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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 203-209

Venous lactate level as a predictor to determine the outcome in patients with acute upper gastrointestinal hemorrhage in the emergency department


1 Department of Emergency Medicine, All India Institute of Medical Sciences (AIIMS), MIA, 1st Phase, Basni 2, Jodhpur 342005, Rajasthan, India
2 Department of Emergency Medicine, Manipal Hospital, Palam Vihar, Sector 6 Dwarka, New Delhi 110075, India
3 Department of Emergency Medicine, Shantiram Medical College and Hospital, NH-40, Nadhyala, Andhra Pradesh 518001, India
4 Department of Nursing, Indian Railway Health Services, Bikaner, Rajasthan 334005, India
5 Department of Emergency Medicine, Max Super Speciality Hospital, Saket, Delhi 110017, India

Date of Submission27-Mar-2021
Date of Acceptance02-Jun-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Mr. Shatrughan Pareek
Department of Nursing, Indian Railway Health Services, Bikaner, Rajasthan.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_19_21

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  Abstract 

Introduction: Gastrointestinal bleeding (GIB) is occasionally seen in various clinical conditions in emergency departments (EDs). It is associated with more disease burden and mortality. Most severe patients with upper GIB (UGIB) have an increased level of lactate, whereas it is still not considering a risk predictor among the patients. The present study aimed to evaluate several levels and a cut-off value of lactate for predicting outcomes of patients with UGIB. Materials and Methods: The present cross-sectional observational prospective study was conducted in the ED of Max Hospital, Saket, New Delhi, over a study period of 18 months from June 2015 to December 2016. The participants selected for the study were more than 17 years old from both genders with UGIB. In the study, 300 subjects were selected by the convenient sampling method. All the analyses was done by SPSS-20. Results: In this study, male and female subjects were 75.7% and 24.3%, respectively. Nearly 25% of the participants were hypertensive and diabetic. The study highlighted that the mean lactate level was 4.55±2.45 mmol/L; however, the range of the lactate level was 1.4–14. Based on the receiver operating characteristic curve analysis, the optimum cutoff of lactate was 4.55 mmol/L, had an area under the curve of 0.905 (confidence interval: 0.861–0.949), sensitivity of 80.5%, specificity of 98.9%, and P-value of less than 0.05. Likewise, the results of this study also communicated that there was a significant positive correlation (P-value = 0.001*) between the level of lactate and the outcome of the patients. The present study also discriminated that venous lactate levels 4.55 mmol/L and above are associated with mortality and hospital stay. Conclusion: Findings of this research study suggested that venous lactate level is an effective predictor of patient outcome among patients with UGIB. Furthermore, early assessment and management are needed to reduced mortality and morbidity among patients with UGIB.

Keywords: Acute upper gastrointestinal hemorrhage, emergency department, outcome, patient, venous lactate


How to cite this article:
Kumar N, Verma D, Gupta K, Kiran M, Pareek S, Mehta M. Venous lactate level as a predictor to determine the outcome in patients with acute upper gastrointestinal hemorrhage in the emergency department. MGM J Med Sci 2021;8:203-9

How to cite this URL:
Kumar N, Verma D, Gupta K, Kiran M, Pareek S, Mehta M. Venous lactate level as a predictor to determine the outcome in patients with acute upper gastrointestinal hemorrhage in the emergency department. MGM J Med Sci [serial online] 2021 [cited 2021 Dec 2];8:203-9. Available from: http://www.mgmjms.com/text.asp?2021/8/3/203/325532




