Lactate clearance as the predictor of outcome in pediatric septic shock

Lactate dynamics in paediatric patients with severe sepsis: insights from a prospective cohort study

BACKGROUND

Sepsis is an infection-related systemic inflammatory response that often leads to elevated lactate levels. Monitoring lactate levels during severe sepsis is vital for influencing clinical outcomes. The aim of this study was to assess the association between plasma lactate levels and mortality in children with severe sepsis or septic shock.

METHODS

The current prospective study was conducted in the PICU of University Children's Hospital. The International Paediatric Sepsis Consensus Conference criteria for Definitions of Sepsis and Organ Failure in 2005 were used to diagnose patients with sepsis. We measured plasma lactate levels upon admission (Lac H0) and 6 h later (Lac H6). The static indices included the absolute lactate values (Lac H0 and Lac H6), while the dynamic indices included the delta-lactate level (ΔLac) and the 6-hour lactate clearance. The 6-hour lactate clearance was calculated using the following formula: [(Lac H0-Lac H6)100/Lac H0]. ΔLac was calculated as the difference between the Lac H0 and Lac H6 levels. Patient survival or death after a PICU stay was the primary outcome.

RESULTS

A total of 46 patients were included in this study: 25 had septic shock, and 21 had severe sepsis. The mortality rate was 54.3%. The Lac H0 did not significantly differ between survivors and nonsurvivors. In contrast, the survivors had significantly lower Lac H6 levels, higher ΔLac levels, and higher 6-hour lactate clearance rates than nonsurvivors. Lactate clearance rates below 10%, 20%, and 30% were significantly associated with mortality. The best cut-off values for the lactate clearance rate and Lac H6 for the prediction of mortality in the PICU were < 10% and ≥ 4 mmol/L, respectively. Patients with higher Lac H6 levels and lower lactate clearance rates had significantly higher PICU mortality based on Kaplan-Meier survival curve analysis.

CONCLUSIONS

This study highlights the significance of lactate level trends over time for the prediction of mortality in the PICU in patients with severe sepsis or septic shock. Elevated lactate levels and decreased lactate clearance six hours after hospitalisation are associated with a higher mortality rate.

Hierarchical Capability in Distinguishing Severities of Sepsis via Serum Lactate: A Network Meta-Analysis

Background: Blood lactate is a potentially useful biomarker to predict the mortality and severity of sepsis. The purpose of this study is to systematically review the ability of lactate to predict hierarchical sepsis clinical outcomes and distinguish sepsis, severe sepsis and septic shock. Methods: We conducted an exhaustive search of the PubMed, Embase and Cochrane Library databases for studies published before 1 October 2022. Inclusion criteria mandated the presence of case-control, cohort studies and randomized controlled trials that established the association between before-treatment blood lactate levels and the mortality of individuals with sepsis, severe sepsis or septic shock. Data was analyzed using STATA Version 16.0. Results: A total of 127 studies, encompassing 107,445 patients, were ultimately incorporated into our analysis. Meta-analysis of blood lactate levels at varying thresholds revealed a statistically significant elevation in blood lactate levels predicting mortality (OR = 1.57, 95% CI 1.48-1.65, I2 = 92.8%, p < 0.00001). Blood lactate levels were significantly higher in non-survivors compared to survivors in sepsis patients (SMD = 0.77, 95% CI 0.74-0.79, I2 = 83.7%, p = 0.000). The prognostic utility of blood lactate in sepsis mortality was validated through hierarchical summary receiver operating characteristic curve (HSROC) analysis, yielding an area under the curve (AUC) of 0.72 (95% CI 0.68-0.76), accompanied by a summary sensitivity of 0.65 (95% CI 0.59-0.7) and a summary specificity of 0.7 (95% CI 0.64-0.75). Unfortunately, the network meta-analysis could not identify any significant differences in average blood lactate values' assessments among sepsis, severe sepsis and septic shock patients. Conclusions: This meta-analysis demonstrated that high-level blood lactate was associated with a higher risk of sepsis mortality. Lactate has a relatively accurate predictive ability for the mortality risk of sepsis. However, the network analysis found that the levels of blood lactate were not effective in distinguishing between patients with sepsis, severe sepsis and septic shock.

Association between Serum Lactate and Morbidity and Mortality in Neonates: A Systematic Review and Meta-Analysis

OBJECTIVE

Lactate is a marker of hypoperfusion in critically ill patients. Whether lactate is useful for identifying and stratifying neonates with a higher risk of adverse outcomes remains unknown. This study aimed to investigate the association between lactate and morbidity and mortality in neonates.

METHODS

A meta-analysis was performed to determine the association between blood lactate levels and outcomes in neonates. Ovid MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov were searched from inception to 1 May 2021. A total of 49 observational studies and 14 data accuracy test studies were included. The risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and the QUADAS-2 tool for data accuracy test studies. The primary outcome was mortality, while the secondary outcomes included acute kidney injury, necessity for renal replacement therapy, neurological outcomes, respiratory morbidities, hemodynamic instability, and retinopathy of prematurity.

