caused by a dysregulated host response to infection.^1,2 Sepsis is a major healthcare problem, causing mortality among one in four and often even more. Similar to acute coronary syndrome, stroke and polytrauma, early identification and early initiation of goal directed management in the initial hours of sepsis improves outcome.^1,3

Sepsis currently is the tenth most common cause of mortality in the United States and one of the most common causes of mortality in the non-coronary intensive care units.^4,5

Sepsis is a syndrome of physiologic, pathologic, and biochemical abnormalities induced by infection. 28-day mortality and Hospital mortality of severe sepsis in India are 57.6% and 59.3%6 respectively. There is an elevated awareness regarding long term physical, psychological, and cognitive disabilities in patients who survive sepsis.⁶

The diagnosis as sepsis depends on overt symptoms of systemic illness causing a change in the vitals of patient and also indication of infection through microbial cultures and serology. While our understanding of the complex pathophysiologic alterations that occur in septic shock has increased greatly as a result of recent clinical and preclinical studies, mortality associated with the disorder remains unacceptably high.⁵

Septic is the most common cause for hospitalization in the worldwide, patients often hospitalized for prolonged periods of up to 2-3 weeks.⁷ Despite the use of appropriate antimicrobial therapy and advanced supportive care, mortality in patients with sepsis has remained high since the past decade.^8,9 Elderly subjects are especially vulnerable population and are susceptible to a wide array of infectious diseases. Estimations suggest that the global burden of sepsis and septic shock among elderly population is expected to be on the rise in the forthcoming years.

Cultures and serology results will be obtained only after 24 to 72 hours. In the initial hours of sepsis which will determine the outcome and prognosis of sepsis patients, Physician should depend on clinical findings and the demographic data framed in the locality to help in initial provisional diagnosis and further management of patients. Hence, various guidelines propose the use of early empirical broad-spectrum antibiotics that will cover all the likely pathogens, and also supportive care, early recognition and treatment of complications, and intensive monitoring to prevent progression of organ dysfunction.¹⁰ In more than quarter of the patients, aetiology is never determined even till death or discharge.

In India, majority of ICU burden due to sepsis is mainly attributed to multi organ dysfunction caused by various tropical infections. Majority of patients present with fever associated features like myalgia, arthralgia, icterus, rash, or acute encephalitic syndrome.^12,13 Due to varied presentation, multi organ involvement and lack of proposed clinical diagnostic and prognostic criteria these tropical infections often remain undiagnosed.

Cases were selected from patients presenting to HIMS hospital, in MICU and Emergency ward, with sepsis considering the inclusion and exclusion criteria, from January 2023-December 2024.

At confidence level of 95% and allowable error of 5%, the sample size for the study was found to be 117.

Sample size is calculated using formula 4PQ/d2 = 117

Total number of IP admissions under General medicine from Jan 2013 to Dec 2014 -13562.

Total number of inpatient admissions of Sepsis – 1067.

 INCLUSION CRITERIA:

• Patients admitted in Emergency ward and Intensive Care Unit who meet the criteria of sepsis and septic shock.

 EXCLUSION CRITERIA:

• Liver disease
• Past history of COPD
• Acute exacerbation of Bronchial Asthma
• Known malignancy
• Diabetic Ketoacidosis
• Severe anemia
• Drug induced acidosis
• Intestinal Obstruction
• Chronic Kidney Disease.

CASES: Ethical committee approval will be taken and 117 patients presenting with SEPSIS, to MICU, Emergency ward, HIMS Hospital, will be taken for the study after taking informed consent.

DATA COLLECTION: After finalizing the patients to be included in our study, we collect clinical, laboratory, and radiological data from their medical records including demographic data, age, sex, chief complaints, past medical history, and vital signs 

7/9/10/11/ROC q sofa and LACTATE

Table 1: Distribution of Sepsis parameters among study population

The mean lactate level of our study population was 2.77mmol/L, The mean SOFA score of the study population was 5.8. The mean qSOFA score was 1.1 with a median score of 1.

Table 2: Distribution of SOFA score and outcome of study population

The mean SOFA score among the  non survivors is 12.22 and among the survivors is 4.337. On students t test the difference in SOFA score between the two groups is statistically significant.

 Table 3: Distribution of qSOFA and Outcome among study population

In our study of 120 patients, 22 patients had mortality among which13.6% of patients had qSOFA hscore of 1 , 59.1% of patients had qSOFA score of 2 and 6 patients had a qSOFA score of 3. The distribution of qSOFA score with the outcome of the study population is statistically significant with a p value of <0.0001.

Table 4: Distribution of Lactate levels among outcome of study population

The mean lactate level among the survivors of the study population is 2.32 mmol/L and among the non survivors is 4.73 mmol/L. On students T test the difference in mean lactate levels among the outcome is statistically significant with a p value of <0.0001.

