Higher lactate can herald sepsis in end-stage liver disease

  • Am J Emerg Med

  • International Clinical Digest
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Takeaway

  • Patients presenting to emergency departments (EDs) with septic shock and end-stage liver disease (ESLD) are likelier to die than those without liver disease.
  • Higher lactate and pneumonia may aid in risk stratification.
  • Lactate screening may reveal “cryptic shock” in this population.

Why this matters

  • Not enough is known about sepsis in this population, which is often excluded from trials.
  • Baseline metabolic abnormalities, including vasodilation and hyperdynamic circulation, can complicate early sepsis detection.

Key results

  • 161 (6.2%) patients had ESLD. 
  • ESLD vs non-ESLD patients had:
    • Lower temperature, BP, albumin;
    • Higher serum lactate, acute kidney injury incidence; and
    • Higher mortality: 36.6% vs 21.2% (P<.001>
  • Among ESLD patients:
    • 72% were afebrile;
    • 69% had lactate ≥4 mmol/L without systemic hypotension; and
    • Multiple infection sources were common.
  • No between-group differences in antibiotic or fluid administration or sepsis bundle compliance.
  • On multivariate analysis, mortality predictors in ESLD patients:
    • Pneumonia: OR, 4.8 (P=.02).
    • Higher lactate: P=.03.

Study design

  • Single-centre, 13-ED retrospective review of patients presenting in septic shock (n=2584).
  • This centre used a standardised sepsis treatment pathway.
  • Outcomes: clinical and treatment variables in patients with ESLD vs without; survivors vs nonsurvivors in ESLD subgroup.
  • Funding: None.

Limitations

  • Single, nonmasked reviewer.