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Study Objective: To examine the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt and severe complications during tracheal intubation of critically ill adults in an emergency department (ED) or ICU., Methods: We performed a secondary analysis of data from 2 multicenter randomized trials in critically ill adults undergoing tracheal intubation in an ED or ICU. Using a generalized linear mixed-effects model with prespecified baseline covariates, we examined the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt (primary outcome) and severe complications during tracheal intubation (secondary outcome)., Results: Among the 2,440 patients in the trial data sets, 2,339 (95.9%) were included in the current analysis; 475 patients (20.3%) received succinylcholine and 1,864 patients (79.7%) received rocuronium. Successful intubation on the first attempt occurred in 375 patients (78.9%) who received succinylcholine and 1,510 patients (81.0%) who received rocuronium (an adjusted odds ratio of 0.87; 95% CI 0.65 to 1.15). Severe complications occurred in 67 patients (14.1%) who received succinylcholine and 456 patients (24.5%) who received rocuronium (adjusted odds ratio, 0.88; 95% CI 0.62 to 1.26)., Conclusion: Among critically ill adults undergoing tracheal intubation, the incidences of successful intubation on the first attempt and severe complications were not significantly different between patients who received succinylcholine and patients who received rocuronium., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Patients frequently visit the emergency department with conditions that place them at risk of worse outcomes when accompanied by coagulopathy. Routine tests of coagulation-prothrombin time, partial thromboplastin time, platelets, and fibrinogen-have shortcomings that limit their use in providing emergency care. One alternative is to investigate coagulation disturbance with viscoelastic monitoring (VEM), a coagulation test that measures the timing and strength of blood clot development in real time. VEM is widely used and studied in cardiac surgery, liver transplant surgery, anesthesia, and trauma. In this article, we review the technique of VEM and the biologic rationale of using it in addition to routine tests of coagulation in emergency clinical situations. Then, we review the evidence (or lack thereof) for using VEM in the diagnosis and treatment of specific conditions. Finally, we describe the limitations of the test and future directions for clinical use and research in emergency medicine., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Prompt intravenous fluid therapy is a fundamental treatment for patients with septic shock. However, the optimal approach for administering intravenous fluid in septic shock resuscitation is unknown. Two competing strategies are emerging: a liberal fluids approach, consisting of a larger volume of initial fluid (50 to 75 mL/kg [4 to 6 L in an 80-kg adult] during the first 6 hours) and later use of vasopressors, versus a restrictive fluids approach, consisting of a smaller volume of initial fluid (≤30 mL/kg [≤2 to 3 L]), with earlier reliance on vasopressor infusions to maintain blood pressure and perfusion. Early fluid therapy may enhance or maintain tissue perfusion by increasing venous return and cardiac output. However, fluid administration may also have deleterious effects by causing edema within vital organs, leading to organ dysfunction and impairment of oxygen delivery. Conversely, a restrictive fluids approach primarily relies on vasopressors to reverse hypotension and maintain perfusion while limiting the administration of fluid. Both strategies have some evidence to support their use but lack robust data to confirm the benefit of one strategy over the other, creating clinical and scientific equipoise. As part of the National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Network, we designed a randomized clinical trial to compare the liberal and restrictive fluids strategies, the Crystalloid Liberal or Vasopressor Early Resuscitation in Sepsis trial. The purpose of this article is to review the current literature on approaches to early fluid resuscitation in adults with septic shock and outline the rationale for the upcoming trial., (Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objective: