Article, Emergency Medicine

Emergency department septic shock patient mortality with refractory hypotension vs hyperlactatemia: A retrospective cohort study

a b s t r a c t

Background: Our objective was to compare in-hospital mortality among emergency department (ED) patients meeting trial-based criteria for septic shock based upon whether presenting with refractory hypotension (systol- ic blood pressure b 90 mm Hg after 1 L intravenous fluid bolus) versus hyperlactatemia (initial lactate

>= 4 mmol/L).

Methods: We conducted a retrospective cohort analysis by chart review of ED patients admitted to an intensive care unit with suspected infection during 1 August 2012-28 February 2015. We included all patients with body fluid cultures sampled either during their ED stay without antibiotic administration or within 24 h of anti- biotic administration in the ED. We excluded patients not meeting criteria for either refractory hypotension or hyperlactatemia. Trained chart abstractors blinded to the study hypothesis double entered data from each patient’s record including demographics, clinical data, treatments, and in-hospital mortality. We compared in- hospital mortality among patients with isolated refractory hypotension, isolated hyperlactatemia, or both. We also calculated odds ratios (ORs) via logistic regression for in-hospital mortality based on presence of refractory hypotension or hyperlactatemia.

Results: Of 202 patients included in the analysis, 38 (18.8%) died during hospitalization. Mortality was 10.9% among 101 patients with isolated refractory hypotension, 24.4% among 41 patients with isolated hyperlactatemia, and 28.3% among 60 patients with both (p = 0.01). Logistic regression analyses yielded in-hos- pital mortality OR for refractory hypotension of 1.3 (95% CI 0.5-3.8) versus OR for hyperlactatemia of 2.9 (95% CI 1.2-7.4).

Conclusions: Hyperlactatemia appears associated with higher in-hospital mortality compared to refractory hypo- tension among ED patients with septic shock.

  1. Introduction
    1. Background

Sepsis is a clinical syndrome resulting from a systemic host response to infection [1,2]. A spectrum of severity exists in which patients with hypo-perfusion or refractory hypotension experience higher mortality rates [3]. These patients require early recognition, careful resuscitation,

? Disclaimers: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense or the U.S. Government.

?? Funding: None.

??? Conflicts of interest: None.

* Corresponding author at: MCHE-EMR, 3551 Roger Brooke Dr., Fort Sam Houston, TX 78234, United States.

E-mail address: [email protected] (M.D. April).

and often admission to an intensive care unit (ICU) setting to maximize their chances of survival [4].

Clinical definitions of sepsis remain an ongoing challenge in the field of sepsis research, particularly among this sickest subset of patients. Specific inclusion criteria vary slightly across studies, but most of the landmark randomized controlled trials of the treatment of patients with septic shock required that subjects meet at least one of two types of inclusion criteria. The first type is refractory hypotension, or a systolic blood pressure b 90 mm Hg after an intravenous fluid bolus. The second type is hyperlactatemia, or a lactate concentration equal to 4 mmol/L or greater [5-9]. While not aligned exactly with these trial-based criteria, international consensus statements and the Surviving sepsis campaign guidelines alike emphasize both hypotension and lactate levels in their various sepsis definitions [2,10,11].

Despite this consensus that both of these clinical features are impor-

tant indicators of sepsis patient acuity and need for resuscitation, the comparative prognostic value of these two criteria is uncertain. There 0735-6757/

is some limited data to suggest sepsis patients may have very different characteristics and outcomes based upon whether they exhibit refracto- ry hypotension, hyperlactatemia, or both. A pair of ICU-based observa- tional studies did compare clinical parameters and survival among septic shock patients with and without hyperlactatemia [12,13]. These studies both concluded that the concomitant finding of hyperlactatemia with refractory hypotension appears to represent a very distinct patho- physiological profile. Indeed, patients with lactate levels exceeding

2.4 mmol/L had a significantly higher mortality (42.9%) compared to pa-

tients without elevated lactate levels (7.7%) [13].

Mortality risk with refractory hypotension versus hyperlactatemia remains unclear. Emergency physicians would benefit from clarification of the different implications of refractory hypotension versus hyperlactatemia for eventual hospital outcomes.

