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Early hyperlactataemia in critically ill children
M Hatherill1, A G McIntyre, M Wattie
1Paediatric Intensive Care Unit, Guy's Hospital, London, UK.
Insights
Hyperlactataemia, or high blood lactate levels, in children admitted to intensive care is linked to increased mortality. Persistent high lactate after 24 hours or a higher peak lactate level can indicate a poorer outcome.
Area of Science:
- Pediatric Critical Care Medicine
- Biochemistry
- Clinical Pathology
Background:
- Hyperlactataemia is a common finding in critically ill children.
- The prognostic significance of hyperlactataemia, acidosis, and organ failure in pediatric intensive care remains an area of active research.
Purpose of the Study:
- To investigate the association between early hyperlactataemia, acidosis, organ failure, and mortality in children admitted to the intensive care unit (ICU).
Main Methods:
- A prospective observational study enrolled 50 children with hyperlactataemia (lactate > 2 mmol/l) admitted to the ICU, excluding post-operative patients and those with inherited metabolic diseases.
- Data collected included Paediatric Risk of Mortality (PRISM) score, Multiorgan System Failure (MOSF) score, lactate levels, pH, and base excess (BE) up to 24 hours post-admission.
- Statistical analyses included Mann-Whitney, Fisher's Exact, Kruskal-Wallis, and chi-squared tests for trend.
Main Results:
- Overall mortality in the screened population was 10%, while the hyperlactataemia group (n=50) had a 64% mortality rate.
- Admission lactate, pH, and base excess did not significantly differ between survivors and nonsurvivors.
- Peak lactate (P=0.02) and cumulative average lactate (P=0.0003) were significantly higher in nonsurvivors. Persistent hyperlactataemia at 24 hours was a strong predictor of mortality (likelihood ratio = 7).
Conclusions:
- Hyperlactataemia upon ICU admission is a significant indicator of high mortality risk in children.
- Peak lactate levels and persistent hyperlactataemia after 24 hours are key indicators for identifying nonsurvivors among children with hyperlactataemia.
Objective:
To examine the relationships between early hyperlactataemia, acidosis, organ failure, and mortality in children admitted to intensive care.
Design:
Prospective observational study. Children with lactate levels > 2 mmol/l were eligible for enrolment. Post-operative patients and those with inherited metabolic disease were excluded. Seven hundred and five children admitted to intensive care were screened, and 50 children with hyperlactataemia (incidence 7%), aged 20.3 months (0.1-191) were enrolled and followed up. The Paediatric Risk of Mortality (PRISM) score, Multiorgan System Failure (MOSF) score, length of ICU stay, and outcome were recorded. Data were collected for lactate (mmol/l), pH, and base excess (BE) until 24 h after admission. Data are reported as median (range) and were analysed by the Mann-Whitney, Fisher's Exact, and Kruskal-Wallis tests, and chisquared test for trend.
Results:
Overall mortality in the screening group was 70/705 (10%). In the study group (n = 50) median PRISM score was 19 (4-49), median MOSF score 2 (1-4), and observed mortality 32/50 (64%). Median duration of ICU stay was 6 days (2-32) in survivors, and median time until death 3 days (0-13) in nonsurvivors. Eleven nonsurvivors (34%) died within 24 h. In the screening group, hyperlactataemia on admission identified mortality with likelihood ratio = 15. In the study group, neither the admission lactate (3.8 vs 4.6 mmol/l, P = 0.27), pH (7.32 vs 7.30, P = 0.6), nor BE (-7.5 vs -8, P = 0.45) differed significantly between survivors and nonsurvivors. Neither the admission nor peak lactate increased with increasing MOSF score (P = 0.5 and 0.54). The median peak lactate level was 5 mmol/l (2-9.3) in survivors compared to 6.8 mmol/l (2.3-22) in nonsurvivors (P = 0.02), and the cumulative average lactate level was 2.4 mmol/l (1-4.9) in survivors, compared to 4.5 mmol/l (1.6-21) in nonsurvivors (P = 0.0003). Persistent hyperlactataemia 24 h after admission identified mortality with likelihood ratio = 7.
Conclusion:
Hyperlactataemia on admission to intensive care is associated with a high mortality in children. Nonsurvivors within this group may be distinguished by the peak lactate level, or by persistent hyperlactataemia after 24 h of treatment.