotensive shock was 9.5-19/1000 EMS contacts with an inhospital mortality of shock between 33 to 52%. ED prevalence of hypotension was 4-13/1000 contacts with a mortality of 12%. Information on mortality, prevalence and etiology of shock in the ED was limited. A meta-analysis was not feasible due to substantial heterogeneity between studies. Conclusion There is inadequate evidence to establish concise estimates of the characteristics of nontraumatic hypotension and shock in the ED or in the prehospital setting. The available studies suggest that 2% of EMS contacts present with nontraumatic hypotension while 1-2% present with shock. The inhospital mortality of prehospital shock is 33-52%. Prevalence of hypotension in the ED is 1% with an inhospital mortality of 12%. Prevalence, etiology and mortality of shock in the ED are not well described.

Is Shock Index a Valid Predictor of Mortality in Emergency Department Patients With Hypertension, Diabetes, High Age, or Receipt of β- or Calcium Channel Blockers?

STUDY OBJECTIVE Shock index is a widely reported tool to identify patients at risk for circulatory collapse. We hypothesize that old age, diabetes, hypertension, and β- or calcium channel blockers weaken the association between shock index and mortality. METHODS This was a cohort study of all first-time emergency department (ED) visits between 1995 and 2011 (n=111,019). We examined whether age 65 years or older, diabetes, hypertension, and use of β- or calcium channel blockers modified the association between shock index and 30-day mortality. RESULTS The 30-day mortality was 3.0%. For all patients, with shock index less than 0.7 as reference, a shock index of 0.7 to 1 had an adjusted odds ratio (OR) of 2.9 (95% confidence interval [CI] 2.7 to 3.2) for 30-day mortality, whereas shock index greater than or equal to 1 had an OR of 10.5 (95% CI 9.3 to 11.7). The crude OR for shock index greater than or equal to 1 in patients aged 65 years or older was 8.2 (95% CI 7.2 to 9.4) compared with 18.9 (95% CI 15.6 to 23.0) in younger patients. β- Or calcium channel-blocked patients had an OR of 6.4 (95% CI 4.9 to 8.3) versus 12.3 (95% CI 11.0 to 13.8) in nonusers and hypertensive patients had an OR of 8.0 (95% CI 6.6 to 9.4) versus 12.9 (95% CI 11.1 to 14.9) in normotensive patients. Diabetic patients had an OR of 9.3 (95% CI 6.7 to 12.9) versus 10.8 (95% CI 9.6 to 12.0) in nondiabetic patients. A shock index of 0.7 to 1 was associated with ORs greater than 1 (range 2.2 to 3.1), with no evident differences within subgroups. The adjusted analyses showed similar ORs. CONCLUSION Shock index is independently associated with 30-day mortality in a broad population of ED patients. Old age, hypertension, and β- or calcium channel blockers weaken this association. However, a shock index greater than or equal to 1 suggests substantial 30-day mortality risk in all ED patients.

Systolic blood pressure and short-term mortality in the emergency department and prehospital setting: a hospital-based cohort study

IntroductionSystolic blood pressure is a widely used tool to assess circulatory function in acutely ill patients. The systolic blood pressure limit where a given patient should be considered hypotensive is the subject of debate and recent studies have advocated higher systolic blood pressure thresholds than the traditional 90 mmHg. The aim of this study was to identify the best performing systolic blood pressure thresholds with regards to predicting 7-day mortality and to evaluate the applicability of these in the emergency department as well as in the prehospital setting.MethodsA retrospective, hospital-based cohort study was performed at Odense University Hospital that included all adult patients in the emergency department between 1995 and 2011, all patients transported to the emergency department in ambulances in the period 2012 to 2013, and all patients serviced by the physician-staffed mobile emergency care unit (MECU) in Odense between 2007 and 2013. We used the first recorded systolic blood pressure and the main outcome was 7-day mortality. Best performing thresholds were identified with methods based on receiver operating characteristics (ROC) and multivariate regression. The performance of systolic blood pressure thresholds was evaluated with standard summary statistics for diagnostic tests.ResultsSeven-day mortality rates varied from 1.8 % (95 % CI (1.7, 1.9)) of 112,727 patients in the emergency department to 2.2 % (95 % CI (2.0, 2.5)) of 15,862 patients in the ambulance and 5.7 % (95 % CI (5.3, 6.2)) of 12,270 patients in the mobile emergency care units. Best performing thresholds ranged from 95 to 119 mmHg in the emergency department, 103 to 120 mmHg in the ambulance, and 101 to 115 mmHg in the MECU but area under the ROC curve indicated poor overall discriminatory performance of SBP thresholds in all cohorts.ConclusionsSystolic blood pressure alone is not sufficient to identify patients at risk regardless of the defined threshold for hypotension. If, however, a threshold is to be defined, a systolic blood pressure threshold of 100 to 110 mmHg is probably more relevant than the traditional 90 mmHg.