RESULTS

Of the 3184 articles screened, 63 studies fulfilled all eligibility criteria, comprising 46,069 neonates. Higher lactate levels are associated with mortality (standard mean difference, -1.09 [95% CI, -1.46 to -0.73]). Using the estimated sensitivity (0.769) and specificity (0.791) and assuming a prevalence of 15% for adverse outcomes (median of prevalence among studies) in a hypothetical cohort of 10,000 neonates, assessing the lactate level alone would miss 346 (3.46%) cases (false negative) and wrongly diagnose 1776 (17.76%) cases (false positive).

CONCLUSIONS

Higher lactate levels are associated with a greater risk of mortality and morbidities in neonates. However, our results do not support the use of lactate as a screening test to identify adverse outcomes in newborns. Research efforts should focus on analyzing serial lactate measurements, rather than a single measurement.

Can lactate be valuable in early diagnosis and prognosis of neonatal sepsis?

Background

Sepsis monitoring tissue perfusion is crucial for detecting circulatory failure early, implementing the right treatments, and assessing response. Insufficient oxygenation leads to a rise in lactate level and has been shown to be useful in predicting mortality and morbidity in newborns. There have not been many studies on how lactate measurement affects neonatal sepsis diagnosis and prognosis.

Aim

The aim of our study was to determine the impact of lactate on early diagnosis and prognosis in neonatal sepsis.

Materials and Methods

Eighty-seven newborns diagnosed with neonatal sepsis at a neonatal intensive care unit between January 2010 and July 2021 were included in the study. Venous blood gas, lactate, and C-reactive protein (CRP) levels and complete blood count on the first, second, and third day of hospitalization were noted. Lactate values were correlated with other variables to determine the impact of hyperlactatemia on morbidity and to determine factors affecting the length of stay. IBM SPSS Statistics version 22.0 for Windows was used to analyze the data (SPSS Inc., Chicago, IL, United States).

Results

A strong negative correlation between lactate and oxygenation and perfusion indicators (HCO3, BE, PaO2) during the therapeutic process was observed. With treatment, the initial measured lactate value decreased, and a significant increase in CRP and oxygen saturation was observed, which was interpreted as the observation of an early lactate response to infection before a CRP response. The initial lactate level, as well as the change in lactate levels, was not, however, significantly correlated with the length of stay.

Conclusion

Lactate can be used in the early diagnosis of neonatal sepsis and for determining prognosis.

The role of cardiac power and lactate clearance as an indicator of resuscitation success among pediatric patients with shock in the intensive care unit of Cipto Mangunkusumo Hospital

BACKGROUND

Shock in children remains the primary cause of mortality and morbidity worldwide. Furthermore, its management outcome is improved using many hemodynamic parameters, such as cardiac power (CP) and lactate clearance (LC). Cardiac power is a contractility index based on the measurement of flow and pressure, and it is a relatively new hemodynamic parameter with limited studies. In contrast, LC has been proven useful as a target outcome in shock resuscitation. This study aims to explore the values of CP and LC in pediatric shock and their association with clinical outcomes.

METHODS

This prospective observational study was conducted on children (1 month-18 years old) with shock at Cipto Mangunkusumo Hospital, Indonesia, from April to October 2021. We measured CP using ultrasonic cardiac output monitoring (USCOM®) and serum lactate levels at 0, 1, 6, and 24 h post-initial resuscitation. Subsequently, the variables were described and analyzed with the resuscitation success, length of stay, and mortality.

RESULTS

A total of 44 children were analyzed. There were 27 (61.4%), 7 (15.9%), 4 (9.1%), 4 (9.1%), and 2 (4.5%) cases of septic, hypovolemic, cardiogenic, distributive, and obstructive shock, respectively. Within the first 24 h post-initial resuscitation, CP and LC had an increasing trend. Compared to children who had successful resuscitation, those who did not have successful resuscitation had similar CP at all time points (p > 0.05) and lower LC at 1 and 24 h post-initial resuscitation (p < 0.05). Lactate clearance was an acceptable predictor of resuscitation success (area under the curve: 0.795 [95% CI: 0.660-0.931]). An LC of 7.5% had a sensitivity, specificity, positive predictive value, and negative predictive value of 75.00%, 87.5%, 96.43%, and 43.75%, respectively. Lactate clearance in the first hour post-initial resuscitation had a weak correlation (r=-0.362, p < 0.05) with hospital length of stay. We found no difference in CP and LC among survivors compared to nonsurvivors.

CONCLUSIONS

We found no evidence that CP was associated with resuscitation success, length of stay, or mortality. Meanwhile, higher LC was associated with successful resuscitation and shorter length of stay at the hospital, but not mortality.

Pediatric Sepsis: a Summary of Current Definitions and Management Recommendations

Purpose of Review

Pediatric sepsis remains an important cause of morbidity and mortality in children. This review will summarize the main aspects of the definition, the current evidence base for interventions discuss some controversial themes and point towards possible areas of improvement.

Recent Findings

Controversy remains regarding the accurate definition, resuscitation fluid volume and type, choice of vasoactive/inotropic agents, and antibiotic depending upon specific infection risks. Many adjunctive therapies have been suggested with theoretical benefits, although definitive recommendations are not yet supported by data. We describe best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices.

