American Journal of Emergency Medicine 36 (2018) 687-688

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Controversy

Another failure in predicting sepsis outcomes in the emergency department

Daryelle S. Varon, MS^a, Joseph Varon, MD^b,c,d,?

^a St. James School of Medicine, Lesser Antilles, Anguilla

^b The University of Texas Health Science Center at Houston, Houston, TX, USA

^c The University of Texas Medical Branch at Galveston, Houston, TX, USA

^d United Memorial Medical Center, Houston, TX, USA

A R T I C L E I N F O

Article history:

Received 5 December 2017

Accepted 5 December 2017

Keywords:

Lactate

Platelet-lymphocyte ratio outcome prediction Sepsis

Septic shock

The quest for predictors of outcome in patients evaluated in the emergency department (ED) has evolved over the past several decades. Scoring systems in this context have been validated, but have not been well adopted among practitioners, as in many instances they fail to achieve their objective, as some patients do not follow the predictive rules [1-3].

A variety of biomarkers have proven useful in attempting to deter- mine which patients are likely to survive sepsis. Of them, the use of ED admission levels of procalcitonin , lactate, and C-reactive pro- tein are widely utilized [4-7]. The value of some of these biomarkers have been followed by the Federal Government though the National Quality Forum (NQF #0500), and the Center for Medicare & Medicaid Services have developed and mandated the “SEP-1 Early Management Bundle for Severe Sepsis and Septic Shock” [8-9]. According to this “rule”, all patients admitted to hospitals in the United States who are suspected to have a diagnosis of sepsis require an immediate blood lac- tate measurement in the ED, blood cultures and the administration of broad spectrum antibiotics within 3 h of presentation to hospital. In ad- dition, those patients with hypotension or a lactate concentration.

N 4 mmol/l are required to receive a 30 ml/Kg bolus of crystalloid within this time period.

Unfortunately, in many EDs, these biomarkers, such as lactate and procalcitonin, are not readily available due to lack of resources. In

? Conflicts of interest: None.

* Corresponding author at: 2219 Dorrington Street, Houston, TX 77030, USA.

URL: [email protected] (J. Varon).

addition, the results of some of these markers may not be ready by the time the patient leaves the ED. For that reason, investigators around the World have looked for alternative, inexpensive, and easy to obtain test in an attempt to predict of outcome for these patients.

In this issue of The American Journal of Emergency Medicine, Biyikli and collaborators, in a busy ED in Turkey, reviewed data of 131 patients admitted to their unit with the diagnoses of sepsis and septic shock and determined the platelet-lymphocyte ratio (PLR) and compared it to the admission lactate levels [10]. The authors found no statistical signifi- cance in the PLR between surviving and non-surviving patients. In addi- tion, they found a weak correlation with initial lactate levels and recommended serial measurements in order to ascertain outcomes.

As the PLR is an inexpensive and easy to obtain parameter, ED clini- cians, regardless of where they practice, could use it. Some authors have shown a direct correlation between the presence of deep tissue sepsis and PLR levels [11-13]. Any ED practitioner could use this inexpensive test. Even though the study in this issue was elegant and well conducted, we identified a few issues that may have yielded different results. For example, the patients in this study were aged N 65 years, and this may have skewed the results in a negative way. It is clear that the outcome of elderly sepsis patients is different from younger individuals [14-15]. It would have been interesting to assess the lactate and PLR ratio in the younger group as well and then make a comparison. Second, the au- thors utilized the most recent definition of sepsis and septic shock. We wonder if using prior terminology in the inclusion criteria would have

influences their results.

We fully agree with Biyikli and coinvestigators in that there need to be additional studies to ascertain the usefulness of the PLR. Predictors of outcome in these patient populations are difficult to establish in general. A prospective study that includes both young and old patients is defi- nitely required before we abandon the PLR as a potential predictor of outcome in patients with sepsis and septic shock in the ED.

Despite their negative results, we applaud the efforts of Biyikli and associates in validating a low cost and easy to obtain parameter trying to assess outcome of patients with sepsis and septic shock in the ED.

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