Objectives Lactate/albumin (L/A) ratio is a biomarker in sepsis that has been shown to outperform lactate. This prospective study aims to validate the superior prognostic value of the L/A ratio to lactate in sepsis and septic shock. Methods Prospective cohort conducted from September 2018 till February 2021 on adult patients presenting to the Emergency Department (ED) at a tertiary care centre with sepsis or septic shock. The primary outcome was the prognostic value of the L/A ratio compared to lactate with regards to mortality. Results A total of 939 septic patients were included throughout the study period. A total of 236 patients developed septic shock. The AUC value of the L/A ratio in septic patients was 0.65 (95% CI 0.61–0.70) and was higher than that of lactate alone 0.60 (95% CI 0.55–0.64) with a p < .0001. The optimal L/A ratio cut-off threshold that separated survivors from non-survivors was found to be 0.115 for all septic patients. The AUC of the L/A ratio was significantly higher for patients with a lactate ≥2 mmol/L: 0.69 (95% CI 0.64–0.74) versus 0.60 (95% CI 0.54–0.66) with a p < .0001 as well as for patients with an albumin level less than 30 g/L (AUC = 0.69 95% CI= 0.62–0.75 vs AUC= 0.66 95% CI= 0.59–0.73, p = .04). Among septic shock patients there was no statically significant difference in the AUC value of the L/A ratio compared to lactate (0.53 95% CI 0.45–0.61 vs 0.50 95% CI 0.43–0.58 respectively with a p -value = .11). Conclusions The L/A ratio is a better predictor of in-patient mortality than lactate in sepsis patients. This superiority was not found in the septic shock subgroup. Our results encourage the use of the ratio early in the ED as a superior prognostic tool in sepsis patients. Key messages We aimed to assess the prognostic usefulness of the Lactate/Albumin ratio compared to lactate alone in septic and septic shock patients. The L/A ratio proved to be a better predictor of in-patient mortality than lactate alone in sepsis patients. This pattern also applies across various subgroups in our study (malignancy, diabetics, age above 65, lactate level less than 2 mmol/L, albumin less than 30 g/L). Our results favour the use of the L/A ratio over lactate alone in patients with sepsis and the previously mentioned subgroups. Our results do not favour the use of the ratio instead of lactate in septic shock patients as there was no statistically significant difference between the AUCs of the ratio and lactate alone.

BackgroundHigh-risk unscheduled return visits (HRURVs), defined as return visits within 72 hours that require admission or die in the emergency department (ED) on representation, are a key quality metric in the ED. The objective of this study was to determine the incidence and describe the characteristics and predictors of HRURVs to the ED.MethodsCase–control study, conducted between 1 November 2014 and 31 October 2015. Cases included all HRURVs over the age of 18 that presented to the ED. Controls were selected from patients who were discharged from the ED during the study period and did not return in the next 72 hours. Controls were matched to cases based on gender, age (±5 years) and date of presentation.ResultsOut of 38 886 ED visits during the study period, 271 are HRURVs, giving an incidence of HRURV of 0.70% (95% CI 0.62% to 0.78%). Our final analysis includes 270 HRURV cases and 270 controls, with an in-ED mortality rate of 0.7%, intensive care unit admission of 11.1% and need for surgical intervention of 22.2%. After adjusting for other factors, HRURV cases are more likely to be discharged with a diagnosis related to digestive system or infectious disease (OR 1.64, 95% CI 1.02 to 2.65 and OR 2.81, 95% CI 1.05 to 7.51, respectively). Furthermore, presentation to the ED during off-hours is a significant predictor of HRURV (OR 1.64, 95% CI 1.11 to 2.43) as is the presence of a handover during the patient visit (OR 1.68, 95% CI 1.02 to 2.75).ConclusionHRURV is an important key quality outcome metric that reflects a subgroup of ED patients with specific characteristics and predictors. Efforts to reduce this HRURV rate should focus on interventions targeting patients discharged with digestive system, kidney and urinary tract and infectious diseases diagnosis as well as exploring the role of handover tools in reducing HRURVs.

Objective There is an increase in Emergency Department (ED) utilization globally. Understanding what patients present to EDs with is important for resource allocation, training and staffing purposes. There is paucity of data pertaining to ED visit presentations in Lebanon. This study aims at describing the spectrum of diseases among adult patients who present to a tertiary care center in Lebanon, an upper-middle income country (UMIC). Methods A retrospective chart review of adult patients (age ≥ 19) presenting to a tertiary care hospital ED during 2010–2011 was completed. Common diagnoses in three categories (all adult visits, treat and release, admitted visits) were assessed. Diagnoses were classified according to the Clinical Classifications Software. Descriptive statistics were presented in tables as frequencies and percentages. Results During the study period, 32787 adults presented to the ED with 18.7% resulting in hospital admission. The most common diagnoses in ED patients were injuries and conditions due to external causes, abdominal pain, non-specific chest pain and intestinal infections. In the treat and release group, intestinal infections emerged in the common list for ages 19–44. Coronary atherosclerosis was common in admitted patients aged ≥45 years. Summer was the busiest season, with abdominal pain and intestinal infection being prominent diagnoses during that season. Conclusions This study is the first to assess adult ED visits in a Lebanese setting. Our study suggests that patients in our population suffer from the double burden of both communicable and non-communicable disease, with coronary atherosclerosis common in admitted patients (≥ 45 years) and intestinal infections common in treat and release adult patients (19-44years), the latter condition peaking in summer and driving seasonal surges in ED visits.

Purpose To describe injuries and outcomes of casualties of Beirut Port Blast treated at a large tertiary care center in Beirut, Lebanon. Methods A retrospective observational study assessing the spectrum of injuries, treatment, and medical outcome among casualties of the Beirut Port Blast, immediately after the blast and up to 1 week from the blast to the emergency department of the American University of Beirut Medical Center (AUBMC). Results A total of 359 patients were included. Most ( n = 343, 95.6%) were adults (> 19 years), and males (56%) with a mean age of 42 ± 20 years. The most frequent mechanism of injury was a penetrating injury (45.7%), followed by other blast-related injuries (30.4%), and blunt injuries (23.4%). The most affected anatomical location were the limbs. Most ( n = 217, 60.4%) patients required imaging. The most frequently administered medication was analgesics (38%), followed by anesthetics (35%), antibiotics (31%), tetanus vaccine (31%), and fluids (28%). Blood and blood products were administered in 3.8% of cases. Emergent procedures included endotracheal intubation ( n = 18, 5%), surgical airway ( n = 3, 0.8%), chest tube insertion ( n = 4, 1.1%), thoracotomy ( n = 1, 0.3%), and CPR ( n = 5, 1.4%). A quarter of patients required surgical operations in the operating room ( n = 85, 23.6%) and 18% required noncritical care admissions, 5.3% required critical care admissions, and 2.8% were dead on arrival. Conclusion Casualties from this event had significant injuries requiring lifesaving interventions, surgical procedures, and admission to critical care units. High utilization of imaging modalities and of medications from existing stockpiles was also observed.

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