Emergency Department Lactate Is Associated with Mortality in Older Adults Admitted With and Without Infections

Authors

  • Daniel A. Del Portal MD,

    1. From the University of Pennsylvania School of Medicine (DAdP), Philadelphia, PA; the Department of Emergency Medicine (FS, DFG, MG, JMP), the Pulmonary, Allergy, and Critical Care Division (MEM), the Division of General Internal Medicine (MS, MGW), and the Department of Medicine, Center for Clinical Epidemiology and Biostatistics (MEM, JMP), University of Pennsylvania School of Medicine, Philadelphia, PA; and Tulane University School of Medicine (PJD), New Orleans, LA. Dr. del Portal is currently with the Department of Emergency Medicine, Temple University, Philadelphia, PA. Dr. Shofer is currently with the Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. Dr. Goyal is currently with the Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Dr. Pines is currently with the Department of Emergency Medicine, George Washington University School of Medicine and the Department of Health Policy, George Washington School of Public Health, Washington, DC.
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  • Frances Shofer PhD,

    1. From the University of Pennsylvania School of Medicine (DAdP), Philadelphia, PA; the Department of Emergency Medicine (FS, DFG, MG, JMP), the Pulmonary, Allergy, and Critical Care Division (MEM), the Division of General Internal Medicine (MS, MGW), and the Department of Medicine, Center for Clinical Epidemiology and Biostatistics (MEM, JMP), University of Pennsylvania School of Medicine, Philadelphia, PA; and Tulane University School of Medicine (PJD), New Orleans, LA. Dr. del Portal is currently with the Department of Emergency Medicine, Temple University, Philadelphia, PA. Dr. Shofer is currently with the Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. Dr. Goyal is currently with the Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Dr. Pines is currently with the Department of Emergency Medicine, George Washington University School of Medicine and the Department of Health Policy, George Washington School of Public Health, Washington, DC.
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  • Mark E. Mikkelsen MD, MSCE,

    1. From the University of Pennsylvania School of Medicine (DAdP), Philadelphia, PA; the Department of Emergency Medicine (FS, DFG, MG, JMP), the Pulmonary, Allergy, and Critical Care Division (MEM), the Division of General Internal Medicine (MS, MGW), and the Department of Medicine, Center for Clinical Epidemiology and Biostatistics (MEM, JMP), University of Pennsylvania School of Medicine, Philadelphia, PA; and Tulane University School of Medicine (PJD), New Orleans, LA. Dr. del Portal is currently with the Department of Emergency Medicine, Temple University, Philadelphia, PA. Dr. Shofer is currently with the Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. Dr. Goyal is currently with the Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Dr. Pines is currently with the Department of Emergency Medicine, George Washington University School of Medicine and the Department of Health Policy, George Washington School of Public Health, Washington, DC.
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  • Philip J. Dorsey Jr. MD, MPH,

    1. From the University of Pennsylvania School of Medicine (DAdP), Philadelphia, PA; the Department of Emergency Medicine (FS, DFG, MG, JMP), the Pulmonary, Allergy, and Critical Care Division (MEM), the Division of General Internal Medicine (MS, MGW), and the Department of Medicine, Center for Clinical Epidemiology and Biostatistics (MEM, JMP), University of Pennsylvania School of Medicine, Philadelphia, PA; and Tulane University School of Medicine (PJD), New Orleans, LA. Dr. del Portal is currently with the Department of Emergency Medicine, Temple University, Philadelphia, PA. Dr. Shofer is currently with the Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. Dr. Goyal is currently with the Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Dr. Pines is currently with the Department of Emergency Medicine, George Washington University School of Medicine and the Department of Health Policy, George Washington School of Public Health, Washington, DC.
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  • David F. Gaieski MD,

    1. From the University of Pennsylvania School of Medicine (DAdP), Philadelphia, PA; the Department of Emergency Medicine (FS, DFG, MG, JMP), the Pulmonary, Allergy, and Critical Care Division (MEM), the Division of General Internal Medicine (MS, MGW), and the Department of Medicine, Center for Clinical Epidemiology and Biostatistics (MEM, JMP), University of Pennsylvania School of Medicine, Philadelphia, PA; and Tulane University School of Medicine (PJD), New Orleans, LA. Dr. del Portal is currently with the Department of Emergency Medicine, Temple University, Philadelphia, PA. Dr. Shofer is currently with the Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. Dr. Goyal is currently with the Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Dr. Pines is currently with the Department of Emergency Medicine, George Washington University School of Medicine and the Department of Health Policy, George Washington School of Public Health, Washington, DC.
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  • Munish Goyal MD,

    1. From the University of Pennsylvania School of Medicine (DAdP), Philadelphia, PA; the Department of Emergency Medicine (FS, DFG, MG, JMP), the Pulmonary, Allergy, and Critical Care Division (MEM), the Division of General Internal Medicine (MS, MGW), and the Department of Medicine, Center for Clinical Epidemiology and Biostatistics (MEM, JMP), University of Pennsylvania School of Medicine, Philadelphia, PA; and Tulane University School of Medicine (PJD), New Orleans, LA. Dr. del Portal is currently with the Department of Emergency Medicine, Temple University, Philadelphia, PA. Dr. Shofer is currently with the Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. Dr. Goyal is currently with the Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Dr. Pines is currently with the Department of Emergency Medicine, George Washington University School of Medicine and the Department of Health Policy, George Washington School of Public Health, Washington, DC.
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  • Marie Synnestvedt PhD,

