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Original Investigation
Caring for the Critically Ill Patient
March 2017

Association Between Early Lactate Levels and 30-Day Mortality in Clinically Suspected Sepsis in Children

Author Affiliations
  • 1Department of Pediatrics, University of Colorado, Aurora
  • 2Section of Emergency Medicine, Department of Pediatrics, Children’s Hospital Colorado, Aurora
  • 3Department of Pediatrics, Children’s Hospital Colorado, Aurora
  • 4Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Aurora
  • 5Colorado School of Public Health, Aurora
JAMA Pediatr. 2017;171(3):249-255. doi:10.1001/jamapediatrics.2016.3681
Key Points

Question  Is an initial venous lactate level of greater than 36 mg/dL associated with 30-day in-hospital mortality in children with clinically suspected sepsis?

Findings  In this observational cohort study of 1299 children included in a pediatric emergency department sepsis registry, an initial lactate level of greater than 36 mg/dL was associated with 30-day mortality. Lactate levels had a sensitivity of 20% and specificity of 92% for mortality.

Meaning  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.

Abstract

Importance  Improving emergency care of pediatric sepsis is a public health priority, but optimal early diagnostic approaches are unclear. Measurement of lactate levels is associated with improved outcomes in adult septic shock, but pediatric guidelines do not endorse its use, in part because the association between early lactate levels and mortality is unknown in pediatric sepsis.

Objective  To determine whether the initial serum lactate level is associated with 30-day mortality in children with suspected sepsis.

Design, Setting, and Participants  This observational cohort study of a clinical registry of pediatric patients with suspected sepsis in the emergency department of a tertiary children’s hospital from April 1, 2012, to December 31, 2015, tested the hypothesis that a serum lactate level of greater than 36 mg/dL is associated with increased mortality compared with a serum lactate level of 36 mg/dL or less. Consecutive patients with sepsis were identified and included in the registry following consensus guidelines for clinical recognition (infection and decreased mental status or perfusion). Among 2520 registry visits, 1221 were excluded for transfer from another medical center, no measurement of lactate levels, and patients younger than 61 days or 18 years or older, leaving 1299 visits available for analysis. Lactate testing is prepopulated in the institutional sepsis order set but may be canceled at clinical discretion.

Exposures  Venous lactate level of greater than 36 mg/dL on the first measurement within the first 8 hours after arrival.

Main Outcomes and Measures  Thirty-day in-hospital mortality was the primary outcome. Odds ratios were calculated using logistic regression to account for potential confounders.

Results  Of the 1299 patients included in the analysis (753 boys [58.0%] and 546 girls [42.0%]; mean [SD] age, 7.3 [5.3] years), 899 (69.2%) had chronic medical conditions and 367 (28.3%) had acute organ dysfunction. Thirty-day mortality occurred in 5 of 103 patients (4.8%) with lactate levels greater than 36 mg/dL and 20 of 1196 patients (1.7%) with lactate levels of 36 mg/dL or less. Initial lactate levels of greater than 36 mg/dL were significantly associated with 30-day mortality in unadjusted (odds ratio, 3.00; 95% CI, 1.10-8.17) and adjusted (odds ratio, 3.26; 95% CI, 1.16- 9.16) analyses. The sensitivity of lactate levels greater than 36 mg/dL for 30-day mortality was 20.0% (95% CI, 8.9%-39.1%), and specificity was 92.3% (90.7%-93.7%).

Conclusions and Relevance  In children treated for sepsis in the emergency department, lactate levels greater than 36 mg/dL were associated with mortality but had a low sensitivity. Measurement of lactate levels may have utility in early risk stratification of pediatric sepsis.

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