Summary

Early diagnosis and timely intervention with antibiotics, fluid resuscitation, and vasoactive medications are the most important interventions in sepsis. The implementation of protocols, resource-adjusted sepsis bundles, and advanced technologies will have an impact on reducing sepsis mortality.

AACC Guidance Document on the Clinical Use of Procalcitonin

BACKGROUND

Procalcitonin (PCT), a peptide precursor of the hormone calcitonin, is a biomarker whose serum concentrations are elevated in response to systemic inflammation caused by bacterial infection and sepsis. Clinical adoption of PCT in the United States has only recently gained traction with an increasing number of Food and Drug Administration-approved assays and expanded indications for use. There is interest in the use of PCT as an outcomes predictor as well as an antibiotic stewardship tool. However, PCT has limitations in specificity, and conclusions surrounding its utility have been mixed. Further, there is a lack of consensus regarding appropriate timing of measurements and interpretation of results. There is also a lack of method harmonization for PCT assays, and questions remain regarding whether the same clinical decision points may be used across different methods.

CONTENT

This guidance document aims to address key questions related to the use of PCT to manage adult, pediatric, and neonatal patients with suspected sepsis and/or bacterial infections, particularly respiratory infections. The document explores the evidence for PCT utility for antimicrobial therapy decisions and outcomes prediction. Additionally, the document discusses analytical and preanalytical considerations for PCT analysis and confounding factors that may affect the interpretation of PCT results.

SUMMARY

While PCT has been studied widely in various clinical settings, there is considerable variability in study designs and study populations. Evidence to support the use of PCT to guide antibiotic cessation is compelling in the critically ill and in some lower respiratory tract infections but is lacking in other clinical scenarios, and evidence is also limited in the pediatric and neonatal populations. Interpretation of PCT results requires guidance from multidisciplinary care teams of clinicians, pharmacists, and clinical laboratorians.

Comparison of Blood Pressure Measurements by Currently Available Multiparameter Monitors and Mercury Column Sphygmomanometer in Patients Admitted in Pediatric Intensive Care Unit

Background

The multiparameter monitor (MPM) is replacing mercury column sphygmomanometers (MCS) in acute care settings. However, data on the former's accuracy in critically ill children are scarce and mostly extrapolated from adults. We compared non-invasive blood pressure (NIBP) measurements by MPMs with MCS in pediatric intensive care unit (PICU).

Patients

Adequately sedated and hemodynamically stabilized children (age, 1-144 months) were prospectively enrolled.

Materials and methods

Three NIBP measurements were obtained from MCS (Diamond®, India) and MPM (Intellivue MX800® or Ultraview SL®) in rapid succession in the upper limb resting in supine position. Respective three measurements were averaged to obtain a paired set of NIBP readings, one each from MCS and MPM. Such readings were obtained thrice a day. NIBP readings were then compared, and agreement was assessed.

Results

From 39 children [median age (IQR), 30 (10-72) months], 1,690 sets of NIBP readings were obtained. A-third of readings were from infants and children >96 months, while 383 (22.6%) readings were from patients on inotropes. Multiparameter monitors gave significantly higher NIBP readings compared to MCS [median systolic blood pressure (SBP), 6.5 (6.4-6.7 mm Hg); diastolic blood pressure (DBP), 4.5 (4.3-4.6 mm Hg); mean arterial pressure (MAP), 5.3 (5.1-5.4 mm Hg); p < 0.05]. It was consistent across age, gender, and critical care characteristics. Multiparameter monitors overestimated SBP in 80% of readings beyond the maximal clinically acceptable difference (MCAD).

Conclusions

Non-invasive blood pressure readings from MCS and MPMs are not interchangeable; SBP was 6-7 mm Hg higher with the latter. Overestimation beyond MCAD was overwhelming. Caution is required while classifying systolic hypotension with MPMs. Confirmation with auscultatory methods is advisable. More studies are required to evaluate currently available MPMs in different pediatric age groups.

How to cite this article

Khan AA, Gupta PK, Baranwal AK, Jayashree M, Sahoo T. Comparison of Blood Pressure Measurements by Currently Available Multiparameter Monitors and Mercury Column Sphygmomanometer in Patients Admitted in Pediatric Intensive Care Unit. Indian J Crit Care Med 2023;27(3):212-221.

Cardiovascular Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT

Cardiovascular dysfunction is associated with poor outcomes in critically ill children.

OBJECTIVE

We aim to derive an evidence-informed, consensus-based definition of cardiovascular dysfunction in critically ill children.

DATA SOURCES

Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 using medical subject heading terms and text words to define concepts of cardiovascular dysfunction, pediatric critical illness, and outcomes of interest.

STUDY SELECTION

Studies were included if they evaluated critically ill children with cardiovascular dysfunction and assessment and/or scoring tools to screen for cardiovascular dysfunction and assessed mortality, functional status, organ-specific, or other patient-centered outcomes. Studies of adults, premature infants (≤36 weeks gestational age), animals, reviews and/or commentaries, case series (sample size ≤10), and non-English-language studies were excluded. Studies of children with cyanotic congenital heart disease or cardiovascular dysfunction after cardiopulmonary bypass were excluded.