    1. From the University of Pennsylvania School of Medicine (DAdP), Philadelphia, PA; the Department of Emergency Medicine (FS, DFG, MG, JMP), the Pulmonary, Allergy, and Critical Care Division (MEM), the Division of General Internal Medicine (MS, MGW), and the Department of Medicine, Center for Clinical Epidemiology and Biostatistics (MEM, JMP), University of Pennsylvania School of Medicine, Philadelphia, PA; and Tulane University School of Medicine (PJD), New Orleans, LA. Dr. del Portal is currently with the Department of Emergency Medicine, Temple University, Philadelphia, PA. Dr. Shofer is currently with the Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. Dr. Goyal is currently with the Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Dr. Pines is currently with the Department of Emergency Medicine, George Washington University School of Medicine and the Department of Health Policy, George Washington School of Public Health, Washington, DC.
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  • Mark G. Weiner MD,

    1. From the University of Pennsylvania School of Medicine (DAdP), Philadelphia, PA; the Department of Emergency Medicine (FS, DFG, MG, JMP), the Pulmonary, Allergy, and Critical Care Division (MEM), the Division of General Internal Medicine (MS, MGW), and the Department of Medicine, Center for Clinical Epidemiology and Biostatistics (MEM, JMP), University of Pennsylvania School of Medicine, Philadelphia, PA; and Tulane University School of Medicine (PJD), New Orleans, LA. Dr. del Portal is currently with the Department of Emergency Medicine, Temple University, Philadelphia, PA. Dr. Shofer is currently with the Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. Dr. Goyal is currently with the Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Dr. Pines is currently with the Department of Emergency Medicine, George Washington University School of Medicine and the Department of Health Policy, George Washington School of Public Health, Washington, DC.
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  • Jesse M. Pines MD, MBA, MSCE

    1. From the University of Pennsylvania School of Medicine (DAdP), Philadelphia, PA; the Department of Emergency Medicine (FS, DFG, MG, JMP), the Pulmonary, Allergy, and Critical Care Division (MEM), the Division of General Internal Medicine (MS, MGW), and the Department of Medicine, Center for Clinical Epidemiology and Biostatistics (MEM, JMP), University of Pennsylvania School of Medicine, Philadelphia, PA; and Tulane University School of Medicine (PJD), New Orleans, LA. Dr. del Portal is currently with the Department of Emergency Medicine, Temple University, Philadelphia, PA. Dr. Shofer is currently with the Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. Dr. Goyal is currently with the Department of Emergency Medicine, Washington Hospital Center, Washington, DC. Dr. Pines is currently with the Department of Emergency Medicine, George Washington University School of Medicine and the Department of Health Policy, George Washington School of Public Health, Washington, DC.
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  • This study was supported by funding from the Institute of Aging at the University of Pennsylvania.

  • None of the authors has any relevant financial interests in this manuscript.

Address for correspondence and reprints: Jesse M. Pines, MD, MBA, MSCE; e-mail: jesse.pines@gmail.com.

Abstract

Objectives:  Serum lactate values in the emergency department (ED) have been associated with mortality in diverse populations of critically ill patients. This study investigates whether serum lactate values measured in the ED are associated with mortality in older patients admitted to the hospital, both with and without infections.

Methods:  This is a retrospective cohort study performed at two urban teaching hospitals. The study population includes 1,655 older ED patients (age ≥ 65 years) over a 3-year period (2004–2006) who had serum lactate measured prior to admission. The presence or absence of infection was determined by review of International Classification of Diseases Ninth Revision (ICD-9) admission diagnosis codes. Mortality during hospitalization was determined by review of inpatient records. Mortality at 30 and at 60 days was determined using a state death registry.

Results:  In patients with infections, increasing serum lactate values of ≥2.0 mmol/L were linearly associated with relative risk (RR) of mortality during hospitalization (RR = 1.9 to 3.6 with increasing lactate), at 30 days (RR = 1.7 to 2.6), and at 60 days (RR = 1.4 to 2.3) when compared to patients with serum lactate levels of <2.0 mmol/L. In patients without infections, a similar association was observed (RR = 1.1 to 3.9 during hospitalization, RR = 1.2 to 2.6 at 30 days, RR = 1.1 to 2.4 at 60 days). In both groups of patients, serum lactate had a greater magnitude of association with mortality than either of two other commonly ordered laboratory tests, leukocyte count and serum creatinine.

Conclusions:  Higher ED lactate values are associated with greater mortality in a broad cohort of admitted patients over age 65 years, regardless of the presence or absence of infection.

ACADEMIC EMERGENCY MEDICINE 2010; 17:260–268 © 2010 by the Society for Academic Emergency Medicine

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