Base excess is an accurate predictor of elevated lactate in ED septic patients.

BACKGROUND: Prior studies showed that lactate is a useful marker in sepsis. However, lactate is often not routinely drawn or rapidly available in the emergency department (ED). OBJECTIVE: The study aimed to determine if base excess (BE), widely and rapidly available in the ED, could be used as a surrogate marker for elevated lactate in ED septic patients. METHODS: This was a prospective and observational cohort study. From March 2009 to March 2010, consecutive patients 18 years or older who presented to the ED with a suspected severe sepsis were enrolled in the study. Lactate and BE measurements were performed. We defined, a priori, a clinically significant lactate to be greater than 3 mmol/L and BE less than -4 mmol/L. RESULTS: A total of 224 patients were enrolled in the study. The average BE was -4.5 mmol/L (SD, 4.9) and the average lactate was 3.5 mmol/L (SD, 2.9). The sensitivity of a BE less than -4 mmol/L in predicting elevated lactate greater than 3 mmol/L was 91.1% (95% confidence interval, 85.5%-96.6%) and the specificity was 88.6% (95% confidence interval, 83.0%-94.2%). The area under the curve was 0.95. CONCLUSION: Base excess is an accurate marker for the prediction of elevated lactate in the ED. The measurement of BE, obtained in a few minutes in the ED, provides a secure and quick method, similar to the electrocardiogram at triage for patients with chest pain, to determine the patients with sepsis who need an early aggressive resuscitation.

Withholding and withdrawing life-support therapy in an Emergency Department: prospective survey.

OBJECTIVES: Few studies have focused on decisions to withdraw or withhold life-support therapies in the emergency department. Our objectives were to identify clinical situations where life-support was withheld or withdrawn, the criteria used by physicians to justify their decisions, the modalities necessary to implement these decisions, patient disposition, and outcome. DESIGN AND SETTING: Prospective unicenter survey in an Emergency Department of a tertiary care teaching hospital. PATIENTS: All non-trauma patients (n=119) for whom a decision to withhold or withdraw life-sustaining treatments was taken between January and September 1998. MAIN OUTCOME MEASURES: Choice of criteria justifying the decision to withhold or withdraw life-sustaining treatments, time interval from ED admission to the decision; type of decision implemented, outcome. RESULTS: Fourteen thousand eight hundred and seventy-five non-trauma patients were admitted during the study period, 119 were included, mean age 75+/-13 years. Resuscitation procedures were instituted for 96 (80%) patients before a subsequent decision was taken. Physicians chose on average 6+/-2 items to justify their decision; the principal acute medical disorder and futility of care were the two criteria most often used. Median time interval to reach the decision was 187 min. Withdrawal involved 37% of patients and withholding 63% of patients. The family was involved in the decision-making process in 72% of patients. The median time interval from the decision to death was 16 h (5 min to 140 days). CONCLUSION: Withdrawing and withholding life-support therapy involved elderly patients with underlying chronic cardiopulmonary disease or metastatic cancer or patients with acute non-treatable illness.