DATA EXTRACTION

Data were abstracted from each eligible study into a standard data extraction form, along with risk-of-bias assessment by a task force member.

RESULTS

Cardiovascular dysfunction was defined by 9 elements, including 4 which indicate severe cardiovascular dysfunction. Cardiopulmonary arrest (>5 minutes) or mechanical circulatory support independently define severe cardiovascular dysfunction, whereas tachycardia, hypotension, vasoactive-inotropic score, lactate, troponin I, central venous oxygen saturation, and echocardiographic estimation of left ventricular ejection fraction were included in any combination. There was expert agreement (>80%) on the definition.

LIMITATIONS

All included studies were observational and many were retrospective.

CONCLUSIONS

The Pediatric Organ Dysfunction Information Update Mandate panel propose this evidence-informed definition of cardiovascular dysfunction.

Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce

OBJECTIVE

To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020.

STUDY SELECTION

Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract.

DATA EXTRACTION

Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.

DATA SYNTHESIS

One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001).

CONCLUSIONS

Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.

Hemodynamic monitoring and management of pediatric septic shock

Sepsis remains a major cause of morbidity and mortality among children worldwide. Furthermore, refractory septic shock and multiple organ dysfunction syndrome are the most critical groups which account for a high mortality rate in pediatric sepsis, and their clinical course often deteriorates rapidly. Resuscitation based on hemodynamics can provide objective values for identifying the severity of sepsis and monitoring the treatment response. Hemodynamics in sepsis can be divided into two groups: basic and advanced hemodynamic parameters. Previous therapeutic guidance of early-goal directed therapy (EGDT), which resuscitated based on the basic hemodynamics (central venous pressure and central venous oxygen saturation (ScvO2)) has lost its advantage compared with “usual care”. Optimization of advanced hemodynamics, such as cardiac output and systemic vascular resistance, has now been endorsed as better therapeutic guidance for sepsis. Despite this, there are still some important hemodynamics associated with prognosis. In this article, we summarize the common techniques for hemodynamic monitoring, list important hemodynamic parameters related to outcomes, and update evidence-based therapeutic recommendations for optimizing resuscitation in pediatric septic shock.

The Role of Lactate and Other Laboratory Markers on Detection of Subtle Myocardial Dysfunction in Critically ill Children

BACKGROUND: Critically ill patients have a high risk of developing life-threatening infections that can eventually lead to multi-organ failure. The cardiovascular system involvement could increase the mortality rate by 70-90%. Myocardial dysfunction is often accompanied by a state of metabolic acidosis, liver damage, kidney damage, and anemia. Therefore laboratory markers and elevated lactate levels may aid in the early assessment of a myocardial dysfunction AIM: The aim of this study was to prove the role of lactate and other laboratory markers on detection of subtle myocardial dysfunction (SMD) in critically ill children admitted to the Pediatric Intensive Care Unit (PICU). METHODS: An observasional cohort study in PICU Haji Adam Malik General Hospital, Medan. Assessment of complete blood count, kidney function, liver function, lactic acid, blood gas analysis, and troponin I within 48 hoursPICU admission. The results of the troponin value was said to be subtle myocardial dysfunction if the troponin I value is ≥ 0.4 ng/ml RESULT: 55 subjects were recruited in this study, 23 subject (41.1%) with SMD. Laboratory marker in SMD that has significant finding were lactate, AST, ALT, Hemoglobin (p = 0.003; p = 0.028; p = 0.01; p = 0.001, repectively). High lactate ( > 2.5 ng/ml) could be used as a predictor for SMD with sensitivity 74% and specificity 72%. Subject with SMD has significant association with mortality (p <0.001). CONCLUSION: Subtle myocardial dysfunction should be suspected in patient with blood lactate level > 2.5 ng/ml, with significant association between SMD and mortality.

Can Lactate Clearance Predict Mortality in Critically Ill Children?

Serial evaluation of blood lactate, including lactate clearance, may have greater value over single measurement at the time of presentation. The rationale of the current study was to evaluate the use of lactate clearance after 6 hours of admission to pediatric intensive care unit (PICU) as a predictor of mortality in critically ill children. A prospective observational study was conducted in a nine-bed PICU of a tertiary care teaching hospital over a period of 6 months. Lactate levels were measured in arterial blood samples of 76 patients at the time of admission and 6 hours later. According to calculated lactate clearance, patients were divided into group A (lactate clearance more than 0) which included 71% of patients and group B (lactate clearance ≤0) which included 29% of patients. Lactate level at admission was a poor predictor of mortality (area under receiver operating characteristic curve [AUC] = 0.519, p = 0.789). Lactate clearance after 6 hours of admission was a significant predictor of mortality (AUC = 0.766, p < 0.001). Using Kaplan–Meier survival curve, overall survival was significantly better among group A (p < 0.001). Using multivariate logistic regression model, lactate clearance after 6 hours (odds ratio = 0.98, 95% confidence interval [CI]: 0.96–0.99) and The Pediatric Index of Mortality 2 (PIM2) score (odds ratio = 4.7, 95% CI: 1.85–12.28) had independent prognostic significance as regard to mortality (p = 0.030, 0.001 respectively). We conclude that lactate clearance after 6 hours of admission can predict mortality in critically ill children.