The Third International Consensus Definitions Task Force (SEP-3) proposed revised criteria defining sepsis and septic shock. We seek to evaluate the performance of the SEP-3 definitions for prediction of inhospital mortality in an emergency department (ED) population and compare the performance of the SEP-3 definitions to that of the previous definitions., Methods: This was a secondary analysis of 3 prospectively collected, observational cohorts of infected ED subjects aged 18 years or older. The primary outcome was all-cause inhospital mortality. In accordance with the SEP-3 definitions, we calculated test characteristics of sepsis (quick Sequential Organ Failure Assessment [qSOFA] score ≥2) and septic shock (vasopressor dependence plus lactate level >2.0 mmol/L) for mortality and compared them to the original 1992 consensus definitions., Results: We identified 7,754 ED patients with suspected infection overall; 117 had no documented mental status evaluation, leaving 7,637 patients included in the analysis. The mortality rate for the overall population was 4.4% (95% confidence interval [CI] 3.9% to 4.9%). The mortality rate for patients with qSOFA score greater than or equal to 2 was 14.2% (95% CI 12.2% to 16.2%), with a sensitivity of 52% (95% CI 46% to 57%) and specificity of 86% (95% CI 85% to 87%) to predict mortality. The original systemic inflammatory response syndrome-based 1992 consensus sepsis definition had a 6.8% (95% CI 6.0% to 7.7%) mortality rate, sensitivity of 83% (95% CI 79% to 87%), and specificity of 50% (95% CI 49% to 51%). The SEP-3 septic shock mortality was 23% (95% CI 16% to 30%), with a sensitivity of 12% (95% CI 11% to 13%) and specificity of 98.4% (95% CI 98.1% to 98.7%). The original 1992 septic shock definition had a 22% (95% CI 17% to 27%) mortality rate, sensitivity of 23% (95% CI 18% to 28%), and specificity of 96.6% (95% CI 96.2% to 97.0%)., Conclusion: Both the new SEP-3 and original sepsis definitions stratify ED patients at risk for mortality, albeit with differing performances. In terms of mortality prediction, the SEP-3 definitions had improved specificity, but at the cost of sensitivity. Use of either approach requires a clearly intended target: more sensitivity versus specificity., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: Although storage alters red blood cells, several recent, randomized trials found no differences in clinical outcomes between patients transfused with red blood cells stored for shorter versus longer periods of time. The objective of this study was to see whether storage impairs the in vivo ability of erythrocytes to traverse the microcirculation and deliver oxygen at the tissue level., Methods: A subset of subjects from a clinical trial of cardiac surgery patients randomized to receive transfusions of red blood cells stored ≤10 days or ≥21 days were assessed for thenar eminence and cerebral tissue hemoglobin oxygen saturation (S t O 2 ) via the use of near-infrared spectroscopy and sublingual microvascular blood flow via side-stream darkfield videomicroscopy., Results: Among 55 subjects, there was little change in the primary endpoint (thenar eminence S t O 2 from before to after transfusion of one unit) and the change was similar in the 2 groups: +1.7% (95% confidence interval, -0.3, 3.8) for shorter-storage and +0.8% (95% confidence interval, -1.1, 2.9) for longer-storage; P = .61). Similarly, no significant differences were observed for cerebral S t O 2 or sublingual microvascular blood flow. These parameters also were not different from preoperatively to 1 day postoperatively, reflecting the absence of a cumulative effect of all red blood cell units transfused during this period., Conclusions: There were no differences in thenar eminence or cerebral S t O 2 , or sublingual microcirculatory blood flow, in cardiac surgery patients transfused with red blood cells stored ≤10 days or ≥21 days. These results are consistent with the clinical outcomes in the parent study, which also did not differ, indicating that storage may not impair oxygen delivery by red blood cells in this setting., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Study Objective: Shock index is a widely reported tool to identify patients at risk for circulatory collapse. We hypothesize that old age, diabetes, hypertension, and β- or calcium