  Introduction Top


Gastrointestinal bleeding (GIB) is occasionally seen in various clinical conditions in emergency departments (EDs). It is associated with more disease burden and mortality. Assessment of risk before endoscopy is based on clinical features and laboratory findings of the patient. In the ED, lactic acidosis and base imbalance are some of the key parameters related to tissue perfusion disorders and sepsis follow-up. In conditions such as dehydration, septic shock, hypovolemia due to bleeding, severe hypoxemia, and severe anemia, the level of lactic acid in the blood is increased. Poor prognosis can be noted among the GIB patients with altered lactic acid level.[1] Every year, 36 people per 100,000 population were admitted to the hospital due to acute GIB. In the United States, around 20,000 people deceased annually due to upper GIB (UGIB), whereas mortality related to lower GIB is between 2% and 10%. Appropriate risk assessment among acute GIB patients is effective in determining hospital admission, level of care during indoor, and further interventions.[2] Acute upper gastrointestinal hemorrhage is frequently associated with morbidity and mortality among the elderly population.[3] UGIB is defined as the loss of blood from the proximal part of the gastrointestinal tract. However, it is more common among males and the elderly population. Early evaluation and diagnosis of patients with GIB are needed to differentiate between UGIB and lower GIB. The prevalence rate of UGIB is more than that of lower GIB. Peptic ulcer disease (55% incidence, 4% mortality) and esophageal varices (14% incidence, 50% mortality) are the commonest reasons for UGIB.[4] In the ED, initial clinical management decision in patients with acute GIB is effective in identifying high- and low-risk patients. Various scoring systems have been developed to assess high- and low-risk patients with GIB. High-risk patients are prone to fatal conditions such as rebleeding, coma, or death.[5] In recent times, various scoring systems have been created to predict outcomes in patients with UGIB, such as albumin, international normalized ratio, altered mental status, systolic blood pressure, age older than 65 years score (AIMS65), pre-endoscopic Rockall score, and Glasgow–Blatchford score. However, it is reported that these three tools helped differentiate for 30-day mortality.[6] Lactate is an effective biomarker that can be accessed from both venous and arterial blood. The level of lactate may be elevated in conditions such as cardiogenic shock, hypovolemic shock, burn, sepsis, severe trauma, and intoxication.[7] Most severe patients with UGIB have increased levels of lactate, whereas it is still not considered a risk predictor among the patients.

Hyperlactatemia may be developed due to hypovolemic conditions in patients with GIB. Increased serum lactate level can predict recurrent hypotension in patients with GIB.[8] Various studies have communicated that the level of lactate is related to predict the severity of the disease, mortality, and morbidity, especially in critical patients.[9],[10],[11]

Aims of the study

This investigation aimed to study the value of lactate in predicting patient mortality in patients admitted to the hospital with UGIB and risk stratifications according to the value of lactate.

Objectives of the study

The primary objective was to determine the clinical significance of lactate elevation in patients admitted for UGIB in the ED.

A secondary objective was to find out the prognostic significance of lactate elevation in patients admitted for UGIB in the ED.


  Materials and methods Top


The present cross-sectional observational prospective study was conducted in the ED of Max Hospital, Saket, New Delhi, over a study period of 18 months from June 2015 to December 2016. The participants selected for the study were more than 17 years old from both genders with UGIB attending the ED in the hospital. We excluded patients who have trauma and pregnancy. In the study, 300 subjects were selected by the convenience sampling method. The patients were selected as per inclusion and exclusion criteria. Data collection was done from the patients by using a custom-designed case report form. The initial value of lactate when the patient attended the ED was recorded by venous blood sampling to determine the outcome in the form of risk stratification and mortality associated with UGIB. The present study, the informed consent document, and any subsequent modifications were reviewed and approved by the Institutional Ethics Committee (IEC).

Inclusion criteria

The inclusion criteria were as follows:

  1. Age ≥18 years


  2. Both males and females


  3. All the patients presenting with UGIB


Exclusion criteria

The exclusion criteria were as follows:

  1. Age <18 years


  2. Trauma patient


  3. Pregnant patient


  4. Death due to other reasons (due to all other co-morbidities except upper GI hemorrhage)


Data collection method

Clinical features were recorded by the researcher and treating physician using a custom-designed case report form. The treating physician was asked to record the initial value of lactate by doing venous blood gas sampling to determine the outcome in the form of risk stratification and mortality associated with UGIB. As these data were recorded at the time of initial presentation and before the results of investigations are available, the treating clinicians were blinded to the outcome of the patient. An arterial blood sample was not taken for the current study purpose; moreover, only venous lactate value was recorded as per the study protocol. The evaluation of venous lactate was done bedside in the ED. The value of venous lactate was measured in mmol/L.

