A Retrospective Study on the Availability of Arterial Lactate Levels as a Biomarker of Mortality in Critically Ill Children

Abstract

Objective: We aimed to determine the threshold value of lactate levels, and to analyze its avaliability as mortality biomarker by correlating it with scoring systems in pediatric intensive care unit (PICU). Material and Methods: Observational retrospective cohort study. Our study was conducted among patients admitted to the 24-bed tertiary PICU of our hospital in 2015. All children between the ages of 1 month and 18 years were evaluated. Among 433 patients whose arterial blood gases were obtained during hospitalization, a total of 382 were included in the study. Patients with congenital metabolic disease with lactic acidosis were excluded. The arterial blood lactate levels on admission, PIM-2, PRISM-III and PELOD scores and survival status of the patients were evaluated. Correlation between lactate levels and mortality scores, threshold values of lactate levels and the factors affecting mortality risk were the main variable of interest. Results: There was a significant correlation between lactate levels and scores in patients who died (p<0.001). Receiver operating characteristic (ROC) curve analysis showed that blood lactate level was an effective parameter on mortality (area under the curve=AUC: 0.861; p<0.001) with a cut-off value of 2.55 mmol/L. The mortality risk was 1.38 fold higher in patients with higher levels of lactate. Conclusion: In our series, the levels of lactate were higher in critically ill children who died. Again, lactate levels and mortality scores of these children were correlated. In our series, the levels of lactate were higher in critically ill children who died. Again, lactate levels and mortality scores of these children were correlated. We were able to establish a cut-off point with high specificity for predicting evolution. These findings should be validated in prospective and multicenter studies for their incorporation into scoring systems.

Keywords

• Lactate
• Mortality
• Pediatric intensive care
• PELOD
• PIM-2
• PRISM-III

Kritik Hasta Çocuklarda Arteriyel Laktat Düzeylerinin Mortalite Biyobelirteci Olarak Kullanılabilirliğine İlişkin Retrospektif Bir Çalışma

Abstract

Amaç: Çocuk yoğun bakım ünitesinde (ÇYBÜ) laktat düzeylerinin eşik değerini belirlemeyi ve bunun mortalite biyobelirteci olarak kullanımının skorlama sistemleriyle korelasyonunu analiz etmeyi amaçladık. Gereç ve Yöntemler: Gözlemsel retrospektif bir kohort çalışmasıdır. Çalışmamız 2015 yılında hastanemizin 24 yataklı üçüncü basamak ÇYBÜ’sine başvuran hastalar arasında yapılmıştır. 1 ay-18 yaş arasındaki tüm çocuklar değerlendirildi. Yatış sürecinde takipte arteriyel kan gazı alınan 433 hastanın 382’si çalışmaya alındı. Laktik asidozlu konjenital metabolik hastalığı olan hastalar çalışma dışı bırakıldı. Hastaların başvuru anında alınan arteriyel kan laktat düzeyleri, PIM-2, PRISM-III, PELOD skorları ve hastaların sağkalım durumları değerlendirildi. Laktat seviyeleri ile mortalite skorları arasındaki korelasyon, laktat seviyelerinin eşik değerleri ve mortalite riskini etkileyen faktörler ana değişkenlerdi. Bulgular: Ölen hastaların laktat düzeyleri ile mortalite skorları arasında anlamlı bir ilişki vardı (p<0.001). ROC eğrisi analizinde kan laktat düzeylerinin mortalite üzerinde etkili bir parametre olduğu (eğri altındaki alan=AUC: 0.861; p<0.001) ve eşik değeri 2.55 mmol/L olarak bulundu. Laktat düzeyi yüksek olan hastalarda ölüm riski 1.38 kat daha fazlaydı. Sonuç: Mortalite olan kritik çocuklar hastalarda laktat düzeyleri daha yüksekti. Aynı çocukların laktat seviyeleri ve mortalite skorları korele edildi. Tanımladığımız eşik değerlerin üzerinde mortalitenin arttığı görüldü. Bu bulguların skorlama sistemlerine dahil edilebilmesi için prospektif ve çok merkezli daha fazla çalışma ile doğrulanması gerekmektedir.