How to interpret lactate

The association between hyperlactataemia and poorer outcomes in acutely unwell adults and children is well recognised. Blood lactate testing has become readily available in acute settings and is considered a first-line investigation in international guidelines for the management of sepsis. However, while healthcare professionals do appreciate the value of measuring blood lactate in acute severe illness, its clinical significance and interpretation remain less well understood. In this paper, we present the evidence for the use of lactate as a diagnostic test and prognostic marker in acutely unwell children.

Relationship Between Lactate Levels and Length of Hospital Stay in Infants with Lower Respiratory Tract Infection

Background: Increased lactate concentrations are directly related to the severity of shock and mortality rates. There are limited data regarding the prognostic value of lactate among lower respiratory tract infections. We aimed to investigate the impact of lactate levels on admission on the clinical outcomes of children with lower respiratory tract infections. Methods: We performed a retrospective study of hospitalized patients aged 1-12 months. We recorded data on patient demographics, clinical, laboratory, treatment, and outcomes. The primary outcome measure was the length of hospital stay, and the secondary outcome was transfer to the pediatric intensive care unit (PICU) and/or mortality rates. Results: A total of 304 infants were included in the study. There were 198 infants with lactate levels of >2 mmol/L. Lactic acidosis was present in 6 infants, with a mean hospital stay of 8 ± 3 days. Only 1 (0.3%) patient required intubation, and 5 (1.6%) were transferred to the PICU. The overall mortality rate was 0%. Lactate levels (≤2 and >2 mmol/L) were not related to the length of hospital stay, transfer to PICU/discharge, and the need for intubation (P = 0.16, 0.8, and 0.46, respectively). The length of hospital stay was not correlated with lactate levels on admission (r = 0.01, P = 0.84), pCO₂ (r = 0.03, P = 0.52), pH (r = 0.07, P = 0.19), C-reactive protein (r = 0.06, P = 0.28), and oxygen saturation (r = -0.02, P = 0.72). Conclusions: Lactate levels on admission did not predict the length of hospital stay in children with lower respiratory infections and were not related to the need for transfer to the intensive care unit. We suggest using lactate levels in combination with clinical, laboratory, and physical examination findings as predictors of disease severity.

Early lactate measurements for predicting in-hospital mortality in paediatric sepsis

AIM

We compared the performance of plasma lactate with high-sensitivity C-reactive protein (hs-CRP), and paediatric sepsis-related organ failure assessment (pSOFA) score for predicting mortality in septic children.

METHODS

Serial plasma lactate and hs-CRP levels and pSOFA score was assessed during early hospital stay in septic children.

RESULTS

Out of 149 participants, 45 died. Plasma lactate at 0 h and 6 h was significantly higher, and lactate clearance was significantly lower in non-survivors. The optimal cut-off of plasma lactate at 6h for identifying mortality was 2.5 mmol/L (sensitivity 85% and specificity 74%). pSOFA score had the best predictive ability for mortality (AUC 0.89) followed by hs-CRP at 0 h (AUC 0.86), hs-CRP at 48 h (AUC 0.83), plasma lactate levels at 6 h (AUC 0.83), and plasma lactate at 0 h (AUC 0.67).

CONCLUSION

pSOFA score, hs-CRP and hyperlactemia at 6 h can identify septic children at risk of dying.

Comparison of cardiac output, IVC diameters and lactate levels in prediction of mortality in patients in emergency department; An observational study

Objective:

Fluid overload is an independent marker for mortality in critically ill patients. Assessment of fluid status and fluid responsiveness is crucial for the management of these patients. In this study, we compared the lactate level, inferior vena cava (IVC) diameter and non-invasive cardiac output (CO) monitoring in prediction of mortality in emergency department.

Methods:

This was a cross sectional observational study which comprised of 68 patients and was performed in ED of Tabriz University of Medical Sciences, Iran, from Sept 2016 until Sept 2017. IVC diameter was measured before the P-wave on ECG to avoid interference with a-wave and v-wave on the venous pressure curve, and during maximal inspiration and expiration to avoid Valsalva-like maneuvers. An arterial lactate sample was taken from all patients before performing the initial resuscitation. All patients underwent non-invasive CO monitoring by CO₂ rebreathing technique. Mortality was noted on day 28.

Results:

Deceased patients had a significantly low level of IVC diameters, less CO values and more lactate levels. However, based on ROC curve analysis, the prediction accuracy and validity of both CO values obtained by rebreathing CO₂ and IVC diameter was poor and the highest accuracy was obtained by lactate level assessment.

Conclusion:

Initial lactate value is a reliable parameter for prediction of mortality in non-traumatic critically ill patients. IVC diameter changes during spontaneous ventilation and non-invasive CO monitoring does not possess acceptable accuracy for prediction of mortality in these patients.