Statically analysis

The best cutoff of lactate for predicting mortality was obtained by the receiver operating characteristic (ROC) curve. Sensitivity and specificity were worked out at this cutoff. The odds ratio of the predictors was indicating the relative importance of each, keeping all other predictors fixed. A multivariate analysis determines factors associated with increased mortality in these patients. All the analyses were done by SPSS-20.


  Results Top


As per [Table 1], out of the 300 subjects, the majority of adults were between 41 and 50 years (31%), and 27% were from the age group of 61–70 years with the mean age of 55.1±14.22 years. In this study, male and female subjects were 75.7% and 24.3%, respectively. Nearly 25% of the participants were hypertensive and diabetic. A major proportion (90.67%) of the subjects were not suffering from any bleeding disorders, whereas about 15% were having GI ulcers. Furthermore, findings related to the use of nonsteroidal anti-inflammatory drug (NSAID) revealed that a proportion of the subjects (34%) were using NSAID, whereas 66% were not using NAISD. Most of the subjects (around 90%) have no disease like end-stage renal disease (ESRD), cancer, coagulopathy, and chronic liver disease (CLD). The study also highlighted that most of the participants (60.7%) were discharged from the hospital, whereas 39.3% died [Figure 1]. Additionally, the present study also highlighted that the mean lactate level was 4.55±2.45 mmol/L; however, the range of lactate level was 1.4–14 mmol/L [Table 2]. Moreover, the hospital stay of the participants communicated that duration of hospital stay was 1–5 days with a mean value of 2.37±0.76. Based on the ROC curve analysis, the optimum cutoff of lactate was 4.55 mmol/L, had area under the curve of 0.905 [confidence interval (CI): 0.861–0.949], sensitivity of 80.5%, specificity of 98.9%, positive predictive value of 97.9%, negative predictive value of 88.7%, accuracy of 91.7%, and P-value of less than 0.05 [Figure 2]. The results of this study also communicated that there was a significant positive correlation (0.001) between the level of lactate and the outcome of the patients. Mortality was significantly higher among patients with lactate levels equal to and above 4.55 mmol/L. Moreover, the outcomes of the patient have significant association with their demographic and clinical variables such as age (P-value <0.001), gender (P-value <0.001), hypertension (P-value <0.001), diabetes (P-value <0.001), ESRD (P-value = 0.009), bleeding disorders (P-value <0.001), use of NSAID (P-value = 0.012), smoking (P-value = 0.014), alcohol (P-value = 0.003), and lactate level (P-value <0.001). Furthermore, other variables such as CLD, cancer, coagulopathy, and GI ulcer were not significantly associated with outcomes of the patients [Table 3]. The study highlighted that lactate levels up to 2 mmol/L were discharged from the hospital but as the level increases, stay duration was simultaneously increased. The majority of the patients (70) were discharged from the hospital within 3 days. Moreover, the patients with lactate level of 4.55 mmol/L and above have 4 or more days hospital stay. The mortality was 95 out of 118 among these patients. Only two patients with the lactate level of 4.55 mmol/L and above were discharged from the hospital [Table 4].
Table 1: Sociodemographic profile of the subjects: N=300

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Figure 1: Bar diagram showing the relationship between level of lactate and outcome of patient

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Table 2: Mean value of clinical presentations of the subjects: N=300

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Figure 2: ROC curve comparing the lactate level and outcome of the patients

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Table 3: Association between selected variables and outcome of the subjects: N=300

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Table 4: Relation between lactate level, hospital stay, and outcomes: N=300

