title: Sepsis-associated pulmonary complications in emergency department patients monitored with serial lactate: An observational cohort study.
abstract: OBJECTIVE
  Patients with severe sepsis and septic shock are at high risk for development of pulmonary complications, including acute respiratory distress syndrome (ARDS). Serial lactate monitoring is a useful tool to gauge global tissue hypoxia in emergency department (ED) patients with sepsis. We hypothesized that patients undergoing serial lactate monitoring (SL) would demonstrate a decreased incidence of pulmonary complications.
  
  
  METHODS
  This is a retrospective observational cohort study of adult severe sepsis and septic shock patients with elevated lactate presenting to a large academic ED. A total of 243 patients were assigned to SL (n=132) or no serial lactate monitoring (NL; n=111). The primary outcome was a composite of pulmonary complications: (1) ARDS development and (2) respiratory failure.
  
  
  RESULTS
  Twenty-eight patients (21%) in the SL group and 37 patients (33%) in the NL group developed the primary outcome (P=.03). Multivariate analysis demonstrated an association between the NL group and development of pulmonary complications (adjusted odds ratio [aOR], 2.1; confidence interval [CI], 1.15-3.78). Emergency department mechanical ventilation was independently associated with development of ARDS (aOR, 3.5; 1.8-7.0). In the a priori subgroup of patients mechanically ventilated in the ED (n=97), those who developed ARDS received higher tidal volumes compared to patients who did not develop ARDS (8.7 mL/kg predicted body weight [interquartile range, 7.6-9.5] vs 7.6 [interquartile range, 6.8-9.0]; P<.01).
  
  
  CONCLUSIONS
  Serial lactate monitoring is associated with a decrease in major pulmonary complications in severe sepsis and septic shock. Acute respiratory distress syndrome incidence is also influenced by ED-based mechanical ventilation. These results provide 2 potentially modifiable variables to be targeted in future studies to prevent pulmonary complications in this patient subset.
authors.affiliation: Division of Critical Care Medicine, Department of Medicine, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ 08103. Electronic address: dettmer-matthew@cooperhealth.edu.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Dettmer
authors.affiliation: Department of Emergency Medicine, Roy J. Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242; Division of Critical Care, Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242. Electronic address: nicholas-mohr@uiowa.edu.
authors.forename: Nicholas M
authors.initials: NM
authors.lastname: Mohr
authors.affiliation: Division of Emergency Medicine, Washington University School of Medicine in St Louis, St Louis, MO 63110; Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, MO 63110. Electronic address: fullerb@wusm.wustl.edu.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Fuller
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004635:Emergency Medicine / Q000379:methods*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D015994:Incidence; D019344:Lactic Acid / Q000097:blood*; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D012121:Respiration, Artificial / Q000379:methods; D012128:Respiratory Distress Syndrome / Q000209:etiology*; D012189:Retrospective Studies; D018805:Sepsis / Q000150:complications*; D012772:Shock, Septic / Q000150:complications*; D013990:Tidal Volume
chemical_list: D019344:Lactic Acid
keywords: ARDS; Emergency department; Lactate; Sepsis