title: Clinical predictors of adverse outcome in severe sepsis patients with lactate 2-4 mM admitted to the hospital.
abstract: BACKGROUND
  Severe sepsis patients with initial lactate level 2-4 mM are commonly considered to have lower risk for mortality and adverse outcomes.
  
  
  OBJECTIVE
  We aim to determine clinical variables that are associated with adverse outcome in these patients.
  
  
  METHODS
  A retrospective cohort study.
  
  
  METHODS
  Severe sepsis patients with initial lactate ≥ 2 and < 4 mM admitted to our hospital were examined for any of the following primary outcomes: (i) in-hospital death, (ii) vasopressor requirement, (iii) use of mechanical ventilator, (iv) lactate ≥ 4.0 mM or (v) need care in the intensive care unit (ICU) within 48 h.
  
  
  RESULTS
  Five-hundred and thirty-five patients were enrolled, age 58.7 ± 19.3 years, 53.2% male. The most common sources of infection were urinary tract infection and pneumonia, 38.3 and 35.7%, respectively. One-hundred and twenty-four (23.2%) patients had at least one primary adverse outcome within 48 h, including in-hospital death 1.1%, vasopressor requirement 12.9%, use of mechanical ventilator 13.3%, increase lactate ≥ 4.0 mM in 5.6% patients and 21.5% of patients requiring ICU (including 13.8% of the patients admitted directly to ICU from the emergency department, and 7.7% initially admitted to the general medical ward but later required ICU transfer). Altered mentation, hypotension, tachypnea and elevated blood urea nitrogen at admission were associated with the primary outcome in multivariable logistic regression analysis, odds ratio 2.50 (95% confidence interval: 1.54, 4.06), 3.76 (2.31, 6.10), 1.97 (1.22, 3.17) and 1.78 (1.11, 2.83), respectively.
  
  
  CONCLUSIONS
  Our study suggests that clinicians should be cautious about the potential adverse outcomes in severe sepsis patients with initial lactate level between 2 and 4 mM and a presentation of altered mentation, hypotension, tachypnea and/or elevated blood urea nitrogen.
authors.affiliation: From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA.
authors.forename: Y
authors.initials: Y
authors.lastname: Tang
authors.affiliation: From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA.
authors.forename: J
authors.initials: J
authors.lastname: Choi
authors.affiliation: From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA.
authors.forename: D
authors.initials: D
authors.lastname: Kim
authors.affiliation: From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA.
authors.forename: L
authors.initials: L
authors.lastname: Tudtud-Hans
authors.affiliation: From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA.
authors.forename: J
authors.initials: J
authors.lastname: Li
authors.affiliation: From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA.
authors.forename: A
authors.initials: A
authors.lastname: Michel
authors.affiliation: From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA.
authors.forename: H
authors.initials: H
authors.lastname: Baek
authors.affiliation: From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA.
authors.forename: A
authors.initials: A
authors.lastname: Hurlow
authors.affiliation: From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA.
authors.forename: C
authors.initials: C
authors.lastname: Wang
authors.affiliation: From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA From the Department of Medicine, Hospitalist Medicine, School of Medicine, Department of Emergency Medicine and Department of Medicine, Critical Care, Loma Linda University, Loma Linda, CA, USA hbnguyen@llu.edu.
authors.forename: H B
authors.initials: HB
authors.lastname: Nguyen
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D015897:Comorbidity; D005260:Female; D006760:Hospitalization; D006801:Humans; D019344:Lactic Acid / Q000097:blood*; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000150:complications; D011379:Prognosis; D012189:Retrospective Studies; D018805:Sepsis / Q000097:blood / Q000175:diagnosis* / Q000382:microbiology / Q000628:therapy; D014552:Urinary Tract Infections / Q000150:complications; D055986:Vital Signs
chemical_list: D015415:Biomarkers; D019344:Lactic Acid