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  Discussion Top


In the ED, triage and management of critically ill patients with UGIB are essential to survive the patient.[12] Berger et al.[2] communicated that in patients with acute gastrointestinal hemorrhage, lactate is an independent predictor of inpatient mortality. Risk stratification in UGIB is important to select low-risk patients for early discharge and high-risk patients for ICU management. Several scoring systems have been developed to predict outcomes after UGIB, but none of these scoring systems used serum lactate level as a predictor of outcomes. The main scoring systems that predict outcomes after UGIB, such as clinical Rockall score, Glasgow–Blatchford score, and AIMS65 score use systolic blood pressure and heart rate as a part of the scoring system, but none of these scores used serum lactate level to predict outcomes.[6] Stokbro et al.[13] communicated that lactate has a significant role in clinical risk assessment, specifically in UGIB patients. The authors revealed that arterial lactate is significantly associated with mortality and its cutoff value is 1.98 mmol/L.

Lactate as a predictor of patient outcome

The main result of this study is that lactate was a useful biomarker to risk stratify for mortality in adult ED patients with UGIB. We found that the optimum cut point for risk stratification using lactate was 4.55 mmol/L. Gulen et al.[7] reported that the mean venous lactate in survived patients was 2.37 mmol/L and in expired patients it was 4.80 mmol/L. The cutoff value of lactate for the prediction of mortality was 2.32 mmol/L. In this context, we investigated that the cutoff value of lactate for predicting mortality was 4.55 mmol/L. The association between lactate levels and mortality in sepsis is well known and has been widely utilized in various studies.[10],[11],[14] El-Kersh et al.[9] reported that levels of lactate are highly correlated with the mortality rate. Few studies have highlighted the predictive use of lactate in predicting active bleeding or mortality among patients with acute GIB. Our study also measured the impact of lactate on hospital stay and mortality. Koch et al.[10] found increased serum lactate level in patients with acute gastrointestinal hemorrhage on admission to the ICU and predicting mortality. Furthermore, the elevated serum lactate level on presentation to the ED with acute gastrointestinal hemorrhage was found to be associated with higher in-hospital mortality and it was independently correlated with death. The present study revealed that an increased level of lactate is highly associated with the mortality rate. Based on the ROC curve analysis, the optimum cutoff of lactate was 4.55 mmol/L. In the context of our study, Lee et al.[8] also revealed that average lactate (odds ratio 1.501; 95% CI 1.150–1.959; P = 0.003) related to mortality rate. Shapiro et al.[15] conducted a study among trauma patients and communicated that the survival rate was 100% for those who had normalization of their serum lactate level in 24 h. Mortality rates increased as lactate increased: 43 (4.9%) of the 877 patients with a lactate level between 0 and 2.5 mmol/L died, 24 (9.0%) of the 267 patients with a lactate level between 2.5 and 4.0 mmol/L died, and 38 (28.4%) of the 134 patients with a lactate level greater than or equal to 4.0 mmol/L died, whereas our study also communicated that increasing level of lactate enhances stay duration of the patient in the hospital.

Risk factors associated with patient’s outcome

Few studies investigated that bleeding was found to be associated with a high mortality rate. Bleeding due to UGIB causes hypotension and results in a fatal outcome for the patient. Our study also communicated that bleeding is significantly associated with mortality among patients with UGIB.[1],[16],[17] In addition to the risk factors, Kim et al.,[6] Klebl et al.,[18] Rodríguez-Hernández et al.,[19] and Lee et al.[20] investigated that various risk factors like co-morbidities, including glucocorticoid (glucose + cortex + steroid) use, smoking, alcohol consumption, chronic obstructive pulmonary disease, diabetes mellitus, and malignancy, are associated with mortality among patients with UGIB. In this context, our findings also revealed that the outcomes of the patient (mortality) have significant association with their demographic and clinical variables such as age (P-value <0.001), gender (P-value <0.001), hypertension (P-value <0.001), diabetes (P-value <0.001), ESRD (P-value = 0.009), bleeding disorders (P-value <0.001), use of NSAID (P-value =0.012), smoking (P-value = 0.014), alcohol (P-value = 0.003), and lactate level (P-value <0.001). In addition, Gulen et al.[7] communicated that risk factors like bleeding and cancer are associated with mortality among patients with UGIB; our results are consistent with the findings. In 1996, Faigel and Metz[21] reported that the use of NSAID is associated with mortality. In addition, the present study revealed that the outcome of the patient is significantly associated with the use of NSAIDs. Moreover, our study also highlighted that risk factors such as age, gender, and hypertension are significantly associated with patient’s outcome, whereas there was little literature to compare the findings. Bernhard et al.[22] revealed that higher levels of lactate at admission are associated with enhanced 24-h and 30-day mortality. The present study also discriminated that the venous lactate level of 4.55 mmol/L and above is associated with mortality and hospital stay. Despite complex evaluation processes, increased lactate levels usually reflect increased morbidity and high mortality.


