High Early Lactate Tied to Mortality in Children With Sepsis

Beth Skwarecki

January 11, 2017

Children with suspected sepsis were more likely to die within 30 days if their initial serum lactate was more than 36 mg/dL, according to a clinical registry study of 1299 patients. Although the test showed 95% specificity, it had low sensitivity, at just 20%, as most patients with high lactate levels survived.

"Lactate levels do not represent an optimal stand-alone screening test but may have utility as a prognostic tool in the emergency care of clinically suspected sepsis in children," Halden F. Scott, MD, from the Department of Pediatrics at the University of Colorado, Aurora, and colleagues write in an article published online January 9 in JAMA Pediatrics.

Elevated lactate is part of the definition for septic shock in adults, but Dr Scott and colleagues write that evidence relating to lactate in pediatric cases is limited. "The finding of this study...although new, is consistent with findings of other studies of lactate levels in pediatric sepsis," they write.

Of the 103 patients with lactate levels more than 36 mg/dL, five died within 30 days vs 20 deaths among the 1196 patients with lower lactate levels (4.8% vs 1.7%).

That relationship held in both unadjusted (odds ratio, 3.00; 95% confidence interval, 1.10 - 8.17) and adjusted (adjusted odds ratio, 3.26; 95% confidence interval, 1.16 - 9.16) analyses. The authors note, however, that the lower confidence limits are close to 1.0, and that future studies could find that confounders render the association insignificant.

Patients with the highest lactate levels were at the greatest risk for death, according to the authors.

"Rather than as a screening test, lactate levels might best be used to identify the highest-risk patients among those in whom the treating clinician has already identified a potential clinical concern for sepsis," the authors write.

The authors examined records from a tertiary pediatric hospital with 75,000 emergency department visits per year. Children aged 5 to 18 years who visited the emergency department between April 2012 and December 2015 and had lactate levels measured in the first 8 hours after arrival were included in the review. The primary outcome was in-hospital, all-cause mortality within 30 days.

Of the 1299 patients included, 69.2% had chronic medical conditions, 28.3% had acute organ dysfunction, and 19.4% had hypotension at admission. The patients were 58.0% boys.

Lactate levels were measured early in treatment, at a median of 24 minutes after arrival for survivors and 21 minutes for nonsurvivors, before any vasoactive agents or fluid resuscitation was given. In total, 25 patients, or 1.9%, died within 30 days.

The authors note several limitations, including that the clinicians knew their patients' test results and may have given different care to patients with higher lactate levels. In addition, as the study was conducted at a single center, and with fewer very sick patients than other studies of sepsis, it is not clear whether the results are representative of all children presenting with sepsis.

The authors have disclosed no relevant financial relationships.

JAMA Pediatrics. Published online January 9, 2017. Abstract

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