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

Abstract

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.

Early lactate measurements for predictingin‐hospitalmortality in paediatric sepsis

“…We found that plasma lactate at 6 h > 2.5 mmol/L had a sensitivity 85% and a specificity 74% for mortality among septic children. Similar results have been reported in another study from India, 18 wherein the optimal cut-off of Lactate at 6 h for identifying early was 2.65 mmol/L mortality with 76% sensitivity and 85% specificity. Another significant observation was that plasma lactate at 6 h was better than lactate clearance for predicting in hospital mortality in septic children.…”

“…A decreased plasma lactate clearance was shown to have a greater association with nonsurvival. Similar association between lactate and mortality is supported by findings yielded by other studies 10,13–18 . However, another study in children did not find lactate at admission to be significantly associated with hospital mortality in children with severe sepsis, although it was strongly correlated with PRISM III scores which have been established as valid predictor of mortality in children 19 …”

“…Similar association between lactate and mortality is supported by findings yielded by other studies. 10,[13][14][15][16][17][18] However, another study in children did not find lactate at admission to be significantly associated with hospital mortality in children with severe sepsis, although it was strongly correlated with PRISM III scores which have been established as valid predictor of mortality in children. 19 Compared to plasma lactate levels at presentation, plasma lactate levels after 6 h of care were a better predictor of mortality as reflected by its greater AUC.…”

“…A positive response to resuscitation would result in falling of lactate and its normalization. Thus, lactate levels at 6 h may in fact serve as guide to the clinicians working in hectic emergency settings, 18,20 allowing them to prioritise sick children warranting greater care. We found that plasma lactate at 6 h > 2.5 mmol/L had a sensitivity 85% and a specificity 74% for mortality among septic children.…”

Plasma Endothelial Glycocalyx Components as a Potential Biomarker for Predicting the Development of Disseminated Intravascular Coagulation in Patients With Sepsis

“…The recent Sepsis-3 guidelines recommend that the persistence of a serum lactate levels >2 mmol/L, despite adequate fluid resuscitation, should be included as a new criterion in the clinical evaluation of septic shock.1 In this context, serum lactate is typically used to evaluate disease severity, treatment response, and prognosis. 26,27 In this study, plasma levels of glycocalyx components correlated significantly with lactate levels. These data suggest that the endothelial glycocalyx plays an important role in the pathophysiological progression of sepsis.…”