Study purpose

This study comprises a retrospective cohort analysis by chart review measuring patient characteristics, interventions, and outcomes among patients admitted from the emergency department (ED) to an ICU. All patients met at least one of two trial-based criteria for septic shock: re- fractory hypotension (systolic blood pressure b 90 mm Hg after a 1 L in- travenous fluid bolus) or hyperlactatemia (initial lactate >= 4 mmol/L). Our objective was to compare in-hospital mortality between patients with isolated refractory hypotension, isolated hyperlactatemia, or both.

  1. Methods
    1. Study design

We conducted a retrospective cohort analysis by chart review of adults presenting to an urban tertiary care hospital ED with an Annual patient volume exceeding 90,000. Providers included Emergency Med- icine attending physicians, residents in training, and physician assis- tants. The hospital has burn, cardiac, medical, surgical, and trauma ICUs. Our hospital’s institutional review board approved the study. We adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement in our research design, reporting, and analysis [14].

Inclusion and exclusion criteria

We defined all inclusion and exclusion criteria a priori. The study in- cluded adult (>= 18 years) ED patients admitted to an ICU with suspected infection during 1 August 2012 to 28 February 2015. We searched the hospital’s medical records to identify eligible patient encounters. We re- trieved the medical charts for all potentially eligible patients. Regarding inclusion criteria, we inferred suspected infection if during the ED stay providers drew any non-wound body fluid cultures (e.g., blood, urine) regardless of antibiotic administration. Alternatively, we inferred infec- tion if providers administered antibiotics during the ED stay and subse- quently sampled body cultures within 24 h of antibiotic administration regardless of whether sampling occurred during the ED stay [15,16].

Exclusion criteria included patients b 18 years of age and pregnant women. We also excluded patients whose primary diagnoses com- prised non-sepsis etiologies potentially causing hypo-perfusion. These diagnoses included acute coronary syndrome, cardiac dysrhythmias other than chronic atrial fibrillation, Active hemorrhage, trauma, burns, and overdoses [7-9,17]. In accordance with the landmark sepsis trial exclusion criteria, we excluded patients with contraindications to standard resuscitation measures such as advanced directives or reli- gious objections to blood product transfusion. Finally, we excluded pa- tients not meeting the trial-based criteria for septic shock as defined by recent RCTs of sepsis management: systolic blood pressure b 90 mm Hg after a 1 L intravenous fluid bolus or initial lactate

>= 4 mmol/L [6-8].

Selection of subjects

We identified eligible subjects by reviewing ED nursing notes for every patient admitted to any ICU in our hospital during the study peri- od. Two investigators independently reviewed these records to deter- mine patient eligibility. We then cross-referenced this list against a computer-generated list of patients admitted to any ICU in our hospital during the study period with diagnoses related to sepsis per Interna- tional Classification of Disease code to maximize capture of eligible pa- tients. We then reviewed the records of these patients not already captured by our previous algorithms for possible inclusion into the study. Investigators resolved discordant eligibility decisions based on mutual agreement between the two investigators.

Data abstraction methodology

We used standard chart review methodology to abstract data from the hospital records for all study subjects [18]. All data abstractors were resident physicians blinded to the study objective. After comple- tion of all data collection, we confirmed that abstractor blinding to the objective was effective by questioning each abstractor. Demographic data collected from each patient chart included age, sex, residence (nursing home versus other) and means of arrival to the ED (ambulance versus private vehicle). Clinical data included initial vital signs, suspected infection source, laboratory data, and past medical history. Therapeutic data included times and quantities of administered crystal- loid fluid, antibiotics, vasopressors, blood products throughout the en- tirety of the ED course and then during the first 6 h of the ICU course. Other data collected included the primary outcome of in-hospital mor- tality as determined by documentation of a death note in each subject’s hospital record. Secondary outcomes collected included dialysis and lengths of vasopressor therapy, mechanical ventilation, and hospitalization.