Early lactate area scores and serial blood lactate levels as prognostic markers for patients with septic shock: a systematic review

Septic shock is the main cause of morbidity and mortality in patients and second leading cause of mortality among subjects in noncoronary intensive care units. Based on the literature, elevated serum lactate levels are associated with poor outcomes in patients with septic shock, which may occur due to various reasons, such as tissue hypoxia and anaerobic metabolism. This systematic review was conducted to collect data on the lactate area and area under the curve (AUC) of serial lactate levels for the determination of the predictive values of these factors to diagnose septic shock. For this purpose, the articles published up to 2019 were searched in four databases, including Google Scholar, PubMed, Scopus, and Medline. This study was carried out based on the seven stages recommended in the Cochrane Handbook. All articles were searched using several keywords, including 'Lactate Area Score' and 'Serial Lactate Levels' in combination with 'Septic Shock'. There were a total of 14 studies mainly focused on the assessment of the lactate area and serial lactate levels in patients with septic shock. The inclusion criteria were a clear explanation of the predictive role of repeated lactate measurements in patients with septic shock, sample size larger than 50, examination on human samples, and publication in English. All case-control, prospective, and retrospective studies on human subjects assessing the predictive value of repeated lactate measurements in the diagnosis of patients with septic shock at high risk of mortality were entered in the present review. The lactate area is a new concept introduced as the sum of the AUC of serial lactate levels. This factor can determine the severity and duration of hyperlactatemia. Based on the obtained results, there was an association between the lactate area score and 28-day mortality of patients with septic shock; therefore, early lactate area score can be considered a prognostic marker for the prediction of mortality rate in these patients. There are few studies on the evaluation of the lactate area score and no more information about the prognostic ability of the lactate area score. This was the main limitation of the present study. Moreover, the lactate area is introduced as the sum of the AUC of serial lactate levels and cannot reflect the trend of serial lactate. The trend may be supported by lactate clearance but not lactate area.

The effect of blood lactate and NT-proBNP predict the survival in patients with invasive mechanical ventilation

Background

Respiratory failure is one of the most common critical diseases. It has already been reported that invasive mechanical ventilation (IMV) should be used to treat respiratory failure. The present study aims to evaluate the prognostic value of blood lactate and NT-proBNP in patients with IMV.

Methods

We retrospectively included 353 patients who were hospitalized in the emergency department of Shanghai Sixth People’s Hospital from 2016 to 2019. All patients had IMV. R&D Human Premixed Multi-Analyte Kit detected the expression of various inflammatory factors in serum. Receiver operating characteristic (ROC) curve analysis, survival analysis, and multivariate cox proportional hazards analysis were implemented as statistical analysis methods.

Results

The mean duration of hospitalization was 25.5±20.6 days. Twenty-four men and 41 women died. Compared with the survivors, the nonsurvivors were older, had different types of diagnosis, longer ventilation time, and shorter survival time (P<0.05). Also, the expression levels of PCT, NT-proBNP, lactate in 12 h and lactate in 24 h in the nonsurvivors were significantly higher than those in the survivor group (P<0.05). There was a significant correlation between these parameters and ventilation times (P<0.001). The results showed that age, NT-proBNP, and lactate were independent predictors of survival rate. ROC analysis showed that the cut-off values of age, NT-proBNP and lactate were 61.5 years, 230.5 pg/mL and 3.7 mmol/L, respectively. Patients aged ≥61.5 years or NT-proBNP ≥230.5 pg/mL or lactate ≥3.7 mmol/L had a worse prognosis. Therefore, patients with three parameters higher than cut-off value had the lowest survival rate, while patients with three parameters lower than cut-off value had the best survival rate.

Conclusions

Blood lactate and NT-proBNP may be used as biomarkers to predict the prognosis of patients undergoing IMV.

Lactate Measurements and Their Association With Mortality in Pediatric Severe Sepsis in India: Evidence That 6-Hour Level Performs Best

PURPOSE

To investigate association of static and dynamic lactate indices with early mortality (within 48 hours of admission), as well as need for vasopressors and mechanical ventilation in pediatric severe sepsis/shock. To explore optimal cutoffs of lactate indices. We hypothesized that dynamic indices are superior to static indices in predicting early mortality.

METHODS

This prospective cohort study involved children (aged <14 years) admitted in emergency department, tertiary care teaching hospital in North India with severe sepsis/shock (2015-2016). Arterial lactate was measured at admission (X0) and after 6 hours (X6). Primary outcome of the measurement was early mortality. Association between lactate indices- lactate at 0 hours (Lac0), lactate after 6 hours (Lac6), time-weighted average (LacTW), delta (ΔLac), clearance (LacCl%) and early mortality, need for vasopressors, and mechanical ventilation-was assessed using Student t test/Mann-Whitney test. Area under the receiver operating characteristic curve (AUROC) for early mortality deduced for all lactate indices and compared with reference (Lac0). Optimal cutoffs (maximizing both sensitivity and specificity) and their positive predictive value (PPV) and negative predictive value (NPV) were determined.

RESULTS

During the study period, 116 children were assessed. Septic shock was present at admission in 56.9% children; 50% of children died during the next 48 hours. Lac0, Lac6, and LacTW were significantly higher, and LacCl% was lower in nonsurvivors versus survivors (all P < .001). Lac6 (0.837 [0.76-0.91]) had significantly higher AUROC (95% confidence interval) than Lac0 (0.77; P = .03). Abnormal lactate metrics (higher Lac0, Lac6, LacTW, and lower LacCl%) were associated with vasopressors need and mechanical ventilation. On logistic regression, Lac6 emerged as an independent predictor of early mortality as well as vasopressor and mechanical ventilation need. The optimal cutoff of Lac6 for identifying early mortality with good sensitivity, specificity, PPV, and NPV was ≥2.65 (76, 85, 83, 78).