channel blockers weaken the association between shock index and mortality., Methods: This was a cohort study of all first-time emergency department (ED) visits between 1995 and 2011 (n=111,019). We examined whether age 65 years or older, diabetes, hypertension, and use of β- or calcium channel blockers modified the association between shock index and 30-day mortality., Results: The 30-day mortality was 3.0%. For all patients, with shock index less than 0.7 as reference, a shock index of 0.7 to 1 had an adjusted odds ratio (OR) of 2.9 (95% confidence interval [CI] 2.7 to 3.2) for 30-day mortality, whereas shock index greater than or equal to 1 had an OR of 10.5 (95% CI 9.3 to 11.7). The crude OR for shock index greater than or equal to 1 in patients aged 65 years or older was 8.2 (95% CI 7.2 to 9.4) compared with 18.9 (95% CI 15.6 to 23.0) in younger patients. β- Or calcium channel-blocked patients had an OR of 6.4 (95% CI 4.9 to 8.3) versus 12.3 (95% CI 11.0 to 13.8) in nonusers and hypertensive patients had an OR of 8.0 (95% CI 6.6 to 9.4) versus 12.9 (95% CI 11.1 to 14.9) in normotensive patients. Diabetic patients had an OR of 9.3 (95% CI 6.7 to 12.9) versus 10.8 (95% CI 9.6 to 12.0) in nondiabetic patients. A shock index of 0.7 to 1 was associated with ORs greater than 1 (range 2.2 to 3.1), with no evident differences within subgroups. The adjusted analyses showed similar ORs., Conclusion: Shock index is independently associated with 30-day mortality in a broad population of ED patients. Old age, hypertension, and β- or calcium channel blockers weaken this association. However, a shock index greater than or equal to 1 suggests substantial 30-day mortality risk in all ED patients., (Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objective: Excessive radiation exposure remains a concern for patients with symptoms suggesting acute coronary syndrome and pulmonary embolism but must be judged in the perspective of pretest probability and outcomes. We quantify and qualify the pretest probability, outcomes, and radiation exposure of adults with both chest pain and dyspnea., Methods: This was a prospective, 4-center, outcomes study. Patients were adults with dyspnea and chest pain, nondiagnostic ECGs, and no obvious diagnosis. Pretest probability for both acute coronary syndrome and pulmonary embolism was assessed with a validated method; ultralow risk was defined as pretest probability less than 2.5% for both acute coronary syndrome and pulmonary embolism. Patients were followed for diagnosis and total medical radiation exposure for 90 days., Results: Eight hundred forty patients had complete data; 23 (3%) had acute coronary syndrome and 15 (2%) had pulmonary embolism. The cohort received an average of 4.9 mSv radiation to the chest, 48% from computed tomography pulmonary angiography. The pretest probability estimates for acute coronary syndrome and pulmonary embolism were less than 2.5% in 227 patients (27%), of whom 0 of 277 (0%; 95% confidence interval 0% to 1.7%) had acute coronary syndrome or pulmonary embolism and 7 of 227 (3%) had any significant cardiopulmonary diagnosis. The estimated chest radiation exposure per patient in this ultralow-risk group was 3.5 mSv, including 26 (3%) with greater than 5 mSv radiation to the chest and no significant cardiopulmonary diagnosis., Conclusion: One quarter of patients with chest pain and dyspnea had ultralow risk and no acute coronary syndrome or pulmonary embolism but were exposed to an average of 3.5 mSv radiation to the chest. These data can be used in a clinical guideline to reduce radiation exposure., (Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Study Objective: We test the hypothesis that N-acetylcysteine plus normal saline solution is more effective than normal saline solution alone in the prevention of contrast-induced nephropathy., Methods: The design was a randomized, double blind, 2-center, placebo-controlled interventional trial. Inclusion criteria were patients undergoing chest, abdominal, or pelvic computed tomography (CT) scan with intravenous contrast, older than 18 years, and at least one contrast-induced nephropathy risk factor. Exclusion criteria were end-stage renal disease, pregnancy, N-acetylcysteine allergy, or clinical instability. Intervention for the treatment group was N-acetylcysteine 3 g in 500 mL normal saline solution