  Conclusion Top


According to our study results, serum lactate test on admission can be a useful adjunct to the often difficult task of predicting outcomes in patients with upper gastrointestinal hemorrhage. Moreover, high sensitivity of lactate with patient’s outcome appears that it may be particularly useful as a screening tool for risk prediction in the patients. We investigated that the cutoff value of lactate among patients with UGIB was 4.55 mmol/L. Therefore, increased venous lactate levels are directly associated with longer hospital stays and mortality. However, the presence of various risk factors in a patient with UGIB directly affects the patient outcome. The present findings suggested that a single venous blood lactate measurement provides clinically useful information in patients with UGIB and supports the use of venous lactate measurement in the initial clinical management decision.

Clinical significance

The present study investigates that the lactate level is correlated with the outcome of the patient with UGIB. The lactate level is a prognostic parameter to assess the morbidity and mortality among the patients. The presence of risk factors directly affects the patient outcome. Therefore, the lactate level is helpful in early assessment management of UGIB and patient’s stay in the hospital.

Limitation

The main limitation of this study was that the study was conducted in a single super specialty center of New Delhi.

Acknowledgements

The researchers would like to acknowledge the Ethical Committee, all faculty members, and all the participants for their support in the study.

Financial support and sponsorship

Self-funded.

Conflicts of interest

Nil.

Ethical consideration

The present study, the informed consent document, and any subsequent modifications were reviewed and approved by the Institutional Ethics Committee (IEC), Max Super Speciality Hospital, Saket, New Delhi vide their letter no. TS/MSSH/DDF/EM/IEC/15-09 dated 07 October 2015.



 
  References Top

1.
Konyar Z, Guneysel O, Dogan FS, Gokdag E. Modification of Glasgow–Blatchford scoring with lactate in predicting the mortality of patients with upper gastrointestinal bleeding in the emergency department. Hong Kong J Emerg Med 2019;26:31-8.  Back to cited text no. 1
    
2.
Berger M, Divilov V, Teressa G. Lactic acid is an independent predictor of mortality and improves the predictive value of existing risk scores in patients presenting with acute gastrointestinal bleeding. Gastroenterology Res 2019;12:1-7.  Back to cited text no. 2
    
3.
Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2015;47:a1-46.  Back to cited text no. 3
    
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Williams KL, Dunne C, Parsons MH. Emergency department presentation of a patient with a severe upper gastrointestinal bleed: A simulation case for training emergency medicine residents. Cureus 2019;11:e3908.  Back to cited text no. 4
    
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Shrestha MP, Borgstrom M, Trowers EA. Elevated lactate level predicts intensive care unit admissions, endoscopies and transfusions in patients with acute gastrointestinal bleeding. Clin Exp Gastroenterol 2018;11:185-92.  Back to cited text no. 5
    
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Kim D, Jo S, Lee JB, Jin Y, Jeong T, Yoon J, et al. Comparison of the National Early Warning Score+Lactate score with the pre-endoscopic Rockall, Glasgow-Blatchford, and AIMS65 scores in patients with upper gastrointestinal bleeding. Clin Exp Emerg Med 2018;5:219-29.  Back to cited text no. 6
    