CONCLUSIONS

Lactate6 is the best marker associated with early mortality and higher level of care in severe sepsis/septic shock in resource-poor regions.

Is lactic acidosis predictive of outcomes in pediatric diabetic ketoacidosis?

OBJECTIVES

The objective of this study was to investigate the significance and prevalence of lactic acidosis in pediatric diabetic ketoacidosis (DKA) presenting to the emergency department.

METHODS

A retrospective cohort study of children (age ≤ 21 years) presenting to a tertiary care emergency department in DKA from December 1, 2015 to December 1, 2018. Patients needed to have DKA requiring admission to the pediatric intensive care unit and have had a lactate level collected while in the emergency department to be included.

RESULTS

92 patients resulting in 113 encounters had DKA and a lactate level collected in the emergency department. The mean lactate level was 3.5 mmol/L (±SD 2.1). 72 (63.7%) encounters had lactic acidosis (p < 0.001). There was no significant association between the presence of lactic acidosis and pediatric intensive care unit length of stay (p = 0.321), hospital length of stay (p = 0.426), morbidity (p = 0.552) and mortality (p = 1.000). Initial glucose levels were significantly higher in the patients presenting with lactic acidosis (p = 0.001).

CONCLUSIONS

Lactic acidosis is a common finding in pediatric DKA patients presenting to the emergency department. Serum lactate alone should not be used as an outcome predictor in pediatric DKA.

Lactate clearance prognosticates outcome in pediatric septic shock during first 24 h of intensive care unit admission

This study was undertaken to examine the clinical utility of lactate clearance as an indicator of mortality in pediatric septic shock, and to compare the performance of lactate clearance at 6, 12, and 24 h for predicting in-hospital and 60-day mortality. Pediatric patients with septic shock were prospectively studied. Vital signs, laboratory values, Pediatric Risk of Mortality Score, and pediatric logistic organ dysfunction score were obtained at presentation (hour 0), hour 6, hour 24 and over the first 72 h of hospitalization. Lactate clearance was obtained at 6, 12, and 24 h of hospital admission. Therapy received, outcome parameters of mortality, and duration of hospitalization were recorded. The primary outcome variable of 60-day mortality rate was 31.25%. Only lactate clearance at 6 and 24 h was significantly associated with mortality, with odds of 0.97 (95% CI, 0.951-981; p < 0.001) and 0.975 (95% CI, 0.964-0.986; p < 0.001), respectively. Approximately there was a 24% decrease in likelihood of mortality for each 10% increase in lactate clearance at 24 h. At a threshold value of 10% 6-h lactate clearance had a sensitivity of 0.948 and specificity of 0.571, while at a threshold of 20% 24-h lactate clearance had a sensitivity of 0.922 and specificity of 0.629. The comparison of clearance at 6 and 24 h using receiver operating characteristic showed that former was "fair" (area under the curve = 0.753) and later was "good" (area under the curve = 0.81) in predicting mortality in pediatric septic shock.

Conclusion

We concluded that optimal lactate clearance in pediatric septic shock both during the early presentation and after the initial "golden hours" is associated with lower in-hospital and 60-day mortality. Further, 24-h lactate clearance appears superior to 6 h lactate clearance in predicting mortality in such patients.

Risk stratification to improve Pediatric Early Warning Systems: it is all about the context

Early recognition of critically ill patients is of paramount importance to reduce pediatric mortality and morbidity. We created a risk stratification system combining vital parameters and predefined risk factors aimed at reducing the risk of unrecognized clinical deterioration compared with conventional Pediatric Early Warning Systems (PEWS). This single-center retrospective case cohort study included infants (gestational age ≥ 37 weeks) to adolescents (aged <18 years) with unplanned pediatric intensive care unit (PICU) admission between April 01, 2014, and February 28, 2018. The sensitivity in the 24 h prior to endpoint of the Pediatric Risk Evaluation and Stratification System (PRESS) was compared with that of the conventional PEWS and calculated as the proportion of study patients who received a high-risk score. Seventy-four PICU admissions were included. PRESS and PEWS sensitivities at 2 h prior to endpoint were 0.70 (95%CI 0.59 to 0.80) and 0.30 (95%CI 0.20 to 0.42) respectively (p < 0.001). Excluding patients with seizures, PRESS sensitivity increased to 0.75 (95%CI 0.64 to 0.85). Forty-nine patients (66%) scored positive on at least one high-risk factor, and "worried sign" was scored in 31 patients (42%).Conclusion: Risk stratification seems advantageous for a faster detection of clinical deterioration, providing opportunity for earlier intervention. What is Known: • Prompt detection of clinical deterioration is of essential importance to reduce morbidity and mortality. • Conventional Pediatric Early Warning Systems (PEWS) have limited sensitivity and a short window of detection of 1 to 2 h. What is New: • Risk stratification based on context factors allows earlier identification of patients at risk, well before deviation of vital signs. • Risk stratification combined with continuous monitoring of deteriorating trends in vital signs could lead to the development of next-generation warning systems achieving true patient safety.