Our data abstraction quality assurance measures included hour-long training sessions for each data abstractor prior to study start. This ses- sion entailed data abstraction from a practice patient chart with entry into a template of the study database. During the data collection period, all data abstractors had access to the study manual comprising abstrac- tion rules for all study variables. Investigators abstracted all data into a secure password-protected Excel database (version 14, Microsoft, Red- mond, WA) with data validation for all study variables to minimize data entry errors. Two separate investigators abstracted all study data. Data collection spanned four months. Halfway through data completion, the principal investigator calculated interim kappa coefficients for all categorical variables and intra-class Correlation coefficients for all con- tinuous variables. The investigator provided e-mail reminders of data collection rules for those variables with coefficients demonstrating less than excellent inter-rater agreement (b 0.81). The principal investi- gator acted as final arbiter to resolve all data entry discrepancies be- tween abstractors.

Data analysis

We performed statistical analyses using SPSS (version 22, IBM, Armonk, NY). We used descriptive statistics to describe our data: means or medians for continuous variables and proportions for categor- ical variables with 95% confidence intervals (CIs) or interquartile ranges (IQRs) as applicable. We stratified variables by three groups of patients based upon septic shock inclusion criteria: (1) refractory hypotension;

(2) hyperlactatemia; or (3) both.

As we included all eligible study subjects during the study period, we did not base our sample size on a sample size estimate. We first com- pared in-hospital mortality between the three groups of patients using a chi-squared test. We compared secondary outcomes using chi- squared tests or independent sample student t-tests as applicable. We then calculated odds ratios via logistic regression models for in-hospital

CT characteristics“>mortality based on presence of refractory hypotension or hyperlactatemia. These models included variables for patient demo- graphics, patient clinical characteristics, other ED therapeutic interven- tions (e.g., fluid administration). The models excluded cases with missing data by list-wise deletion.

  1. Results
    1. Subject characteristics

We identified 321 patients admitted to an ICU in our hospital with diagnoses potentially consistent with septic shock during the study pe- riod. We excluded 119 patients. This resulted in 202 subjects included in the study. Of these subjects, 101 (50.0%) met only the trial-based crite- rion for septic shock of refractory hypotension. Forty-one (20.2%) of pa- tients met only the criterion of hyperlactatemia. The remaining 60 (29.7%) patients met both criteria (Fig. 1).

Aside from systolic blood pressure and lactate levels, there were no marked differences in baseline patient characteristics between the three groups (Table 1). Patients with refractory hypotension were more likely than patients with isolated hyperlactatemia to receive

>= 30 mL/kg of intravenous fluid within 30 min of meeting criteria for septic shock. There was similarly a trend towards more vasopressor ad- ministration in this group. ED interventions were otherwise comparable across the three groups (Table 2).

Main results

Of the 202 patients, 164 (81.2%) survived to discharge while 38 (18.9%) died in hospital. In-hospital mortality was 10.9% among the 101 patients with isolated refractory hypotension, 24.4% among pa- tients with isolated hyperlactatemia, and 28.3% among patients meeting

both criteria (p = 0.01). Patients with refractory hypotension underwent longer courses of vasopressor therapy during their hospital- izations. Other outcomes were generally comparable across the three groups (Table 3).

For the logistic regression analysis, there was a significant associa- tion between the presence of hyperlactatemia and in-hospital mortali- ty: odds ratio (OR) 2.9, 95% confidence interval (CI) 1.2-7.4. Conversely, there was no such association between the presence of re- fractory hypotension and in-hospital mortality: OR 1.3, 95% CI 0.5-3.8. There was similarly no association observed between other model var- iables and patient survival (Table 4).

  1. Discussion
    1. Overview of findings

Despite an extensive and growing literature on the therapeutic man- agement of septic shock [6-8], much remains unknown regarding the prognosis for various subsets of these patients. The literature reports both hyperlactatemia [19] and distributive shock as hallmarks of the sepsis syndrome [20]. Most of the landmark trials forming the founda- tion of our contemporary understanding of the therapeutic manage- ment of sepsis patients included subjects meeting criteria consistent with either or both of these physiologic derangements [6-9]. Yet pa- tients with refractory hypotension, hyperlactatemia, or both may all represent very different patient populations with distinct physiologies and outcomes. Our study offers an ED-focused comparison of these pa- tient subsets using an observational design among a critically ill cohort of patients with septic shock ultimately admitted to an ICU.

Our results indicate that patients with hyperlactatemia may repre- sent individuals with more Severe forms of septic shock. Our data show that these patients are at higher risk of in-hospital mortality

Fig. 1. Flow diagram of study subject inclusion.