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Gulen M, Satar S, Tas A, Avci A, Nazik H, Toptas Firat B. Lactate level predicts mortality in patients with upper gastrointestinal bleeding. Gastroenterol Res Pract 2019;2019:5048078.  Back to cited text no. 7
    
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Lee SH, Min YW, Bae J, Lee H, Min BH, Lee JH, et al. Lactate parameters predict clinical outcomes in patients with nonvariceal upper gastrointestinal bleeding. J Korean Med Sci 2017;32:1820-7.  Back to cited text no. 8
    
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El-Kersh K, Chaddha U, Sinha RS, Saad M, Guardiola J, Cavallazzi R. Predictive role of admission lactate level in critically ill patients with acute upper gastrointestinal bleeding. J Emerg Med 2015;49:318-25.  Back to cited text no. 9
    
10.
Koch A, Buendgens L, Dückers H, Bruensing J, Matthes M, Kunze J, et al. [Bleeding origin, patient-related risk factors, and prognostic indicators in patients with acute gastrointestinal hemorrhages requiring intensive care treatment. A retrospective analysis from 1999 to 2010]. Med Klin Intensivmed Notfmed 2013;108:214-22.  Back to cited text no. 10
    
11.
Shah A, Chisolm-Straker M, Alexander A, Rattu M, Dikdan S, Manini AF. Prognostic use of lactate to predict inpatient mortality in acute gastrointestinal hemorrhage. Am J Emerg Med 2014;32:752-5.  Back to cited text no. 11
    
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Triplett L. Lactate in critically ill patients with upper gastrointestinal bleeding (UGIB). CORE EM 2015. Available from: https://coreem.net/journal-reviews/lactate-in-ugib/ [last accessed on May 14, 2021].  Back to cited text no. 12
    
13.
Stokbro LA, Schaffalitzky de Muckadell OB, Laursen SB. Arterial lactate does not predict outcome better than existing risk scores in upper gastrointestinal bleeding. Scand J Gastroenterol 2018;53:586-91.  Back to cited text no. 13
    
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Wada T, Hagiwara A, Uemura T, Yahagi N, Kimura A. Early lactate clearance for predicting active bleeding in critically ill patients with acute upper gastrointestinal bleeding: A retrospective study. Intern Emerg Med 2016;11:737-43.  Back to cited text no. 14
    
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Shapiro NI, Howell MD, Talmor D, Nathanson LA, Lisbon A, Wolfe RE, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med 2005;45: 524-8.  Back to cited text no. 15
    
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Klebl F, Bregenzer N, Schöfer L, Tamme W, Langgartner J, Schölmerich J, et al. Risk factors for mortality in severe upper gastrointestinal bleeding. Int J Colorectal Dis 2005;20: 49-56.  Back to cited text no. 18
    
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Rodríguez-Hernández H, Rodríguez-Morán M, González JL, Jáquez-Quintana JO, Rodríguez-Acosta ED, Sosa-Tinoco E, et al. [Risk factors associated with upper gastrointestinal bleeding and with mortality]. Rev Med Inst Mex Seguro Soc 2009;47:179-84.  Back to cited text no. 19
    
20.
Lee YJ, Min BR, Kim ES, Park KS, Cho KB, Jang BK, et al. Predictive factors of mortality within 30 days in patients with nonvariceal upper gastrointestinal bleeding. Korean J Intern Med 2016;31:54-64.  Back to cited text no. 20
    
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Faigel DO, Metz DC. Prevalence, etiology, and prognostic significance of upper gastrointestinal hemorrhage in diabetic ketoacidosis. Dig Dis Sci 1996;41:1-8.  Back to cited text no. 21
    
22.
Bernhard M, Döll S, Kramer A, Weidhase L, Hartwig T, Petros S, et al. Elevated admission lactate levels in the emergency department are associated with increased 30-day mortality in non-trauma critically ill patients. Scand J Trauma Resusc Emerg Med 2020;28:82.  Back to cited text no. 22
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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