Etiology of Shock in the Emergency Department: A 12 Year Population Based Cohort Study

Introduction: The knowledge of the etiology and associated mortality of undifferentiated shock in the emergency department (ED) is limited. We aimed to describe the etiology-based proportions and incidence rates (IR) of shock, as well as the associated mortality in the ED. Methods: Population-based cohort study at a University Hospital ED in Denmark from January 1, 2000, to December 31, 2011. Patients aged ≥18 years living in the ED-catchment area (N = 225,000) with a first-time ED presentation with shock (n = 1,553) defined as hypotension (systolic blood pressure ⩽100 mm Hg) and ≥1 organ failures were included. Discharge diagnoses defined the etiology and were grouped as follows: distributive septic shock (SS), distributive non-septic shock (NS), cardiogenic shock (CS), hypovolemic shock (HS), obstructive shock (OS), and other conditions (OC). Outcomes were etiology-based characteristics, annual IR per 100,000 person-years at risk (95% confidence intervals [CIs]), mortality at 0 to 7-, and 0 to 90 days (95% CIs) and hazard rates (HR) at 0 to 7, 8 to 90 days (95% CIs). Poisson and Cox regression models were used for analyses. Results: Among 1,553 shock patients: 423 (27.2%) had SS, 363 (23.4%) NS, 217 (14.0%) CS, 479 (30.8%) HS, 14 (0.9%) OS, and 57 (3.7%) OC. The corresponding IRs were 16.2/100,000 (95% CI: 14.8–17.9), 13.9/100,000 (95% CI: 12.6–15.4), 8.3/100,000 (95% CI: 7.3–9.5), 18.4/100,000 (95% CI: 16.8–20.1), 0.5/100,000 (95% CI: 0.3–0.9), and 2.2/100,000 (95% CI: 1.7–2.8). SS IR increased from 8.4 to 28.5/100,000 during the period 2000 to 2011. Accordingly, the 7-, and 90-day mortalities of SS, NS, CS, and HS were 30.3% (95% CI: 25.9–34.7) and 56.2% (95% CI: 50.7–61.5), 12.7% (95% CI: 9.2–16.1) and 22.6% (95% CI: 18.1–27.7), 34.6% (95% CI: 28.2–40.9) and 52.3% (95% CI: 44.6–59.8), 19.2% (95% CI: 15.7–22.7), and 36.8% (95% CI: 33.3–43.3). SS (HR = 1.46 [95% CI: 1.03–2.07]), and CS (HR = 2.15 [95% CI: 1.47–3.13]) were independent predictors of death within 0 to 7 days, whereas SS was a predictor within 8 to 90 days (HR = 1.66 [95% CI: 1.14–2.42]). Conclusion: HS and SS are frequent etiological characteristics followed by NS and CS, whereas OS is a rare condition. We confirm the increasing trend of SS, as previously reported. Seven-day mortality ranged from 12.7% to 34.6%, while 90-day mortality ranged from 22.6% to 56.2%. The underlying etiology was an independent predictor of mortality.