Table 1

Characteristics of patients meeting-trial based criteria for septic shock (n = 202).a


Refractory hypotension only (n = 101)a

Hyperlactatemia only (n = 41)a

Refractory hypotension and hyperlactatemia (n = 60)a

All patients (n = 202)

Patient characteristics

Mean age, years (95% CI)

67.1 (63.9-70.3)

68.9 (63.6-74.4)

69.3 (64.6-74.1)

68.1 (65.8-70.4)

Male sex, % (95% CI)

58.6 (49.6-68.2)

51.4 (37.4-68.1)

60.0 (48.1-72.9)

57.9 (51.0-64.5)

Nursing home resident, % (95% CI)

10.9 (5.9-17.8)

12.2 (2.4-22.0)

10.0 (3.3-18.3)

10.9 (7.2-16.0)

Arrival by ambulance, % (95% CI)

47.5 (37.6-57.4)

63.4 (48.8-78.0)

51.7 (38.3-65.0)

52.0 (45.1-58.8)


Chronic kidney disease, % (95% CI)

14.9 (7.9-20.8)

17.1 (7.3-29.3)

6.7 (1.7-13.3)

12.9 (8.9-18.2)

Congestive heart failure, % (95% CI)

13.9 (7.9-20.8)

12.2 (2.4-22.0)

13.3 (5.0-21.7)

13.4 (9.3-18.8)

Coronary artery disease, % (95% CI)

23.8 (15.8-32.7)

17.1 (7.3-29.3)

31.7 (20.0-43.3)

24.8 (19.3-31.1)

Hypertension, % (95% CI)

46.5 (36.6-56.4)

68.3 (53.7-82.9)

68.3 (56.7-80.0)

57.4 (50.5-64.0)

presumed infection source

Gastrointestinal, % (95% CI)

13.9 (7.9-20.8)

7.3 (0.0-14.6)

11.7 (3.3-20.0)

11.9 (8.1-17.1)

Respiratory, % (95% CI)

43.6 (33.7-53.5)

51.2 (36.6-65.9)

38.3 (25.0-50.0)

43.6 (36.9-50.5)

Soft tissue, % (95% CI)

9.9 (5.0-15.8)


1.7 (3.3-18.3)

5.5 (3.0-9.6)

Urinary, % (95% CI)

17.8 (10.9-25.7)

22.0 (9.8-34.1)

23.3 (13.3-35.0)

20.3 (15.3-26.4)

Other, % (95% CI)

14.9 (6.9-24.8)

19.5 (4.9-24.3)

25.0 (10.0-41.6)

18.8 (14.0-24.8)

Initial vital signs

Median systolic blood pressure, mm Hg (IQR)

108 (90-132)

128 (102-154)

100 (81-112)

107 (90-131)

Median heart rate, beats per minute (IQR)

102 (88-126)

114 (93-132)

104 (87-104)

106 (88-124)

Median respiratory rate, breaths per minute (IQR)

21 (20-26)

22 (20-30)

23 (20-30)

22 (20-28)

Median temperature, degree Fahrenheit (IQR)

98.9 (98.1-101.2)

99.0 (98.1-101.2)

98.3 (97.6-99.9)

98.8 (97.9-101.0)

Median oxygen saturation (IQR)

95 (90-98)

95 (87-98)

95 (91-98)

95 (90-98)

Initial laboratory values

Median bilirubin, mg/dL (IQR)

0.6 (0.4-1.1)

0.8 (0.5-2.2)

0.8 (04-1.5)

0.7 (0.4-1.4)

Median creatinine, mg/dL (IQR)

1.2 (0.9-1.8)

1.1 (0.8-1.6)

1.6 (1.0-2.2)

1.2 (0.9-1.9)

Median hemoglobin, g/dL (IQR)

11.7 (9.9-13.4)

11.6 (9.0-14.7)

11.4 (9.6-11.4)

11.6 (9.7-13.4)

Median lactate, mmol/L (IQR)

1.7 (1.3-2.5)

5.9 (4.8-7.9)

4.2 (4.0-6.3)

2.8 (1.6-5.0)

Median platelets, 10^3/uL (IQR)

207 (130-306)