 Fig 1: ROC of qSOFA score in predicting mortality

On ROC analysis of qSOFA score in predicting mortality, it was found that the AUC is 0.886 and is statistically significant. The sensitivity of predicting mortality with a qSOFA score of ≥2 is 86.4% and specificity is 82.7%.

Fig 2: ROC of Lactate in predicting mortality

On ROC analysis of Lactate levels in predicting mortality, it was found that the AUC is 0.944 and is statistically significant. The sensitivity of predicting mortality with a lactate level of ≥3.33mmol/L is 86.4% and specificity is 82.7%.

In the present study, mortality with initial qSOFA score of 0 was 0%, qSOFA 1 was 5.1% and qSOFA 2 or >2 was 52.7%. In Kristina Rudd et al¹¹ study ,mortality with initial qSOFA score of 0 was 3%, qSOFA 1 was 8% and qSOFA 2 or >2 was 62%.  In Eamon et al study, mortality with initial qSOFA score of 0 was 10%, qSOFA 1 was 14% and qSOFA 2 or >2 was 53.8%    Rudd et al study involved large sample and was a cohort study and data was taken from 17 hospitals ( which included small community hospitals, military hospitals, rural regional hospitals, national referral hospitals, and specialty infectious disease hospitals) in 10 different countries. Mortality increased as the qSOFA score increased. The present study mortality for qSOFA 2or >2 is comparable with Eamon et al, which was multicentre study conducted on a very large population in 2 different countries.

The mean blood lactate values were always more in non-survivor group at the time of admission when compared with survivor group. The association of lactate level with sepsis and its relation to mortality was described in many studies.66,67,69,72 .Our results were in line with the previous studies, which had shown that lactate levels were higher in non-survivors than in the survived.

In the present study, mean lactate levels among survivors were 2.32 ±0.97mmol/lit and 4.73 ±0.92mmol/lit among non survivors. In Bakker et al¹² study, mean lactate levels among survivors were 5.1 ± 2.7 mmol/lit and 8.2 ±5.4mmol/lit among non survivors .In Marceaux et al¹³ study, mean lactate levels among survivors were 3.49 ±2.0mmol/lit and 6.11 ±4.78 mmol/lit among non survivors. In Shapiro et al¹⁴ study, mean lactate levels among survivors were 2.2 /lit and 4mmol/lit among non survivors.  The present study mean lactate level among survivors and non survivors is comparable to that of Shapiro et al study. There is a linear relationship of lactate levels with mortality. In the present study it was found that the probability of mortality increased significantly and in a linear fashion within creasing range of initial lactate values. There is significant relation[p<0.0001] with admission lactate levels and the mortality. It is in accordance with other study done by Shapiro et al

From the ROC curves of lactate levels with outcome in our study, it was observed that the area under curve was 0.944. At the time of admission highest sensitivity and specificity of lactate levels for predicting mortality was 3.33mmol/lit with a confidence interval of 95. The sensitivity was 86.4% and specificity was 82.7%. This finding is in accordance with the study by Smith etal. In the study by Shapiro et al, admission blood lactate was a better predictor of mortality. It was observed that in-patients whose blood lactate levels remain high even after 24 hours of treatment had higher mortality, so probably lactate levels at 24 hours has got better prognostic action than at admission.

In the present study ROC area under the curve for lactate at admission was 0.944 and this was statistically significant.

While the ROC area under the curve for lactate level at admission as a predictor of death was 0.67 in the study by Shapiro et al indicating better sensitivity and specificity of lactate in predicting mortality.

There was decrease in lactate levels with progression of time in both survived and non-survivors. The fall in mean lactate levels in survivor group with time was significant for outcome. Persistently elevated lactate levels had poor outcome. Many studies have showed that the rise of lactate production after initial resuscitation effort could be due to activation of glycolytic pathway triggered by mechanism such as Na+-K+ ATPase rather than the impact of tissue hypoxia. It was also suggested that a high initial lactate levels had caused irreversible organ damage. A significant reduction in lactate levels in survivors indicates that an aggressive therapy for treating the cause of sepsis and thus lowering of lactate levels could reduce the mortality.

Since SOFA score involves six components, it might be a little cumbersome to get the laboratory values often. Lactate levels can be easily done and can be an economical choice even in primary hospital care setting to identify and to know the severity of illness and for prognostication purposes as well. Higher lactate level can be used as an indicator to opt for the aggressive management of sepsis as higher level indicates higher risk of mortality.

Sepsis with multi-organ dysfunction syndrome (MODS) is a common cause of Intensive Care Unit (ICU) mortality and morbidity. qSOFA score of >2 predicts the higher chances of mortality. Lactate levels above 3.33mmol/L has a high sensitivity and specificity in predicting the mortality of the patient.Our study concludes that lactate is a good prognostic factor and is equally as qSOFA in adult patients with sepsis.

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