Age-adjusted and Expanded Lactate Thresholds as Predictors of All-Cause Mortality in the Emergency Department

INTRODUCTION: While numerous studies have found emergency department (ED) lactate levels to be associated with increased in-hospital mortality, little information is available on the role age plays in this association. This study investigates whether age is a necessary variable to consider when using lactate levels as a marker of prognosis and a guide for management decisions in the ED. METHODS: This was a retrospective cohort study in an urban, tertiary-care teaching hospital. A total of 13,506 lactate levels were obtained over a 4.5-year period. All adult patients who had a lactate level obtained by the treating provider in the ED were screened for inclusion. The main outcome measure was in-hospital mortality using age-adjusted cohorts and expanded lactate thresholds with secondary outcomes comparing mortality based on the primary clinical impression. RESULTS: Of the 8796 patients in this analysis, there were 474 (5.4%) deaths. Mortality rates increased with both increasing lactate levels and increasing age. For all ages, mortality rates increased from 2.8% in the less than 2.0 millimoles per liter (mmol/L) lactate level, to 5.6% in the 2.0–2.9 mmol/L lactate level, to 8.0% in the 3.0–3.9 mmol/L lactate level, to 13.9% in the 4.0–4.9 mmol/L lactate level, to 13.7% in the 5.0–5.9 mmol/L lactate level, and to 39.1% in the 6.0 mmol/L or greater lactate level (p <0.0001). Survivors, regardless of age, had a mean lactate level <2.0 whereas non-survivors had mean lactate levels of 6.5, 4.5, and 3.7 mmol/L for age cohorts 18–39, 40–64, and ≥ 65 years, respectively. CONCLUSION: Our findings suggest that although lactate levels can be used as a prognostic tool to risk stratify ED patients, the traditional lactate level thresholds may need to be adjusted to account for varying risk based on age and clinical impressions.