213 (133-273)

165 (123-256)

186 (129-282)

Median white blood cell count, 10^3/uL (IQR)

11.9 (8.1-16.3)

13.5 (8.9-18.0)

15.1 (9.5-20.9)

13.0 (9.0-19.0)

Median white blood cell count bands, % (IQR)

15.0 (8.0-25.0)

25.0 (10.5-37.0)

16.0 (3.0-26.0)

16.0 (8.0-30.0)

Abbreviations: CI-confidence intervals; IQR-interquartile range.

a Septic shock is here defined as the presence of either refractory hypotension (systolic blood pressure b 90 mm Hg after 1 L of intravenous fluid) or hyperlactatemia (lactate N 4 mmol/L).

than patients presenting with isolated refractory hypotension. These main findings held in our logistic regression analyses controlling for pa- tient severity of illness and therapeutic interventions.

Our results are relevant to the ongoing debates about how best to prognosticate patients with sepsis. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) recognize the clinical value of lactate in their revised definition of septic shock as “a

Vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and Serum lactate level greater than 2 mmol/L in the absence of hypovolemia” [2]. Yet, their recommended decision aid for sepsis prognostication, Quick Sequential Organ Failure Assessment does not incorporate lactate [2,16,21].

The literature is still in the process of establishing the applicability of these recommendations to the undifferentiated ED population [22,23].

Table 2

Emergency department therapeutic interventions among emergency department patients with septic shock.a


Refractory hypotension only (n = 101)a

Hyperlactatemia only (n = 41)a

Refractory hypotension and hyperlactatemia (n = 60)a

All patients (n = 202)

Intravenous crystalloid fluid

Intravenous crystalloid fluid administered, % (95% CI)

98.0 (95.0-100.0)

92.7 (82.9-100.0)

93.3 (85.0-98.3)



Mean door-to-fluid bolUS time, minutes (95% CI)

64.7 (46.8-90.6)

65.8 (33.5-105.8)

68.3 (36.1-119.2)


Intravenous crystalloid fluid >= 30 mL/kg administered within 30 min

40.1 (31.1-49.0)

16.0 (5.0-28.7)

33.8 (21.1-45.9)



of meeting septic shock criteriaa, % (95% CI)



Antibiotics administered, % (95% CI)

98.9 (96.8-100.0)

97.1 (91.4-100.0)

96.3 (90.7-100.0)



Mean door-to-antibiotic time, minutes (95% CI)

139.5 (118.0-167.4)

124.8 (72.4-182.2)

105.5 (86.7-128.2)




Vasopressors administered, % (95% CI)

27.7 (19.8-37.6)

12.2 (2.4-22.0)

31.7 (20.0-45.0)



Mean door-to-vasopressor time, minutes (95% CI)

140.5 (90.8-181.8)


120.2 (85.2-164-5)




Abbreviations: CI-confidence intervals; IQR-interquartile range.

a Septic shock is here defined as the presence of either refractory hypotension (systolic blood pressure b 90 mm Hg after 1 L of intravenous fluid) or hyperlactatemia (lactate N 4 mmol/L).

Table 3

Patient outcomes among emergency department patients with septic shock.a


Refractory hypotension only (n = 101)a

Hyperlactatemia only (n = 41)a

Refractory hypotension and hyperlactatemia (n = 60)a

All patients (n = 202)

Mortality, % (95% CI)

10.9 (5.0-16.8)

24.4 (12.2-36.6)

28.3 (16.7-41.6)

18.8 (13.9-24.3)

In-hospital dialysis, % (95% CI)

9.8 (2.4-19.5)

5.9 (2.0-10.9)

8.3 (1.7-15.0)

7.4 (4.0-11.4)

Mean timeb receiving vasopressors, hours (95% CI)

153.8 (109.1-199.4)

30.7 (5.3-67.2)

130.2 (96.2-174.2)

132.2 (102.0-166.7)

Mean timeb on mechanical ventilation, days (95% CI)

6.7 (3.0-10.9)

3.7 (1.8-6.0)

5.2 (2.2-8.7)

5.8 (3.4-8.6)

Mean hospitalization lengthb, days (95% CI)

15.0 (10.5-20.0)

5.5 (2.2-11.0)

12.0 (7.3-16.6)

12.9 (9.7-16.8)

Abbreviations: CI-confidence intervals; IQR-interquartile range.

a Septic shock is here defined as the presence of either refractory hypotension (systolic blood pressure b 90 mm Hg after 1 L of intravenous fluid) or hyperlactatemia (lactate

N 4 mmol/L).

b All time-based outcomes measured over entirety of hospitalization.