as an intravenous bolus and then 200 mg/hour (67 mL/hour) for up to 24 hours; and for the placebo group was 500 mL normal saline solution and then 67 mL/hour for up to 24 hours. The primary outcome was contrast-induced nephropathy, defined as an increase in creatinine level of 25% or 0.5 mg/dL, measured 48 to 72 hours after CT., Results: The data safety and monitoring board terminated the study early for futility. Of 399 patients enrolled, 357 (89%) completed follow-up and were included. The N-acetylcysteine plus saline solution group contrast-induced nephropathy rate was 14 of 185 (7.6%) versus 12 of 172 (7.0%) in the normal saline solution only group (absolute risk difference 0.6%; 95% confidence interval -4.8% to 6.0%). The contrast-induced nephropathy rate in patients receiving less than 1 L intravenous fluids in the emergency department (ED) was 19 of 147 (12.9%) versus 7 of 210 (3.3%) for greater than 1 L intravenous fluids (difference 9.6%; 95% confidence interval 3.7% to 15.5%), a 69% risk reduction (odds ratio 0.41; 95% confidence interval 0.21 to 0.80) per liter of intravenous fluids., Conclusion: We did not find evidence of a benefit for N-acetylcysteine administration to our ED patients undergoing contrast-enhanced CT. However, we did find a significant association between volume of intravenous fluids administered and reduction in contrast-induced nephropathy., (Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Study Objective: Despite its high prevalence, the influence of diabetes on outcomes of emergency department (ED) patients with sepsis remains undefined. Our aim is to investigate the association of diabetes and initial glucose level with mortality in patients with suspected infection from the ED., Methods: Three independent, observational, prospective cohorts from 2 large US tertiary care centers were studied. We included patients admitted to the hospital from the ED with suspected infection. We investigated the association of diabetes and inhospital mortality within each cohort separately and then overall with logistic regression and generalized estimating equations adjusted for age, sex, disease severity, and sepsis syndrome. We also tested for an interaction between diabetes and hyperglycemia/hypoglycemia., Results: A total of 7,754 patients were included. The mortality rate was 4.3% (95% confidence interval [CI] 3.9% to 4.8%) and similar in diabetic and nondiabetic patients (4.1% versus 4.4%; absolute risk difference 0.4%; 95% CI -0.7% to 1.4%). There was no significant association between diabetes and mortality in adjusted analysis (odds ratio [OR] overall 0.85; 95% CI 0.71 to 1.01). Diabetes significantly modified the effect of hyperglycemia and hypoglycemia with mortality; initial glucose levels greater than 200 mg/dL were associated with higher mortality in nondiabetic patients (OR 2.1; 95% CI 1.4 to 3.0) but not in diabetic patients (OR 1.0; 95% CI 0.2 to 4.7), whereas glucose levels less than 100 mg/dL were associated with higher mortality mainly in the diabetic population (OR 2.3; 95% CI 1.6 to 3.3) and to a lesser extent in nondiabetic patients (OR 1.1; 95% CI 1.03 to 1.14)., Conclusion: We found no evidence for a harmful association of diabetes and mortality in patients across different sepsis severities. High initial glucose levels were associated with adverse outcomes in the nondiabetic population only. Further investigation is warranted to determine the mechanism for these effects., (Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Study Objective: We determine whether C-reactive protein (CRP) adds prognostic value to serum lactate levels when assessing mortality risk in emergency department (ED) patients admitted for a suspected infection., Methods: This was an observational cohort of unique adult patients (≥ 21 years of age) who had lactate and CRP testing in the ED and were admitted for a suspected infection during a 1-year period. All data were collected through retrospective chart review. The study site is an urban teaching hospital with an approximate annual census of 95,000 patients. The endpoint was 28-day inpatient mortality., Results: One thousand one hundred forty-three patients had lactate and CRP testing in the ED, an admitting diagnosis of infection, and complete records. Twenty-eight-day inpatient mortality for patients with both a lactate