Early Lactate Dynamics in Critically Ill Non-Traumatic Patients in a Resuscitation Room of a German Emergency Department (OBSERvE-Lactate-Study)

BACKGROUND

Management of critically ill non-trauma patients in the resuscitation room of an emergency department (ED) is very challenging, and it is difficult to identify patients with a higher risk of death. Previous studies have shown that lactate indices can predict survival for selected diseases and syndromes.

OBJECTIVE

As reported for other patient populations, we set out to determine whether admission lactate or lactate dynamics (LD) within 24 h can predict 30-day mortality in unselected critically ill non-traumatic patients.

METHODS

In this retrospective study over a 1-year period, admission lactate, time weighted average lactate (Lac_TW) and LD of all critically ill adult patients admitted from ED to intensive care unit were analyzed. A linear regression model was implemented to estimate lactate data 1 h after admission.

RESULTS

The admission lactate, Lac_TW, and LD within 24 h were analyzed from 392 critically ill patients. The overall 30-day mortality rate was around 29%. Admission lactate (4.1 ± 4.0 mmol/L vs. 6.6 ± 6.1 mmol/L; p < 0.01) and Lac_TW (1.8 ± 1.7 mmol/L vs. 4.1 ± 4.8 mmol/L; p < 0.01) were different between survivors and non-survivors. LD between survivors and non-survivors did not differ at 1 h, 6 h, 12 h, or 24 h. After excluding patients with out-of-hospital or in-hospital cardiac arrest during resuscitation room management, admission lactate and LD between survivors and non-survivors did not differ at 1 h, 12 h, and 24 h. LD at 6 h (44% ± 42% vs. 33% ± 58%; p = 0.042) and Lac_TW (1.7 ± 1.6 mmol/L vs. 2.6 ± 3.0 mmol/L; p < 0.01) did differ.

CONCLUSIONS

In critically ill ED patients initially requiring treatment in a resuscitation room setting, LD at 6 h and Lac_TW may predict their survival beyond 30 days. These findings need to be confirmed in a prospective study design.

Emergency Department Management of Pediatric Shock

Shock, a state of inadequate oxygen delivery to tissues resulting in anaerobic metabolism, lactate accumulation, and end-organ dysfunction, is common in children in emergency department. Shock can be divided into 4 categories: hypovolemic, distributive, cardiogenic, and obstructive. Early recognition of shock can be made with close attention to historical clues, physical examination and vital sign abnormalities. Early and aggressive treatment can prevent or reverse organ dysfunction and improve morbidity and mortality.

Point-of-care testing (POCT) and evidence-based laboratory medicine (EBLM) - does it leverage any advantage in clinical decision making?

Point-of-care testing (POCT) is the analysis of patient specimens outside the clinical laboratory, near or at the site of patient care, usually performed by clinical staff without laboratory training, although it also encompasses patient self-monitoring. It is able to provide a rapid result near the patient and which can be acted upon immediately. The key driver is the concept that clinical decision making may be delayed when samples are sent to the clinical laboratory. Balanced against this are considerations of increased costs for purchase and maintenance of equipment, staff training, connectivity to the laboratory information system (LIS), quality control (QC) and external quality assurance (EQA) procedures, all required for accreditation under ISO 22870. The justification for POCT depends upon being able to demonstrate that a more timely result (shorter turnaround times (TATs)) is able to leverage a clinically important advantage in decision making compared with the central laboratory (CL). In the four decades since POCT was adapted for the self-monitoring of blood glucose levels by subjects with diabetes, numerous new POCT methodologies have become available, enabling the clinician to receive results and initiate treatment more rapidly. However, these instruments are often operated by staff not trained in laboratory medicine and hence are prone to errors in the analytical phase (as opposed to laboratory testing where the analytical phase has the least errors). In some environments, particularly remote rural settings, the CL may be at a considerable distance and timely availability of cardiac troponins and other analytes can triage referrals to the main centers, thus avoiding expensive unnecessary patient transportation costs. However, in the Emergency Department, availability of more rapid results with POCT does not always translate into shorter stays due to other barriers to implementation of care. In this review, we apply the principles of evidence-based laboratory medicine (EBLM) looking for high quality systematic reviews and meta-analyses, ideally underpinned by randomized controlled trials (RCTs), looking for evidence of whether POCT confers any advantage in clinical decision making in different scenarios.

[Changes in blood oxygen metabolism indices and their clinical significance in children with septic shock]

The key to the treatment of septic shock is to provide adequate oxygen supply and improve tissue perfusion. Lactate and central venous oxygen saturation (ScvO₂) are commonly used as the indices of oxygen metabolism, but tissue hypoxia may still exist even when lactate and ScvO₂ are within the normal range. Arteriovenous difference in carbon dioxide partial pressure (CO₂ gap) can accurately reflect oxygen delivery when ScvO₂ is in the normal range. This article reviews the advantages and shortages of lactate, lactate clearance rate, ScvO₂, and CO₂ gap in evaluating tissue hypoxia, in order to provide a reference for treatment and severity evaluation of septic shock.