Keywords

• Laktat
• Mortalite
• Pediatrik yoğun bakım
• PELOD
• PIM-2
• PRISM-III

References

1. Shen Y, Jiang J. Meta-Analysis for the Prediction of Mortality Rates in a Pediatric Intensive Care Unit Using Different Scores: PRISM-III/IV, PIM-3, and PELOD-2. Front Pediatr 2021;9:712276.
2. Recher M, Leteurtre S, Canon V, Baudelet JB, Lockhart M, Hubert H. Severity of illness and organ dysfunction scoring systems in pediatric critical care: The impacts on clinician’s practices and the future. Front Pediatr 2022;10:1054452.
3. Sankar J, Gulla KM, Kumar UV, Lodha R, Kabra SK. Comparison of Outcomes using Pediatric Index of Mortality (PIM) -3 and PIM-2 Models in a Pediatric Intensive Care Unit. Indian Pediatr 2018;55:972-4.
4. Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020;46:10-67.
5. Campbell J. Validation And Analysis of Prognostic Scoring Systems For Critically Ill Patients with Cirrhosis Admitted to ICU. Crit Care 2015;19:364
6. Sandal ÖS, Ceylan G, Sarı F, Atakul G, Çolak M, Topal S, et al. Could lactate clearance be a marker of mortality in pediatric intensive care unit? Turk J Med Sci 2022;52:1771- 8.
7. Hayashi Y, Endoh H, Kamimura N, Tamakawa T, Nitta M. Lactate indices as predictors of in-hospital mortality or 90-day survival after admission to an intensive care unit in unselected critically ill patients. PLoS One 2020;15:e0229135.
8. Swan KL, Avard BJ, Keene T. The relationship between elevated prehospital point-of-care lactate measurements, intensive care unit admission, and mortality: A retrospective review of adult patients. Aust Crit Care 2019;32:100-105.