level greater than or equal to 4.0 mmol/L and CRP level greater than 10.0 mg/dL was 44.0% (95% confidence interval [CI] 32.5% to 55.5%), for lactate greater than or equal to 4.0 mmol/L and CRP less than or equal to 10.0 mg/dL, it was 9.7% (95% CI 2.7% to 16.7%), and for lactate level less than 4.0 mmol/L, it was 9.1% (95% CI 7.3% to 10.9%). In a logistic regression model that included patient demographics and Charlson score, as well as 4 separate dichotomous variables that were positive only in subjects with (1) serum lactate greater than or equal to 4.0 mmol/L and CRP level greater than 10.0 mg/dL, (2) lactate level greater than or equal to 4.0 mmol/L and CRP level less than or equal to 10.0 mg/dL, (3) lactate level less than 4.0 mmol/L and CRP level greater than 10.0 mg/dL, and (4) lactate level less than 4.0 mmol/L and CRP level less than or equal to 10.0 mg/dL (as reference), patients with both a lactate level greater than or equal to 4.0 mmol/L and CRP greater than 10 mg/dL had an increased risk of 28-day inpatient mortality (odds ratio 12.3; 95% CI 6.8 to 22.3)., Conclusion: In this cohort, patients with both an increased CRP level and hyperlactatemia had a higher mortality rate than patients with abnormalities of either laboratory test in isolation., (Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Study Objective: We assess the diagnostic accuracy of plasma neutrophil gelatinase-associated lipocalin (NGAL) to predict acute kidney injury in emergency department (ED) patients with suspected sepsis., Methods: We conducted a secondary analysis of a prospective observational study of a convenience sample of patients from 10 academic medical center EDs. Inclusion criteria were adult patients aged 18 years or older, with suspected infection or a serum lactate level greater than 2.5 mmol/L; 2 or more systemic inflammatory response syndrome criteria; and a subsequent serum creatinine level obtained within 12 to 72 hours of enrollment. Exclusion criteria were pregnancy, do-not-resuscitate status, cardiac arrest, or dialysis dependency. NGAL was measured in plasma collected at ED presentation. Acute kidney injury was defined as an increase in serum creatinine measurement of greater than 0.5 mg/dL during 72 hours., Results: There were 661 patient enrolled, with 24 cases (3.6%) of acute kidney injury that developed within 72 hours after ED presentation. Median plasma NGAL levels were 134 ng/mL (interquartile range 57 to 277 ng/mL) in patients without acute kidney injury and 456 ng/mL (interquartile range 296 to 727 ng/mL) in patients with acute kidney injury. Plasma NGAL concentrations of greater than 150 ng/mL were 96% sensitive (95% confidence interval [CI] 79% to 100%) and 51% (95% CI 47% to 55%) specific for acute kidney injury. In comparison, to achieve equivalent sensitivity with initial serum creatinine level at ED presentation required a cutoff of 0.7 mg/dL and resulted in specificity of 17% (95% CI 14% to 20%)., Conclusion: In this preliminary investigation, increased plasma NGAL concentrations measured on presentation to the ED in patients with suspected sepsis were associated with the development of acute kidney injury. Our findings support NGAL as a promising new biomarker for acute kidney injury; however, further research is warranted., (Copyright 2009 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Study Objective: Abnormal (both low and high) central venous saturation (ScvO(2)) is associated with increased mortality in emergency department (ED) patients with suspected sepsis., Methods: This was a secondary analysis of 4 prospectively collected registries of ED patients treated with early goal-directed therapy-based sepsis resuscitation protocols from 4 urban tertiary care hospitals. Inclusion criteria were sepsis, hypoperfusion defined by systolic blood pressure less than 90 mm Hg or lactate level greater than or equal to 4 mmol/L, and early goal-directed therapy treatment. ScvO(2) levels were stratified into 3 groups: hypoxia (ScvO(2) <70%); normoxia (ScvO(2) 71% to 89%); and hyperoxia (ScvO(2) 90% to 100%). The primary exposures were initial ScvO(2) and maximum ScvO(2) achieved, with the primary outcome as inhospital mortality. Multivariate analysis was performed., Results: There were 619 patients who met criteria and were included. For the maximum ScvO(2), compared with the