Patient selection: adult with severe sepsis as indicated by one or both of the following:
(1) >= 2 of 4 SIRS criteria AND infection AND serum lactate > 4 mmol/L
(2) septic shock (systolic blood pressure < 90 mm Hg despite >= 20 mL/kg IV fluid)
Findings associated with early death:
(1) high admission serum lactate concentration (mean 7.3 vs 3.3 mmol/L)
(2) failure of the serum lactate concentration to normalize after resuscitation
(3) higher admission mSOFA score (median 10 vs 6)
(4) early positive blood cultures
Criteria for lactate normalization - both of the following (Puskarich et al):
(1) initial serum lactate > 2 mmol/L
(2) serum lactate within 6 hours < 2 mmol/L
A repeat serum lactate concentration >= 5 mmol/L had a sensitivity of 55% and specificity of 89% for early death. (The timing of the repeat specimen is not specified but is assumed to be 6 hours.)
Cutoffs are not provided for admission serum lactate or modified SOFA. GT 5 will be used for lactate based on Figure 1. GT 8 will be used for mSOFA based on Figure 3.