9. El-Mekkawy MS, Ellahony DM, Khalifa KAE, Abd Elsattar ES. Plasma lactate can improve the accuracy of the Pediatric Sequential Organ Failure Assessment Score for prediction of mortality in critically ill children: A pilot study. Arch Pediatr 2020;27:206-211.
10. Mazhar MB, Hamid MH. Validity of Pediatric Index of Mortality 2 score as an Outcome Predictor in Pediatric ICU of a Public Sector Tertiary Care Hospital in Pakistan. J Pediatr Intensive Care 2021;11:226-32.
11. Mazloom A, Sears SM, Carlton EF, Bates KE, Flori HR. Implementing Pediatric Surviving Sepsis Campaign Guidelines: Improving Compliance With Lactate Measurement in the PICU. Crit Care Explor 2023;5:e0906.
12. Dewi W, Christie CD, Wardhana A, Fadhilah R, Pardede SO. Pediatric Logistic Organ Dysfunction-2 (Pelod-2) score as a model for predicting mortality in pediatric burn injury. Ann Burns Fire Disasters 2019;32:135-42.
13. 13. Wellbelove Z, Walsh C, Barlow GD, Lillie PJ. Comparing scoring systems for prediction of mortality in patients with bloodstream infection. QJM 2021;114:105-10.
14. MedicineNet. Definition of Chronic Disease. (2016). Available from: http://www.medicinenet.com/script/main/art.asp?articlekey=33490
15. WHO. Noncommunicable Diseases. (2016). Available from: http://www.who.int/topics/noncommunicable_diseases/en/
16. Foucher CD, Tubben RE. Lactic Acidosis. 2022 Jul 18. in: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan.
17. Bronicki RA, Spenceley NC. Hemodynamic Monitoring. In: Nichols DG, Shaffner DH, editors. Rogers’ Textbook of Pediatric Intensive Care. 5th Edition. Philadelphia, Wolters Kluwer, 2016, pp 1065-81.
18. Wilhelm M, Chung WK. Inborn errors of metabolism. In: Rogers’ Textbook of Pediatric Intensive Care. Nichols DG, Shaffner DH, editors. 5th Edition. Philadelphia, Wolters Kluwer, 2016;1703-14.
19. Moustafa AA, Elhadidi AS, El-Nagar MA, Hassouna HM. Can Lactate Clearance Predict Mortality in Critically Ill Children? J Pediatr Intensive Care 2021;12:112-7.
20. Kon AA, Shepard EK, Sederstrom NO, Swoboda SM, Marshall MF, Birriel B, et al. Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee. Crit Care Med 2016;44:1769-74.
21. Bai Z, Zhu X, Li M, Hua J, Li Y, Pan J, et al. Effectiveness Of Predicting in-Hospital Mortality in Critically Ill Children by Assessing Blood Lactate Levels at Admission. BMC Pediatr 2014;14:83.
22. Patki VK, Antin JV, Khare SH. Persistent Hyperlactatemia as the Predictor of Poor Outcome in Critically Ill Children: A Single-Center, Prospective, Observational Cohort Study. J Pediatr Intensive Care 2017;6:152-8.
23. Kliegel A, Losert H, Sterz F, Holzer M, Zeiner A, Havel C, et al. Serial lactate determinations for prediction of outcome after cardiac arrest. Medicine (Baltimore) 2004;83:274-9.
24. Baydın A, Yardan T, Guven H. The relationship between mortality and lactate, base deficit, Injury Severity Score in trauma. Turkiye Acil Tıp Dergisi 2007;7:97-101
25. Wang Y, Lai L, Zhang Q, Zheng L. Lactate acid level and prognosis of neonatal necrotizing enterocolitis: a retrospective cohort study based on pediatric-specific critical care database. J Pediatr (Rio J) 2022:S0021-7557(22)00131-0.
26. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;315:801-10.
27. McCallister R, Nuppnau M, Sjoding MW, Dickson RP, Chanderraj R. In septic patients, initial lactate clearance is highly confounded by comorbidities and poorly predicts subsequent lactate trajectory. Chest 2023:S0012-3692(23)00598-6.
28. 28. Howell MD, Donnino M, Clardy P, Talmor D, Shapiro NI. Occult Hypoperfusion and Mortality in Patients with Suspected Infection. Intensive Care Med 2007;33:1892–9.
29. Anıl AB, Anıl M, Çetin N. Comparison of Child Death Risk I and Child Death Index II in an Internal-Surgical Pediatric Intensive Care Unit. Turkish Pediatrics Archive 2010; 45: 18-24.
30. Scott HF, Brou L, Deakyne SJ, Kempe A, Fairclough DL, Bajaj L. Association Between Early Lactate Levels And 30-Day Mortality in Clinically Suspected Sepsis in Children. JAMA Pediatr 2017;171:249-55.
31. Bernhard M, Döll S, Kramer A, Weidhase L, Hartwig T, Petros S, et al. Elevated admission lactate levels in the emergency department are associated with increased 30-day mortality in non-trauma critically ill patients. Scand J Trauma Resusc Emerg Med 2020;28:82.
32. Kramer A, Urban N, Döll S, Hartwig T, Yahiaoui-Doktor M, Burkhardt R, et al. Early Lactate Dynamics in Critically Ill Non-Traumatic Patients in a Resuscitation Room of a German Emergency Department (OBSERvE-Lactate-Study). J Emerg Med 2019;56:135-44.
33. Asati AK, Gupta R, Behera D. To Determine Blood Lactate Levels in Patients with Sepsis Admitted to a Respiratory Intensive Care Unit and to Correlate with their Hospital Outcomes. Int J Crit Care Emerg Med 2018; 4:045.
34. Scott HF, Brou L, Deakyne SJ, Fairclough DL, Kempe A, Bajaj L. Lactate Clearance And Normalization And Prolonged Organ Dysfunction in Pediatric Sepsis. J Pediatr 2016; 170:149- 55.