mortality rate in the normoxia group of 96 of 465 (21%; 95% confidence interval [CI] 17% to 25%), both the hypoxia mortality rate, 25 of 62 (40%; 95% CI 29% to 53%) and hyperoxia mortality rate, 31 of 92 (34%; 95% CI 25% to 44%) were significantly higher, which remained significant in a multivariate modeling. When the initial ScvO(2) measurement was analyzed in a multivariate model, only hyperoxia was significantly higher., Conclusion: The maximum ScvO(2) value achieved in the ED (both abnormally low and high) was associated with increased mortality. In multivariate analysis for initial ScvO(2), the hyperoxia group was associated with increased mortality, but not the hypoxia group. This study suggests that future research aimed at targeting methods to normalize high ScvO(2) values by therapies that improve microcirculatory flow or mitochondrial dysfunction may be warranted., (Copyright 2009. Published by Mosby, Inc.)

Study Objective: Epidemiologic data on emergency department (ED) patients with sepsis are limited. Inpatient discharge records from 1979 to 2000 show that hospitalizations for sepsis are increasing. We examine the epidemiology of sepsis in US EDs and the hypothesis that sepsis visits are increasing., Methods: The National Hospital Ambulatory Medical Care Survey data (1992 to 2001) provided nationally representative estimates of frequency and disposition in adult ED visits for sepsis. Sepsis visits were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes; severe sepsis was defined as sepsis in conjunction with organ failure., Results: Of 712 million adult visits during the 10-year period, approximately 2.8 million (0.40%, 95% confidence interval [CI] 0.33% to 0.46%) were related to sepsis. We found no significant increase in overall ED visits for sepsis from 1992 to 2001 (P for trend=.09). ED patients with sepsis were more likely to be elderly, non-Hispanic, and publicly insured and to arrive by ambulance compared with nonsepsis patients (all P<.01). The overall admission rate was 87% (95% CI 82% to 92%), with only 12% (95% CI 8% to 16%) of patients admitted to the ICU. The most frequent codiagnoses were pneumonia (13%), urinary tract infection (13%), and dehydration (11%). Severe sepsis accounted for 8% (95% CI 5% to 11%) of sepsis visits, for an annual incidence of 0.01%; 98% of patients with severe sepsis were admitted., Conclusion: In contrast to data from hospital discharges, ED visits for sepsis demonstrated no increase. Most ED visits for sepsis resulted in admission to non-critical care units.

Study Objective: Although it is considered standard of care to obtain blood cultures on patients hospitalized for pneumonia, several studies have questioned the utility and cost-effectiveness of this practice. The objective of this study is to determine the impact of emergency department (ED) blood cultures on antimicrobial therapy for patients with pneumonia., Methods: We performed a prospective, observational, cohort study of consecutive adult (age > or =18 years) patients treated at an urban university ED between February 1, 2000 and February 1, 2001. Inclusion criteria were radiographic evidence of pneumonia, clinical evidence of pneumonia, and blood culture obtained. Blood cultures were classified as positive, negative, or contaminant based on previously established criteria. Additionally, data were collected on antimicrobial sensitivities, empiric antibiotic therapy, antibiotic changes, and reasons for changes., Results: There were 3,926 ED visits with blood cultures obtained for any reason, of which 3,762 (96%) were available for review. Of these, 414 of 3,762 (11%) patients met pneumonia study inclusion criteria, and blood cultures identified 29 of 414 (7.0%) patients with true bacteremia. In the 414 patients, blood culture results altered therapy for 15 patients (3.6%) with suspected pneumonia, of which 11 (2.7%) patients had their coverage narrowed; only 4 (1.0%) patients had their coverage broadened because of resistance to empiric therapy. For the 11 patients with bacteremia whose therapy was not altered, culture results actually supported narrowing therapy in 8 (1.9%) cases, but this was not done., Conclusion: Blood cultures rarely altered therapy for patients presenting to the ED with pneumonia. More discriminatory blood culture use may potentially reduce resource utilization.

