Lactate, Base Excess, and the Pediatric Index of Mortality: Exploratory Study of an International, Multicenter
Kevin P Morris1,2, Melpo Kapetanstrataki3, Barry Wilkins4
1Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, United Kingdom.
Insights
Blood lactate levels at pediatric intensive care unit (PICU) admission are a stronger predictor of mortality than base excess. Incorporating lactate into the Pediatric Index of Mortality may slightly improve its performance in predicting outcomes.
Area of Science:
- Pediatric Critical Care Medicine
- Biomarkers in Critical Illness
- Healthcare Analytics
Background:
- Pediatric Index of Mortality (PIM) is a widely used scoring system for predicting mortality in pediatric intensive care units (PICUs).
- Blood lactate and base excess are established physiological markers of critical illness and tissue hypoperfusion.
- The predictive value of these markers, particularly lactate, for mortality and their potential integration into existing scoring systems requires further investigation.
Purpose of the Study:
- To examine the association between ICU admission blood lactate and base excess with ICU mortality.
- To evaluate the impact of including blood lactate in the Pediatric Index of Mortality (PIM) scoring system.
Main Methods:
- A retrospective cohort study utilizing prospectively collected data from the U.K. Pediatric Intensive Care Audit Network and the Australia and New Zealand Pediatric Intensive Care Registry.
- Analysis included over 123,000 PICU admissions between 2012 and 2015.
- Statistical methods assessed the relationship between lactate, base excess, and mortality, and evaluated model performance with and without these biomarkers.
Main Results:
- Children with recorded lactate levels exhibited higher illness severity, increased need for ventilation, and greater mortality risk compared to those without (p < 0.001).
- Blood lactate demonstrated a stronger association with mortality (OR, 1.32) than absolute base excess (OR, 1.13).
- Incorporating lactate into the PIM score showed a modest performance improvement, with combined lactate and base excess yielding the best predictive performance.
Conclusions:
- Blood lactate at PICU admission is a more potent predictor of mortality than base excess.
- Adding lactate to the PIM model offers a potential, albeit small, improvement in predictive accuracy.
- The clinical utility of enhancing the PIM score must be weighed against the increased data collection burden.
Objectives:
To investigate the relationship between ICU admission blood lactate, base excess, and ICU mortality and to explore the effect of incorporating blood lactate into the Pediatric Index of Mortality.
Design:
Retrospective cohort study based on data prospectively collected on every PICU admission submitted to the U.K. Pediatric Intensive Care Audit Network and to the Australia and New Zealand Pediatric Intensive Care Registry.
Setting:
Thirty-three PICUs in the United Kingdom/Republic of Ireland and nine PICUs and 20 general ICUs in Australia and New Zealand.
Patients:
All ICU admissions between January 1, 2012, and December 31, 2015.
Interventions:
None.
Measurements And Main Results:
One hundred twenty-three thousand two hundred fifty-two admissions were recorded in both datasets; 81,576 (66.2%) in the United Kingdom/Republic of Ireland and 41,676 (33.8%) in Australia and New Zealand. Of these 75,070 (61%) had a base excess recorded, 63,316 (51%) had a lactate recorded, and 60,876 (49%) had both base excess and lactate recorded. Median lactate value was 1.5 mmol/L (interquartile range, 1-2.4 mmol/L) (United Kingdom/Republic of Ireland: 1.5 [1-2.5]; Australia and New Zealand: 1.4 [1-2.3]). Children with a lactate recorded had a higher illness severity, were more likely to be invasively ventilated, admitted after cardiac surgery, and had a higher mortality rate, compared with admissions with no lactate recorded (p < 0.001). The relationship between lactate and mortality was stronger (odds ratio, 1.32; 95% CI, 1.31-1.34) than between absolute base excess and mortality (odds ratio, 1.13; 95% CI, 1.12-1.14). Addition of lactate to the Pediatric Index of Mortality score led to a small improvement in performance over addition of absolute base excess, whereas adding both lactate and absolute base excess achieved the best performance.
Conclusions:
At PICU admission, blood lactate is more strongly associated with ICU mortality than absolute base excess. Adding lactate into the Pediatric Index of Mortality model may result in a small improvement in performance. Any improvement in Pediatric Index of Mortality performance must be balanced against the added burden of data capture when considering potential incorporation into the Pediatric Index of Mortality model.
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