The Sepsis-3 validation cohorts reported qSOFA Prognostic accuracy values for ED encounters as part of pooled analyses including all non- ICU encounters. The implication was that utility of qSOFA among ED pa- tients is equivalent to the high prognostic accuracy values reported among all non-ICU encounters [16]. In fact, the ED population is extraor- dinarily heterogeneous. Emerging data suggests that qSOFA’s prognos- tic accuracy for in-hospital mortality among ED sepsis patients ultimately requiring ICU-level care may more closely resemble the more modest values reported among sicker ICU patients [15,24].

The present study suggests that among these more acutely ill ED sepsis patients, lactate offers an important additional Prognostic tool. Indeed, at least one prospective study of patients admitted to an ICU with suspected infection noted increased prognostic accuracy of qSOFA for in-hospital mortality when coupled with lactate values [25]. Pending future research on optimal prognostication tools for ED pa- tients with sepsis, we believe emergency medicine providers should routinely evaluate lactate values for all of their patients in planning therapeutic and disposition plans.

Study limitations

The main limitation of this study lies in its retrospective chart review design [18]. We sought to minimize data abstraction errors through for- mal chart abstractor training. Furthermore, we double entered all data points used in this study. We also sought to minimize investigator bias through the a priori explication of methods for collection of study vari- ables, systematic training using mock charts, and dissemination of a study manual with regular quality assurance checks to evaluate for

Table 4

Logistic regression analysis.

data entry discrepancies across data abstractors. We minimized selec- tion bias in our study population through the systematic use of multiple data sources to identify all potentially eligible patients during the study period.

Another important limitation is minimal data regarding the specific etiologies for our primary outcome of in-hospital mortality. In particu- lar, we did not identify those patients who died as a result of withdrawal of support. That said, we did exclude all patients with documentation of advanced directives at the time of initial presentation.

Future research

Given that this was a relatively small single center study, the litera- ture would benefit from replication of our study in other settings to es- tablish the external validity of our findings. Such studies would be particularly powerful if gathering data in prospective fashion to mini- mize the potential for data abstraction errors. Such studies would also ideally achieve larger sample sizes, so enabling more robust matching of patient groups prior to mortality comparisons via statistical methods such as regression or propensity matching. Future research should also build upon the growing body of literature seeking to synthesize newer prognostication tools with established laboratory markers such as lac- tate to further optimize the ability to accurately prognosticate undiffer- entiated ED patients with suspected infection [25].


Hyperlactatemia appears associated with higher in-hospital mortal- ity compared to refractory hypotension among ED patients with septic shock. These results highlight the prognostic value of incorporating lac- tate measurements into the assessment of undifferentiated ED patients with suspected infection. Emergency physicians should be particularly

OR for in-hospital mortality

95% confidence interval

Lower Upper

vigilant in formulating treatment and disposition plans for patients with septic shock exhibiting hyperlactatemia.


Age, years




Female sex




[1] Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013;369:

HR, beats per minute





RR, breaths per minute




[2] Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al.

O2 Saturation, %




The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-

Arrival by ambulance




3). JAMA 2016;315:801-10.

Nursing home resident




[3] Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP. The natural

Congestive heart failure




history of the Systemic Inflammatory Response Syndrome . A prospective

Coronary artery disease








Chronic kidney disease




Bolus >= 30 mL/kg within 30 min of meeting




septic shock criteriaa Refractory hypotensiona








Abbreviations: ED-emergency department, HR-heart rate, ICU-intensive care unit, O2-ox- ygen, OR-odds ratio, RR-respiratory rate, SBP-systolic blood pressure.

a Septic shock criteria include the presence of either refractory hypotension

(systolic blood pressure b 90 mm Hg after 1 L of intravenous fluid) or hyperlactatemia (lactate N 4 mmol/L).

study. JAMA 1995;273:117-23.

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