Study Objective: Little is known about risk-stratification biomarkers in emergency department (ED) patients with suspected infection, and lactate is a biologically plausible candidate. We determine whether a serum venous lactate is associated with an increased risk of death in ED patients with infection., Methods: This was a prospective cohort study in an urban, academic medical center with 50,000 annual ED visits. A total of 1,278 consecutive patient visits met enrollment criteria between July 24, 2003, and March 24, 2004, and all patients were enrolled. Inclusion criteria were age 18 years or older, serum lactate level obtained, and admission to the hospital with an infection-related diagnosis. The main outcome measure was all-cause 28-day inhospital mortality and death within 3 days of presentation., Results: Among 1,278 patient visits, there were 105 (8.2%) deaths during hospitalization, with 55 (4.3%) of 1,278 deaths occurring in the first 3 days. Mortality rates increased as lactate increased: 43 (4.9%) of 877 of patients with a lactate level between 0 and 2.5 mmol/L died, 24 (9.0%) of 267 patients with a lactate level between 2.5 and 4.0 mmol/L died, and 38 (28.4%) of 134 patients with a lactate level greater than or equal to 4.0 mmol/L died. Lactate level greater than or equal to 4.0 mmol/L was 36% (95% confidence interval [CI] 27% to 45%) sensitive and 92% (95% CI 90% to 93%) specific for any death; it was 55% (95% CI 41% to 68%) sensitive and 91% (95% CI 90% to 93%) specific for death within 3 days., Conclusion: In this cohort of ED patients with signs and symptoms suggestive of infection, our results support serum venous lactate level as a promising risk-stratification tool. Multicenter validation, as well as comparison of the lactate level with clinical predictors, needs to be done before widespread implementation.

Study Objective: To determine whether the absolute lymphocyte count (ALC) (white blood count x lymphocyte percentage) can be used to predict a low CD4 count., Methods: We conducted a retrospective data analysis of consecutive CD4 count analyses performed between January 1, 1995, through December 1, 1995, at an urban university teaching hospital. Results of consecutive CD4 counts and simultaneously measured ALCs were analyzed from samples obtained in inpatient, clinic, and emergency department settings. The ability of ALC to predict a CD4 count less than 200 cells/mm3 was analyzed by calculating sensitivities, specificities, predictive values, and likelihood ratios for a range of ALC values., Results: Among the 807 samples, 322 results (40%) had a CD4 count less than 200 cells/mm3. The ALC and CD4 count were correlated (r=.69, P<.0001). An ALC less than 1,000 cells/mm3 predicted CD4 counts less than 200 cells/mm3 with a sensitivity of .67 (95% confidence interval .62 to .72), specificity of .96 (.94 to .98), positive predictive value of .91 (.87 to .95), and a negative predictive value of .81 (.78 to .84). An ALC less than 2,000 cells/mm3 predicted CD4 counts less than 200 cells/mm3 with a sensitivity of .97 (.95 to .99), specificity of .41 (.37 to .45), positive predictive value of .52 (.48 to .56), and negative predictive value of .95 (.92 to .98)., Conclusion: A reliable relationship exists between ALC and CD4 count. In a similar population, an ALC less than 1,000 cells/mm3 is predictive of a CD4 count less than 200 cells/mm3, and an ALC greater than or equal to 2,000 cells/mm3 is predictive of a CD4 count greater than or equal to 200 cells/mm3. Physicians may find these criteria useful in identifying patients with increased risk of opportunistic infection.