The Utility of Early Lactate Testing in Undifferentiated Pediatric Systemic Inflammatory Response Syndrome

Abstract

Objectives: Failure to recognize shock contributes to inadequate early resuscitation in many children with sepsis. Serum lactate levels are used to identify adult patients with septic shock, but physical examination diagnosis alone is recommended in pediatric sepsis. The authors sought to test the utility of lactate testing in pediatric emergency department (ED) patients with systemic inflammatory response syndrome (SIRS). The hypothesis was that early hyperlactatemia (serum lactate 4.0 mmol/L) would be associated with increased risk of organ dysfunction.Methods: This was a prospective cohort study of children younger than 19 years with SIRS presenting to a pediatric ED. The primary outcome was organ dysfunction within 24 hours of triage; secondary outcomes included disposition, serious bacterial infection (SBI), treatments, and mortality. Study personnel measured venous lactate level on a point-of-care meter, with clinicians blinded to results, and patients received usual care.Results: A total of 239 subjects were enrolled; 18 had hyperlactatemia. The hyperlactatemia group had a relative risk of 5.5 (95% confidence interval [CI] = 1.9 to 16.0) of developing 24-hour organ dysfunction. As a test for organ dysfunction, hyperlactatemia had a positive likelihood ratio of 5.0, a sensitivity of 31% (95% CI = 13% to 58%), and specificity of 94% (95% CI = 90% to 96%). Subjects with hyperlactatemia were significantly more likely to receive intravenous (IV) antibiotics and fluid boluses; despite increased therapy, they were at significantly increased risk for intensive care unit (ICU) admission and bacterial infection.Conclusions: Among undifferentiated children with SIRS, early hyperlactatemia is significantly associated with increased risk of organ dysfunction, resuscitative therapies, and critical illness. The addition of serum lactate testing to the currently recommended clinical assessment may improve early identification of pediatric sepsis requiring resuscitation.

Diagnostic Characteristics of a Clinical Screening Tool in Combination With Measuring Bedside Lactate Level in Emergency Department Patients With Suspected Sepsis

“…16 Among all study patients, 18 had serum lactates greater than 4 mmol/L. Patients with high lactate levels had a greater than fivefold increased risk of developing organ dysfunction within the first 24 hours of admission.…”

Sepsis in Children

“…Subjects with hyperlactatemia were significantly more likely to receive Intravenous (IV) antibiotics and fluid boluses; despite increased therapy, they were at significantly increased risk for Intensive Care Unit (ICU) admission and bacterial infection. They concluded among undifferentiated children with SIRS, early hyperlactatemia is significantly associated with increased risk of organ dysfunction, resuscitative therapies, and critical illness [47].…”

Shock séptico en pediatría II: Enfoque actual en el diagnóstico y tratamiento

“…En forma independiente, Duke et al y Koliski et al 18,19 , reportaron que el lactato es buen predictor de mortalidad, mientras que Hatherill et al 20 , no encontraron diferencias significativas en los niveles de lactato entre los sobrevivientes y no sobrevivientes. Recientemente en un estudio prospectivo realizado en un servicio de urgencia en pacientes pediátricos con síndrome de respuesta infla-matoria sistémica (SRIS) 21 se encontró que un 7,5% de los pacientes desarrollaban hiperlactacidemia, describiéndose para este grupo un mayor riesgo de disfunción orgánica (RR 5,5% [IC 95% 1,9-16]). Los autores concluyen que la medición de los niveles de lactato sanguíneo en conjunto con la evaluación clínica puede mejorar la identificación precoz de los pacientes con sepsis que requieren resucitación.…”