Erratum to: Shock in the emergency department; a 12 year population based cohort study

Background: The knowledge of the frequency and associated mortality of shock in the emergency department (ED) is limited. The aim of this study was to describe the incidence, all-cause mortality and factors associated with death among patients suffering shock in the ED. Methods: Population-based cohort study at an University Hospital ED in Denmark from January 1, 2000, to December 31, 2011. All patients aged ≥18 years living in the hospital catchment area with a first time ED presentation with shock (n = 1553) defined as hypotension (systolic blood pressure (SBP) ≤100 mmHg)) and ≥1 organ failures. Outcomes were annual incidence per 100,000 person-years at risk (pyar), all-cause mortality at 0–7, and 8–90 days and risk factors associated with death. Results: We identified 1553 of 438,191 (0.4%) ED patients with shock at arrival. Incidence of shock increased from 53.6–74.8 cases per 100,000 pyar. The 7-day, and 90-day mortality was 23.3% (95% CI: 21.2–25.4) and 41.1% (95% CI: 38.6–43.5), respectively. Independent predictors of 7-day mortality were: age (adjusted HR 1.03 (95% CI: 1.03–1.04), and number of organ failures (≥3 organ failures; adjusted HR 3.30 95% CI: 2.33–4.66). Age, comorbidity level and number of organ failure were associated with 90-day mortality. Conclusion: Shock is a frequent and critical finding in the ED, carrying a 7and, 90day mortality of 23.3% and 41.1%, respectively. Age and number of organ failures are independent prognostic factors for death within 7 days, whereas age, comorbidity and organ failures are of significance within 8–90 days.

Increasing incidence of hypotension in the emergency department; a 12 year population-based cohort study

BackgroundThe epidemiology of hypotension as presenting symptom among patients in the Emergency Department (ED) is not clarified. The aim of this study was to describe the incidence, etiology, and overall mortality of hypotensive patients in the ED.MethodsPopulation-based cohort study at an University Hospital ED in Denmark from January 1, 2000, to December 31, 2011. Patients aged ≥18 years living in the hospital catchment area with a first time presentation to the ED with hypotension (systolic blood pressure (SBP) ≤100 mm Hg) were included.Outcomes were annual incidence rates (IRs) per 100,000 person years at risk (pyar) and etiological characteristics by means of the International Classification of Diseases, Tenth Revision (ICD-10), as well as 7-day, 30-day, and 90-day all-cause mortality.ResultsWe identified 3,268 of 438,198 (1 %) cases with a mean overall IR of 125/100,000 pyar (95 % CI: 121–130). The IR increased 28 % during the period (from 113 to 152 cases per 100,000 pyar). Patients ≥65 years had the highest IR compared to age <65 years (rate ratio for men 6.3 (95 % CI: 5.6-7.1) and for women 4.2 (95 % CI: 3.6-4.9)). The etiology was highly diversified with trauma (17 %) and cardiovascular diseases (15 %) as the most common. The overall 7-day, 30-day and 90-day mortality rates were 15 % (95 % CI: 14–16), 22 % (95 % CI: 21–24) and 28 % (95 % CI: 27–30) respectively.ConclusionDuring 2000–2011 the overall incidence of ED hypotension increased and remained highest among the elderly with a diversified etiology and a 90-day all-cause mortality of 28 %.

Incidence and mortality of hypotension in the emergency department; an 12-year population based study

Methods We identified all patients aged ≥ 18 years with a first time presentation to the ED with hypotension within the study period. Patients were included if their initial systolic blood pressure (SBP) recording was below 100 mmHg upon arrival to the ED of Odense University Hospital, Denmark, during the study period (1st January 2000 to 31st December 2011). We excluded patients if they did not have a valid unique personal identification number or lived outside the hospital’s catchment-area. The study population was linked to several populationbased registers using the unique Danish personal identification number in order to determine comorbidity and overall mortality proportions. Incidence rates (IRs) were calculated per 100,000 person years at risk (pyar) and presented as crude annual rates.

Defining hypotension in the emergency department and in the pre-hospital setting: A hospital-based cohort study

Background Systolic blood pressure is a key parameter when identifying patients in shock. However, the systolic blood pressure level below which a given patient should be considered hypotensive is subject to debate. Furthermore, recent studies have advocated higher systolic blood pressure thresholds than the traditionally recognized 90 mmHg. The aim of this study was to identify the best performing systolic blood pressure thresholds with regards to predicting 7-day mortality and to evaluate the applicability of these in the emergency department and in the pre-hospital setting.